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8. Lower Urinary Tract Function and Dysfunction


  • Lower urinary tract dysfunction includes abnormalities of the filling phase and those of the emptying phase.
  • Filling phase dysfunction includes a rise of detrusor pressure (detrusor instability) or incompetence of the urethral sphincter mechanism (stress incontinence).
  • Emptying phase dysfunction includes a failure of the detrusor to maintain sufficient pressures to empty the bladder (detrusor hypotonicity) and obstruction of the urethra (outflow obstruction).

8.1 General Objectives


  • On completion of the educational program, the graduate urologist will be competent to diagnose and treat disorders of the lower urinary tract.
  • The graduate urologist will also be familiar with the role of gynecologists, visiting and hospital based nurses, physiotherapists, and community resources involved in the care of patients with lower urinary tract disorders.
  • The management of lower urinary tract disorders requires an understanding of the embryology, anatomy and physiology of the lower urinary tract as well as the relevant neuro-anatomy and neuro-physiology of the central and peripheral nervous systems.
  • Diagnosis of lower urinary tract dyfunction requires skills in relevant history and examination of the patient, interpretation of laboratory tests and imaging studies, cystoscopic examination, and urodynamic evaluation.
  • Treatment skills include a knowledge of behavioral and lifestyle modification strategies and lower urinary tract pharmacology, as well as performance of endoscopic and open procedures for correction of stress incontinence and outflow obstruction.
  • The graduate urologist must understand and be able to convey to the patient the relative merits of diagnostic and treatment alternatives, based on their indications, contraindications, and complications.
  • The graduate urologist must also be able to interpret the relevant urological literature and be able to incorporate new developments into his or her practice.

8.2 Specific Objectives


  • Dr. Kevin Piercy
  • Dr. A. Leo Winter
  • Dr. Jerold Zikman

Cognitive Skills

The following is a listing of disease entities that are commonly included in the management of Lower Urinary Tract Dysfunction. The list is not exhaustive. The graduate urologist should be able to demonstrate a working knowledge for the following disease entities sufficient for the competent practice of the specialty.

Lower Urinary Tract Anatomy and Physiology

  • Pelvic Floor — muscles, ligaments, blood vessels
  • Organs — bladder, urethra, prostate, vagina
  • Neuroanatomy — CNS, peripheral nerves, somatic vs. autonomic
  • Differences between male and female

Lower Urinary Tract Dysfunction

  • Storage Phase disorders
    • Detrusor Instability(Overactive Bladder)
    • Hypereflexia (Neurogenic Bladder)
    • Non-compliance
    • Fistula
    • Prolapse
    • Urethral incompetence
  • Emptying Phase Dysfunction
    • Detrusor Hypotonicity
    • Flaccid Neurogenic Bladder
    • Urethral Obstruction - BPH, Stricture disease etc.
    • Detrusor-sphincter dyssenergia

Neurological Disease Affecting the Urinary Tract

  • Spinal cord injury
  • Brain injury
  • Stroke
  • M.S.
  • Parkinsons
  • Diabetes

Idiopathic Disorders

  • LUT Symptoms
  • Pelvic pain
  • Abacterial prostatitis

Pharmacology of the lower urinary tract

  • Anticholinergics and Antispasmotics
  • Alpha Blockers
  • 5-DHT inhibitors
  • Alpha adrenergic agonists
  • Cholinergic agonists
  • Other

Behavior and Lifestyle Modification

  • Fluid and diet management
  • Intermittent catheterization
  • Indwelling catheter care
  • Padding and diapers

Technical Skills

The graduate urologist must be able to describe and basic biochemistry, physics and technological application of the following diagnostic and therapeutic modalities.

History and Examination

  • Urological findings
  • Relevant non-urological findings

Diagnostic Tests and Procedures

  • Urinalysis
  • Prostatic fluid examination
  • Imaging
  • Cystourethrography
  • Transrectal ultrasonography
  • Urodynamic Studies
  • C cystometrogram
  • Uroflowmetry
  • Urethral pressure profile
  • Pressure/flow study
  • Pelvic floor electromyography
  • Videourodynamic studies

Therapeutic Procedures List A

  • Endoscopic Procedures
    • Cystoscopy and urethroscopy
    • Urethral dilation, and visual urethrotomy
    • Transurethral biopsy of bladder and hydrodistension
    • Transurethral resection/incision of prostate
    • Transurethral incision of bladder neck
    • Transurethral incision of sphincter
    • Insertion of supra-pubic catheter
  • Open Surgical Procedures
    • Vesical neck suspension by needle or TVT
    • Open vesical neck suspension (Burch or Marshall Marchetti)
    • Insertion of artificial sphincter
    • Repair of urethral and bladder fistulae
    • Repair of bladder and urethral trauma
    • Vesical diverticulectomy
    • Simple retropubic prostatectomy
    • Anterior bladder repair

Therapeutic Procedures List B

  • Open Surgical Procedures
    • One and two stage open urethroplasty
    • Vaginal vault suspension
    • Augmentation cystoplasty

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