clinical assessment of lower urinary tract dysfunction hann-chorng kuo department of urology...
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Clinical Assessment of Lower Urinary Tract
Dysfunction
Hann-Chorng KuoDepartment of UrologyBuddhist Tzu Chi General Hospital
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Lower Urinary Tract Symptoms
Storage symptoms Frequency, Urgency, Nocturia Incontinence Suprapubic fullness and pain Empty symptoms Hesitancy, Intermittency, Small caliber, Dysuria, Residual urine sensation
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Urinary Incontinence Stress incontinence Urge incontinence Total incontinence Overflow incontinence Giggle incontinence Nocturnal enuresis
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Voiding Diary
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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
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Sensory dermatomes of perineum & extremities
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Clinical investigation of Lower urinary tract dysfunction
Urethral sounding Prostatic fluid examination Ultrasound examination Pad weighing test Cystourethroscopy Potassium chloride test
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Urethral Sounding
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Prostatic Massage andExpressed prostatic secretion
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Prostatitis Acute bacterial prostatitis Chronic bacterial prostatitis Abacterial prostatitis Prostatodynia (perineal pain syndrome) Using available symptom score or index
to assess symptomatology
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Symptomatology of Prostatitis Pelvic pain syndrome Disturbance in urination Disturbance in sexual function Depression Disturbance in intimate relationships
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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)
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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
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Prostatic Configuration in Transrectal ultrasound
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Prostatic enlargement Benign prostatic enlargement Prostatic cancer
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Correlation of TZI with Prostate volume & Qmax
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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
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Urethral Ultrasound in SUI and Frequency Urgency Syndrome
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Measurement of Bladder Neck Hypermobility in Frequency Urgency Syndrome in Women
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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
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Bladder Neck Incompetence in Frequency Urgency Syndrome
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Bladder Neck Incompetence and Hypermobility
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Measurement of External Sphincter Volume in SUI
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Different Urethral Structure
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Urethral Ultrasound in ISD and Cystocele
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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
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Female Urethral Incompetence
Bladder neck incompetence Urethral incompetence
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Assessing Pubococcygeus muscle function Inspection Perineum buldging downward Vaginal introitus opens Anus everted Performing straining or coughing Contraction of pubococcygeus m.
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Cystocele and Prolapse
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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
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Voluntary Contraction of Pelvic Floor Muscles
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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
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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
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Office Urodynamic Study Uroflowmetry Postvoid residual urine (PVR) Cystometry with or without EMG Potassium chloride test
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Uroflowmetry – Parameters
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Uroflowmetry – Intermittent flow
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Uroflowmetry – Straining flow
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Uroflowmetry – Low contractility
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Uroflowmetry – Obstructive flow
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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
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Multi-channel Pressure Flow Study
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Relationship of Pressure & Flow
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Cystometry – after contraction
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Pressure flow study – DHIC
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Pressure flow study–Cystocele and BOO in woman
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Low contractility & low flow
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SCI & NVD – Type 1 DESD
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DI & voluntary PFM contraction
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Idiopathic detrusor overactivity in Storage phase
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Detrusor overactivityin contracted bladder
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Neurogenic detrusor overactivity in CVA patient
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Provoked Detrusor overactivity in storage phase
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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%
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Increased Bladder sensation after KCl infusion
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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
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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