Pharmacologic management of non-neurogenic functional obstruction in women

ABSTRACT

Introduction: Impaired bladder emptying in women without neurologic disease may be related to urethral obstruction and/or impaired bladder contractility. Mechanical obstruction generally requires surgical management and options are limited for impaired bladder contractility. However, functional obstruction from voiding dysfunction or primary bladder neck obstruction may present an opportunity for pharmacologic intervention.

Areas covered: In this review, the authors extensively reviewed available literature regarding the use of off-label medications for functional bladder outlet obstruction in women. In addition, side effect profiles and pharmacology of these medications determined from on-label indications are reviewed. Specific medications reviewed include vaginal diazepam, baclofen, urethral botulinum toxin injection, and alpha-adrenergic blockers.

Expert opinion: Alpha-blockers in particular have demonstrated promise in women with demonstrable or suspected bladder outlet obstruction with side effect profiles similar to those observed in men. However, lack of quality data hinders informed decision making with alpha-blockers or any of the other agents studied in women with non-neurogenic functional outlet obstruction. In the absence of well-designed, placebo-controlled multi-institutional trials, those prescribing these medications must be aware of special considerations and side effects associated with relatively unfamiliar treatments in the context of uncertain benefit.

KEYWORDS:

• Women
• urinary retention
• functional obstruction
• voiding dysfunction
• primary bladder neck obstruction
• pharmacology

Article highlights

• Impaired bladder emptying related to functional obstruction in women may result from dysfunctional voiding or primary bladder neck obstruction.

• Dysfunctional voiding is characterized by failure of pelvic floor relaxation during voiding, associated with persistent EMG activity on urodynamics.

• Primary bladder neck obstruction is characterized on fluoroscopy by a closed bladder neck during voiding.

• Vaginal diazepam, oral baclofen, and injection of botulinum neurotoxin have demonstrated efficacy in reducing pelvic floor tone and improving dysfunctional voiding in some women, however, data are both mixed and limited.

• Alpha-adrenergic blockers have demonstrated improvement in about 50% of women with primary bladder neck obstruction and in some women with dysfunctional voiding, however, these are associated with risk of stress urinary incontinence.

• All medications for functional obstruction in women remain off label, and providers should be aware of their unique side effect profiles.

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Declaration of interests

JA Cohn traveled to educational meeting sponsored by Medtronic, Inc. MR Kaufman is a consultant for AMS. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.