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Lower Urinary Tract Symptoms in Men

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, nocturia

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Lower Urinary Tract Symptoms in Men

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  1. Lower Urinary Tract Symptoms in Men Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

  2. Lower Urinary Tract Symptoms in Men • Storage symptoms – increased bladder sensation, frequency, urgency, urge incontinence, nocturia • Empty symptoms- hesitancy, dysuria, intermittency, small caliber of urine, terminal dribble, residual sensation • Painful symptoms- Pelvic pain, perineal pain, urethral pain

  3. 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

  4. IPSS Symptom score

  5. Quality of Life Index

  6. Assessment of LUTS in Men • Uroflowmetry and residual urine • Cystometry and EMG • Prostatic volume and configuration • Pressure flow study • Cystourethroscopy • Neurological examination

  7. Uroflowmetry- Normal

  8. Intermittent Flow

  9. Variability in Uroflow

  10. Qmax and Voided volume

  11. Normal Uroflow rate in Taiwanese Men by Age

  12. Correlation of Qmax and Cqmax with Age in Men

  13. Increased Bladder Sensation • Hypersensitivity • Reduced bladder compliance • Detrusor underactivity • Detrusor overactivity • Postmicturition residual urine sensation

  14. Hypersensitive bladder & Normal bladder outlet

  15. Urgency frequency • Sensory urgency • Detrusor overactivity • Poor relaxation of urethral sphincter • Interstitial cystitis • Bladder outlet obstruction • Neurogenic voiding dysfunction

  16. Sensory urgency • Urinary tract infection • Lower ureteral stone • Foreign body • Surgery of bladder wall • Diuresis • Bladder pathology (carcinoma in situ)

  17. Detrusor Overactivity • Poor cortical perfusion • Post-obstructive overactivity • Ageing process • Idiopathic detrusor overactivity • Low detrusor contractility (DHIC)

  18. CVA & urgency frequency Detrusor overactivity

  19. Postprostatectomy Urgency frequency

  20. Detrusor hyperactivity & Inadequate contractility

  21. 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

  22. Bladder outlet obstruction & Urge incontinence

  23. Idiopathic Detrusor overactivity

  24. Premicturition urge incontinence

  25. 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

  26. Etiology of Nocturia • Detrusor overactivity • Hypersensitive bladder • Bladder outlet obstruction • Nocturnal polyuria • Small bladder capacity

  27. 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

  28. Hesitancy - Poor Urethral Sphincter Relaxation • Learned habit • Chronic prostatitis • Pelvic floor hypertonicity • Occult neuropathy • Increased bladder sensitivity

  29. Hesitancy- Bladder Outlet Obstruction

  30. Dysuria, Small stream- BOO

  31. Prostatic Obstruction

  32. Poor Relaxation of Urethral sphincter

  33. Intermittency of urine • Bladder outlet obstruction • Poor relaxed external sphincter • Increased bladder sensitivity • Detrusor underactivity • Detrusor overactivity & inadequate contractility

  34. Intermittency due to poor relaxation of ES

  35. Urethroscopy - Spastic Urethral Sphincter

  36. Intermittency due to Hypersensitivity & DHIC

  37. Terminal dribbleResidual urine sensation

  38. Postmicturition dribble (detrusor contraction)

  39. 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%)

  40. Normal bladder and normal urethral in VUDS

  41. Poor relaxation of urethral sphincter

  42. Detrusor underactivity without BOO

  43. 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

  44. 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

  45. 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

  46. 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%)

  47. 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 DI • Urge incontinence was found more in DI (66.7%) and DHIC (66.7%) • In 74 incontinent patients, 18 had BOO (24.3%)

  48. Preoperative Prostate volume in post-prostatectomy LUTS

  49. Postprostatectomy Urethral stricture

  50. Urethral stricture

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