Clinical Assessment of Lower Urinary Tract

Dysfunction

Hann-Chorng KuoDepartment of UrologyBuddhist Tzu Chi General Hospital

Lower Urinary Tract Symptoms

Storage symptoms Frequency, Urgency, Nocturia Incontinence Suprapubic fullness and pain Empty symptoms Hesitancy, Intermittency, Small caliber, Dysuria, Residual urine sensation

Urinary Incontinence Stress incontinence Urge incontinence Total incontinence Overflow incontinence Giggle incontinence Nocturnal enuresis

Voiding Diary

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

Sensory dermatomes of perineum & extremities

Clinical investigation of Lower urinary tract dysfunction

Urethral sounding Prostatic fluid examination Ultrasound examination Pad weighing test Cystourethroscopy Potassium chloride test

Urethral Sounding

Prostatic Massage andExpressed prostatic secretion

Prostatitis Acute bacterial prostatitis Chronic bacterial prostatitis Abacterial prostatitis Prostatodynia (perineal pain syndrome) Using available symptom score or index

to assess symptomatology

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

Diagnosis of Prostatitis Expressed prostatic secretions show nu

merous 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)

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

Prostatic Configuration in Transrectal ultrasound

Prostatic enlargement Benign prostatic enlargement Prostatic cancer

Correlation of TZI with Prostate volume & Qmax

Clinical Prostate ScoreUroflowmetry (mL/s) Voided volume (mL)

Qmax ≥ 15 -1 ≥250 0

10 < Qmax < 15 0 <250 1

Qmax ≤ 10 1 TPV (mL)

Flow pattern ≤20 0

Normal -1 >20 but <40 1

Compressive obstructive 1 ≥40 2

Constrictive obstructive 2 TZI

Intermittent 2 ≤0.3 -1

Residual urine (mL) >03 but 0.5 1

<100 0 ≥0.5 2

≥ 100 2 Median lobe enlargement

Key:Abbreviation as in Tables I and Ⅲ

Presence 2

Absence 0

Urethral Ultrasound in SUI and Frequency Urgency Syndrome

Measurement of Bladder Neck Hypermobility in Frequency Urgency Syndrome in Women

Bladder Neck Descent in Women with LUTS

N PVL(cm) PVA(degrees)

Resting Straining Increment Resting Straining Increment*

SUI 191 2.05±0.69 2.20±0.48 0.15±0.58 34.6±23.4 66.5±28.6 31.9±19.9

FUS 78 2.05±0.39 2.11±0.43 0.06±0.20 18.4±19.2 37.4±29.1 19.0±17.6

ASYM 27 2.08±0.33 2.13±0.31 0.05±0.20 8.2±10.6 20.7±23.2 12.6±16.7

ANOVA NS NS NS P<0.05 P0.05 P<0.05

Bladder Neck Incompetence in Frequency Urgency Syndrome

Bladder Neck Incompetence and Hypermobility

Measurement of External Sphincter Volume in SUI

Different Urethral Structure

Urethral Ultrasound in ISD and Cystocele

Striated Urethral Sphincter in SUI and Cystocele

Patients NCross-Sectional

Area(mm2)

Smooth Muscle Component

(mm2)

Striated Muscle Component

(mm2)

A.Non-SUI 51 104.4 ±35.6 46.1±22.5 58.3±27.3

B.SUI 60 86.7 ±29.9 43.9±19.0 42.8±20.7

Cystocele* (9) 75.7 ±23.1 37.9±12.2 37.8±22.8

Statistics A vs B:P=0.005 NS A vs B: P=0.001

Female Urethral Incompetence

Bladder neck incompetence Urethral incompetence

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

Cystocele and Prolapse

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 volunta

ry contraction function

Voluntary Contraction of Pelvic Floor Muscles

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

Laboratory examinations Urinalysis & urine culture- evidence of p

us 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

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

Uroflowmetry – Parameters

Uroflowmetry – Intermittent flow

Uroflowmetry – Straining flow

Uroflowmetry – Low contractility

Uroflowmetry – Obstructive flow

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 o

bstruction, postvoid detrusor contraction, occult neuropathic detrusor overactivity

Multi-channel Pressure Flow Study

Relationship of Pressure & Flow

Cystometry – after contraction

Pressure flow study – DHIC

Pressure flow study–Cystocele and BOO in woman

Low contractility & low flow

SCI & NVD – Type 1 DESD

DI & voluntary PFM contraction

Idiopathic detrusor overactivity in Storage phase

Detrusor overactivityin contracted bladder

Neurogenic detrusor overactivity in CVA patient

Provoked Detrusor overactivity in storage phase

Potassium Test A test for urothelium leak syndrome 40mL of 0.4M KCL was infused into the

bladder following normal saline Record the pain scale after KCl test: nil,

burning, tingling, dull pain, sharp pain, urgency

Acute and irradiation cystitis: 100% Interstitial cystitis: 80%

Increased Bladder sensation after KCl infusion

Potassium sensitivity test in women with frequency urgency and IC

In 196 women with frequency urgency and/or pain, 138 had a positive KCl test (70.4%)

128 women with a positive KCl test, 44 (34.4%)proven IC and 84 non-IC

A positive KCl test indicates urothelial leak but not characteristic IC, nor can bladder pain predict IC

Postvoid Residual Volume Estimated immediately after voiding Transabdominal ultrasound provides a

ccurate volume estimation Diuresis may falsely increase PVR Patient might not void completely due t

o embarrassment Do not forget PVR in clinical assessmen

t of LUTS