Surgical Management of Refractory Overactive Bladder and Detrusor Compliance Abnormalities

Evaluation of Patients

A full patient history is necessary to elucidate the character of urinary symptoms, to evaluate any previous attempts at medical or surgical treatment, and to identify concomitant medical conditions that may influence the success of treatment or provide contraindications to different therapies. In general, a patient who may be considered for surgical treatment of detrusor abnormalities will need to have failed more conservative treatment modalities, and a complete understanding of previous treatments is essential. A thorough physical examination that focuses on the lower abdomen and pelvis is warranted to note any structural abnormalities, including a vaginal speculum examination and bimanual pelvic examination in women to evaluate for any associated pelvic organ prolapse and rule out pelvic pathology. Also, inspection and palpation of the lower back and spine can uncover signs of bony abnormality or scars from any previous spine surgery that may suggest a potential neurologic insult. Finally, the extremities should be examined for pedal edema and neurologic or musculoskeletal abnormalities.

A bladder or voiding diary can be considered to better quantify the degree of urinary dysfunction, not only for diagnostic purposes but also to serve as a baseline for subsequent posttreatment comparison. Similarly, patient self-reported quality-of-life and symptom severity questionnaires can provide a more objective, comparable picture of the degree of urinary dysfunction. Finally, in any patient who fails conservative or empirical therapy, multichannel urodynamics is warranted to objectively characterize the nature of the urinary dysfunction and to identify any negative or worrisome prognostic factors associated with the voiding complaints, including bladder capacity and compliance, the presence of detrusor overactivity, the magnitude of resting detrusor pressures, and the coordination of detrusor and sphincter function, all of which may have negative implications for renal function. Combining fluoroscopy (“videourodynamics”) can add important information regarding structural abnormalities of the bladder or ureters, including vesicoureteral reflux, bladder morphology, and bladder neck function. Videourodynamics should be strongly considered in patients who have detrusor compliance abnormalities that are of neurogenic origin ( Fig. 90.1 ).