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 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 and Expressed 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 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)

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 Score Uroflowmetry (mL/s)Voided volume (mL) Qmax ≥ 15 ≥ < Qmax < 150 <2501 Qmax ≤ 101TPV (mL) Flow pattern ≤200 Normal >20 but <401 Compressive obstructive1 ≥402 Constrictive obstructive2TZI Intermittent2 ≤0.3 Residual urine (mL) >03 but 0.51 <1000 ≥0.52 ≥ 1002Median lobe enlargement Key:Abbreviation as in Tables I and Ⅲ Presence2 Absence0

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 NPVL(cm)PVA(degrees) RestingStrainingIncrementRestingStrainingIncrement* SUI ± ± ± ± ± ±19.9 FUS ± ± ± ± ± ±17.6 ASYM ± ± ± ± ± ±16.7 ANOVA NS P<0.05P0.05P<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 PatientsN Cross-Sectional Area (mm 2 ) Smooth Muscle Component (mm 2 ) Striated Muscle Component (mm 2 ) A.Non-SUI ± ± ±27.3 B.SUI ± ± ±20.7 Cystocele* (9)75.7 ± ± ±22.8 Statistics A vs B: P =0.005NSA 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 voluntary 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 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

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 obstruction, 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 overactivity in 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 accurate volume estimation Diuresis may falsely increase PVR Patient might not void completely due to embarrassment Do not forget PVR in clinical assessment of LUTS