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Lower Urinary Tract Symptoms in Men
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital
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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
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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
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IPSS Symptom score
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Quality of Life Index
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Assessment of LUTS in Men
Uroflowmetry and residual urine
Cystometry and EMG
Prostatic volume and configuration
Pressure flow study
Cystourethroscopy
Neurological examination
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Uroflowmetry- Normal
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Intermittent Flow
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Variability in Uroflow
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Qmax and Voided volume
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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)
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Correlation of Qmax and Cqmax with Age in Men
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Increased Bladder Sensation
Hypersensitivity
Reduced bladder compliance
Detrusor underactivity
Detrusor overactivity
Postmicturition residual urine sensation
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Hypersensitive bladder & Normal bladder outlet
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Urgency frequency
Sensory urgency
Detrusor overactivity
Poor relaxation of urethral sphincter
Interstitial cystitis
Bladder outlet obstruction
Neurogenic voiding dysfunction
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Sensory urgency
Urinary tract infection
Lower ureteral stone
Foreign body
Surgery of bladder wall
Diuresis
Bladder pathology (carcinoma in situ)
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Detrusor Overactivity
Poor cortical perfusion
Post-obstructive overactivity
Ageing process
Idiopathic detrusor overactivity
Low detrusor contractility (DHIC)
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CVA & urgency frequency Detrusor overactivity
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Postprostatectomy Urgency frequency
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Detrusor hyperactivity & Inadequate contractility
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Urge Incontinence
Urinary incontinence at urge sensation
UTI & bladder foreign body
Bladder outlet obstruction
Neurogenic detrusor overactivity
Idiopathic detrusor overactivity
Combined with stress incontinence or chronic retention
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Bladder outlet obstruction & Urge incontinence
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Idiopathic Detrusor overactivity
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Premicturition urge incontinence
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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
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Etiology of Nocturia
Detrusor overactivity
Hypersensitive bladder
Bladder outlet obstruction
Nocturnal polyuria
Small bladder capacity
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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
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Hesitancy - Poor Urethral Sphincter Relaxation
Learned habit
Chronic prostatitis
Pelvic floor hypertonicity
Occult neuropathy
Increased bladder sensitivity
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Hesitancy- Bladder Outlet Obstruction
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Dysuria, Small stream- BOO
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Prostatic Obstruction
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Poor Relaxation of Urethral sphincter
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Intermittency of urine
Bladder outlet obstruction
Poor relaxed external sphincter
Increased bladder sensitivity
Detrusor underactivity
Detrusor overactivity & inadequate contractility
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Intermittency due to poor relaxation of ES
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Urethroscopy - Spastic Urethral Sphincter
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Intermittency due to Hypersensitivity & DHIC
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Terminal dribbleResidual urine sensation
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Postmicturition dribble (detrusor contraction)
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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%)
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Normal bladder and normal urethral in VUDS
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Poor relaxation of urethral sphincter
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Detrusor underactivity without BOO
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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
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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
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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
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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%)
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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%)
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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
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Postprostatectomy Urethral stricture
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Urethral stricture