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
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)

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 dribble Residual 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
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

49. Postprostatectomy Urethral stricture

50. Urethral stricture