排尿障礙治療中心版權所有 Lower Urinary Tract Symptoms in Men Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有

Lower Urinary Tract Symptoms in Men

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


Lower Urinary Tract Symptoms in Men

Storage symptoms – increased bladder sensation, frequency, urgency, urge incontinence, nocturiaEmpty symptoms- hesitancy, dysuria, intermittency, small caliber of urine, terminal dribble, residual sensationPainful symptoms- Pelvic pain, perineal pain, urethral pain


Symptom Score

Boyarsky & Madsen-Iversen indexes, IPSS, AUA symptom score

7 items,scoring 0-5, total score 35

A quarter of men >60 years had moderate symptoms (IPSS >8)

Symptom score is not reliable in defining BOO, 1/3 with LUTS non-BOO


IPSS Symptom score


Quality of Life Index


Assessment of LUTS in Men

Uroflowmetry and residual urine

Cystometry and EMG

Prostatic volume and configuration

Pressure flow study

Cystourethroscopy

Neurological examination


Uroflowmetry- Normal


Intermittent Flow


Variability in Uroflow


Qmax and Voided volume


Normal Uroflow rate in Taiwanese Men by Age

Age

years

Qmax Voided volume CQmax

normal normal normal

≦45 23.9±8.73(127) 339.8±191.1 1.41±0.51

46-55 19.7±6.81(68) 305.4±159.2* 1.21±0.42*

56-65 20.2±6.2*(134) 286.8±138.8 1.27±0.42

66-75 19.2±6.1*(143) 262.8±109.3 1.23±0.39

76-85 18.7±7.5*(42) 225.3±101.5 1.31±0.47*

All ages 20.65±7.33*(514)290.7±123.2(514)

1.29±0.45*(514)


Correlation of Qmax and Cqmax with Age in Men


Increased Bladder Sensation

Hypersensitivity

Reduced bladder compliance

Detrusor underactivity

Detrusor overactivity

Postmicturition residual urine sensation


Hypersensitive bladder & Normal bladder outlet


Urgency frequency

Sensory urgency


Poor relaxation of urethral sphincter

Interstitial cystitis

Bladder outlet obstruction

Neurogenic voiding dysfunction


Sensory urgency

Urinary tract infection

Lower ureteral stone

Foreign body

Surgery of bladder wall

Diuresis

Bladder pathology (carcinoma in situ)


Detrusor Overactivity

Poor cortical perfusion

Post-obstructive overactivity

Ageing process

Idiopathic detrusor overactivity

Low detrusor contractility (DHIC)


CVA & urgency frequency Detrusor overactivity


Postprostatectomy Urgency frequency


Detrusor hyperactivity & Inadequate contractility


Urge Incontinence

Urinary incontinence at urge sensation

UTI & bladder foreign body


Neurogenic detrusor overactivity

Idiopathic detrusor overactivity

Combined with stress incontinence or chronic retention


Bladder outlet obstruction & Urge incontinence


Idiopathic Detrusor overactivity


Premicturition urge incontinence


Nocturia

LUTS are common in elderly

Nocturia is the third most bothersome LUTS

Prevalence of nocturia increases to 80% in patients aged over 80 years

Nocturia is one of the most common causes of disturbed sleep pattern


Etiology of Nocturia


Hypersensitive bladder


Nocturnal polyuria

Small bladder capacity


Nocturnal Polyuria

Excessive amount of urine production at night due to postural change

Noctural polyuria >35% daily urine

Nocturnal urine amount > 900 mL

Abnormal lower urinary tract function

A combination of etiologies


Hesitancy - Poor Urethral Sphincter Relaxation

Learned habit

Chronic prostatitis

Pelvic floor hypertonicity

Occult neuropathy

Increased bladder sensitivity


Hesitancy- Bladder Outlet Obstruction


Dysuria, Small stream- BOO


Prostatic Obstruction


Poor Relaxation of Urethral sphincter


Intermittency of urine


Poor relaxed external sphincter

Increased bladder sensitivity

Detrusor underactivity

Detrusor overactivity & inadequate contractility


Intermittency due to poor relaxation of ES


Urethroscopy - Spastic Urethral Sphincter


Intermittency due to Hypersensitivity & DHIC


Terminal dribbleResidual urine sensation


Postmicturition dribble (detrusor contraction)


VUDS Analysis in 112 Non-obstructive Men with LUTS

Normal bladder & urethra 25 (22.3%)

Hypersensitive bladder 17 (15.2%)

Detrusor instability 6 (4.5%)

Detrusor failure 3 (2.7%)

Poor relaxed external sphincter 61(54.5%)


Normal bladder and normal urethral in VUDS


Poor relaxation of urethral sphincter


Detrusor underactivity without BOO


Painful syndrome

Painful bladder – Interstitial cystitis, BOO, poor compliant bladder, TCC(CIS)

Painful urethra - UTI, urethral stricture, BPO, chronic prostatitis

Painful pelvis or perineum - pelvic floor hypertonicity, chronic prostatitis, spastic urethral sphincter, perianal inflammation


Assessment of Painful Syndromes in Men

Uroflowmetry

Urine routine & culture

Prostatic massage and EPS examination

Cystoscopy & biopsy

KCL test & Bladder hydrodilatation

Cystometry & pressure flow study


Postprostatectomy LUTS

Symptoms are not reliable in predicting urodynamic findings

Over half of patients with post-prostatectomy LUTS had a small total prostate volume and resected adenoma weight, indicating non-BOO before TURP


Etiology of Post-prostatectomy LUTS

Normal urethra &bladder 17(9.1%)

Detrusor overactivity 18(9.6%)

Detrusor underactivity 35(18.7%)

Poor relaxed external sphincter 36(19.3%)

DHIC 27 (14.4%)

Bladder outlet obstruction 52 (27.8%)


Postprostatecomy BOO and Incontinence

Among 52 with BOO, 12 had prostatic BOO, 13 bladder neck BOO, 27 urethral BOO (51.9%)Obstructive symptoms are less frequent in pure DIUrge incontinence was found more in DI (66.7%) and DHIC (66.7%)In 74 incontinent patients, 18 had BOO (24.3%)


Preoperative Prostate volume in post-prostatectomy LUTS

Resected

prodtatic weight,g

Preoperative

prostatic vol, mlPreoperativQmax, ml/s

Normal tracing(n=17) 12.3 ± 7.4 22.5 ± 14.2 11.0 ± 5.2

DI (n=18) 14.3 ± 15.4 26.5 ± 21.7 10.9 ± 4.0

LC (n=35) 8.9 ± 8.7 17.6 ± 13.8 9.6 ± 4.5

PRS (n=35) 9.2 ± 5.2 17.6 ± 8.8 8.4 ± 4.6

DHIC (n=27) 10.3 ± 7.1 19.9 ±10.3 10.5 ± 4.5

BOO (n=52) 14.4 ± 12.6 25.6 ± 18.7 9.7 ± 4.5

Statistics (ANOVA) P=0.131 P=0.140 P=0.559


Postprostatectomy Urethral stricture


Urethral stricture

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排尿障礙治療中心 版權所有 Lower Urinary Tract Symptoms in Men Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有 Lower Urinary Tract Symptoms in Men Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital