Functional BOO is a condition, that deserves further attention. Terms such as female aseptic dysuria, female prostatitis, abacterial cystitis, and, most often, the "urethral syndrome" have been used to describe this condition in the literature.16,17 Such variation in terms reflects both the common symptoms among these patients (recurrent episodes of urinary frequency, urgency, and dysuria without pelvic pain) and the lack of consensus over the etiology and pathophysiology of this condition. Some authors suggest that "the urethral syndrome is probably the most frequent reason for urological consultation among women."15
The pathophysiology of this syndrome has been addressed by several different theories including infection and inflammation of the paraurethral glands, spasticity of the urethral musculature, and increased periurethral scar formation. Animal studies have shown that partial outflow obstruction is first evidenced by increased frequency of voids and increased voiding detrusor pressure.18 Over time, the detrusor muscle decompensates, and manifestations of the disease change. Bladder capacity, volume, and compliance increase as bladder contractility and voiding pressures decrease.19 This can eventually lead to elevated PVRs, retention, and ultimately overflow incontinence.
In the past, treatments have included: a) urethral dila-tion,20,21 b) urethrotomy,22,23 c) combined use of antibiotics and muscle relaxant,24 and d) cryosurgery25 or diathermy.26 Clearly, there remains a lack of an effective and generally accepted treatment modality for these patients.
Based on a review of the literature and our clinical observations, we have theorized that these patients have inflammation/infection of the urethra (urethritis) with a subsequent functional hyperactivity of the smooth muscle components of the urethra. Such spasm of the smooth muscle of the bladder outlet may manifest in symptoms of frequency, urgency, and frequent cystitis. The spasm may create a functional BOO that can be demonstrated in a pressure flow study by elevated detrusor pressure at maximum flow and decreased rate of urine flow.
We treat our patients with functional BOO with a combination of an alpha-adrenergic blocking agent and a prophylactic antibiotic before activities that may cause urethral irritation. This combined therapy may decrease the recurrence of infection and the tension of the urethral spasms - thereby breaking the vicious cycle between spasm and infection. This treatment is experimental, and, currently, a randomized placebo-controlled trial is underway at our institution to assess the efficacy of this treatment.
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