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Clinical Assessment of Lower Urinary Tract Dysfunction

Clinical Assessment of Lower Urinary Tract Dysfunction. Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital. Lower Urinary Tract Symptoms. Storage symptoms Frequency, Urgency, Nocturia Incontinence Suprapubic fullness and pain Empty symptoms

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Clinical Assessment of Lower Urinary Tract Dysfunction

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  1. Clinical Assessment of Lower Urinary Tract Dysfunction Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

  2. Lower Urinary Tract Symptoms • Storage symptoms Frequency, Urgency, Nocturia Incontinence Suprapubic fullness and pain • Empty symptoms Hesitancy, Intermittency, Small caliber, Dysuria, Residual urine sensation

  3. Urinary Incontinence • Stress incontinence • Urge incontinence • Total incontinence • Overflow incontinence • Giggle incontinence • Nocturnal enuresis

  4. Voiding Diary

  5. Physical Examination • Abdominal physical examination Bladder, Operation scar • Perineal examination Cystocele, Rectocele, Uterine prolapse Urine leakage on cough, fistula Vaginal mucosa, Vaginal tenderness • Neurological examination B-C Reflex, PFM contractility, Anal tone

  6. Sensory dermatomes of perineum & extremities

  7. Clinical investigation of Lower urinary tract dysfunction • Urethral sounding • Prostatic fluid examination • Ultrasound examination • Pad weighing test • Cystourethroscopy • Potassium chloride test

  8. Urethral Sounding

  9. Prostatic Massage andExpressed prostatic secretion

  10. Prostatitis • Acute bacterial prostatitis • Chronic bacterial prostatitis • Abacterial prostatitis • Prostatodynia (perineal pain syndrome) • Using available symptom score or index to assess symptomatology

  11. Symptomatology of Prostatitis • Pelvic pain syndrome • Disturbance in urination • Disturbance in sexual function • Depression • Disturbance in intimate relationships

  12. Diagnosis of Prostatitis • Expressed prostatic secretions show numerous WBC and macrophage • Abnormal EPS: WBC>10 or 15/HPF • After massage U/A: WBC >10/HPF • Calcification in prostatic ultrasound • Elevated prostatic specific antigen • Increased EPS PH (>7.8)

  13. Ultrasound Examination in Male LUTS • Prostate enlargement is not indicator of BOO in men with LUTS • Transition zone index provides a better indicator for BOO • Bladder neck dysfunction • Trabeculated bladder • Low residual urine

  14. Prostatic Configuration in Transrectal ultrasound

  15. Prostatic enlargement • Benign prostatic enlargement • Prostatic cancer

  16. Correlation of TZI with Prostate volume & Qmax

  17. Clinical Prostate Score

  18. Urethral Ultrasound in SUI and Frequency Urgency Syndrome

  19. Measurement of Bladder Neck Hypermobility in Frequency Urgency Syndrome in Women

  20. Bladder Neck Descent in Women with LUTS

  21. Bladder Neck Incompetence in Frequency Urgency Syndrome

  22. Bladder Neck Incompetence and Hypermobility

  23. Measurement of External Sphincter Volume in SUI

  24. Different Urethral Structure

  25. Urethral Ultrasound in ISD and Cystocele

  26. Striated Urethral Sphincter in SUI and Cystocele

  27. Female Urethral Incompetence • Bladder neck incompetence • Urethral incompetence

  28. Assessing Pubococcygeus muscle function • Inspection Perineum buldging downward Vaginal introitus opens Anus everted Performing straining or coughing Contraction of pubococcygeus m.

  29. Cystocele and Prolapse

  30. Assessing Pubococcygeus muscle function • Palpation In normal vagina, resistance is met in all direction by finger palpation The atrophied pubococcygeus m. is not easily palpated with little resistance One third of women have a good voluntary contraction function

  31. Voluntary Contraction of Pelvic Floor Muscles

  32. Pad Weighing Test for Stress Urinary Incontinence • Provide semi-objective measurement of urine loss • 1 hr, 2 hr, 24 hr, 48 hr test • Drink 500ml, walking & stair climbing 30 min, standing up 10x, coughing 10x, running 1 min, bending 5x, wash hands 1 min • Pad weight gain by 1 gm

  33. Laboratory examinations • Urinalysis & urine culture- evidence of pus cells and bacteria in urine • Blood chemistry, blood sugar- azotemia, diabetes may cause polyuria, detrusor underactivity • KUB- a lower ureteral stone cause storage symptoms and empty symptoms

  34. Office Urodynamic Study • Uroflowmetry • Postvoid residual urine (PVR) • Cystometry with or without EMG • Potassium chloride test

  35. Uroflowmetry – Parameters

  36. Uroflowmetry – Intermittent flow

  37. Uroflowmetry –Straining flow

  38. Uroflowmetry –Low contractility

  39. Uroflowmetry –Obstructive flow

  40. Voiding Cystometry (Pressure flow study) • Filling cystometry cannot diagnose 24% of the patients with LUTS • Patients with voiding symptoms should undergo pressure flow study • Detrusor underactivity, bladder outlet obstruction, postvoid detrusor contraction, occult neuropathic detrusor overactivity

  41. Multi-channel Pressure Flow Study

  42. Relationship of Pressure & Flow

  43. Cystometry –after contraction

  44. Pressure flow study –DHIC

  45. Pressure flow study–Cystocele and BOO in woman

  46. Low contractility & low flow

  47. SCI & NVD –Type 1 DESD

  48. DI & voluntary PFM contraction

  49. Idiopathic detrusor overactivity in Storage phase

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