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 Empty symptoms- hesitancy, dysuria, intermittency, small caliber of urine, terminal dribble, residual sensation Painful 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 years Qmax Voided volume CQmax 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 Detrusor overactivity 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 Bladder outlet obstruction 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 Detrusor overactivity Hypersensitive bladder Bladder outlet obstruction 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 Bladder outlet obstruction 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 dribble Residual 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 DI Urge 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, ml PreoperativQmax, 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