Transcript Clinical Assessment of Lower Urinary Tract Dysfunction

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)
Qmax ≥ 15
Voided volume (mL)
-1
≥250
0
10 < Qmax < 15
0
<250
1
Qmax ≤ 10
1 TPV (mL)
Flow pattern
≤20
0
>20 but <40
1
≥40
2
Normal
-1
Compressive obstructive
1
Constrictive obstructive
2 TZI
Intermittent
2
Residual urine (mL)
≤0.3
>03 but 0.5
1
≥0.5
2
<100
0
≥ 100
2 Median lobe enlargement
Key:Abbreviation as in Tables I and Ⅲ
-1
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
NS
NS
NS
P<0.05
P0.05
P<0.05
ANOVA
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
N
Cross-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
(9)
75.7 ±23.1
37.9±12.2
37.8±22.8
A vs B:P=0.005
NS
A vs B: P=0.001
Patients
Cystocele*
Statistics
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 sugarazotemia, 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
