male luts - hkcs workshop/case discussion...o video urodynamics study was arranged bladder diary vud...
TRANSCRIPT
Male LUTS
Dr. Brian Ho Division of Urology
Department of Surgery
Queen Mary Hospital
Mr. Siu M/78
O Known to have HT & DM since 2008 on follow
up with General Out-Patient Clinic (GOPC)
O Noticed to have worsening RFT in GOPC
O From Cr 191 umol/L to Cr 262
O MSU: normal
O HbA1c 6.1% (static)
O Good drug compliance
O No active complaints from patient
Mr. Siu M/78
Past Medical History:
O HT
O DM, previously on diamicron but switched to insulin in view of deteriorating RFT
O Alzheimer’s disease
O Hyperlipidemia
O Vit B12 deficiency
O Currently living in an old age home
Mr. Siu M/78
USG Urinary
system
(May 2014)
Mr. Siu M/78
O USG (May 2014):
O Marked hydronephrosis and hydroureter
(right > left)
O Renal parenchymal disease & right cortical
thinning
O Enlarged prostate
O Thus, patient was admitted to QMH and
urology was consulted
Mr. Siu M/78
O Foley’s catheter had been inserted
O 1st cath volume 1450mL
O Post-obstructive diuresis seen
O DRE: 40gm prostate, no nodules, median
groove preserved
O Creatinine improved from 266umol/L to
164umol/L after Foley’s catheterization
Mr. Siu M/78
USG Urinary
system
(June 2014)
Mr. Siu M/78
Mr. Siu M/78
Mr. Siu M/78
Mr. Siu M/78
Filling Phase (50mL/min):
O 1st desire 343mL, normal desire 390mL, strong desire 473mL
O Terminal overactive detrusor
O Borderline compliance (13cmH2O at 322mL)
O ∆24.8mL/cmH2O
O Relatively smooth bladder outline
O No VUR
O MCC at 506mL due to urgency
Mr. Siu M/78
Voiding phase:
O Volitional voiding
O Bladder neck & prostatic urethra remains closed
O Voided volume 98mL
O Pdet 72cmH2O at Qmax 3.5mL/s
O BOOI = 65
O BCI = 89.5
O Residual Urine: 400mL
Mr. Siu M/78
ICS Nomogram
O Derived from the Abrams-Griffiths nomogram
O Determines whether there is bladder outflow obstruction
O May predict success rate of TURP
O Robertson et al (1996) O 79% of obstructed pts had subjective good outcome
O 40% of non-obstructed pts had subjective good outcome
O Seo et al (2006) O 93% of obstructed pts had successful outcome
O 64% of non-obstructed pts had successful outcome O Success defined as Qmax > 15mL/s, RU <100mL, or >50% reduction in IPSS
Bladder Contractility
O ICS classification (2002)
O Normal
O Under-activity: a contraction of reduced
strength and/or duration, resulting in
prolonged bladder emptying and/or failure to
achieve complete bladder emptying within a
normal time span
Bladder Contractility Index
O Derived from Schafer’s
normogram (1995)
BCI = Pdet@Qmax + 5 x Qmax
O >150 = strong
O 100-150 = normal
O <100 = weak
Bladder Contractility Index
O Seki et al (2006 J Urol)
O 88 pts with detrusor underactivity (BCI ~85)
with 12 months follow up
O Patients with underactivity generally had poor
outcomes after TURP when compared to
general male population
O IPSS improvement of 48% (vs 70-80%)
O Qmax improvement of 64% (vs 115%)
Mr. Chau M/66
Patient seen in January 2014
O Referred from Dept. of Medicine for lower urinary tract symptoms (LUTS) for 6 months
O Chief complaint is frequency of urination O Daytime voiding ranges from every 30 – 60mins
O No urgency
O Nocturia 2-3x / night
O Fair stream
O Occasional intermittency
O Involuntary leakage of urine on stress and occasionally on prolonged standing
O Use of tissue paper for protection during daytime
O Nocturnal enuresis requiring diapers at night time
Mr. Chau M/66
Past Medical History
O Chronic rheumatic heart disease on warfarin
O History of right inguinal hernia repair
O Ca rectum with laparoscopic LAR + loop ileostomy in June 2013
O Pathology: pT3N1
O Required adjuvant chemotherapy and completed in Dec 2013
O PET-CT (Dec 2013): no local recurrence or distant metastases. No hydronephrosis or urinary stones.
Mr. Chau M/66
Physical Examination
O General examination unremarkable
O Abdomen: soft with ileostomy, no abdominal
mass nor palpable bladder
O DRE: normal anal tone, 25gm prostate,
mildly indurated but no tenderness
Mr. Chau M/66
Investigations
O Complete blood counts normal
O Creatinine 76 umol/L
O Liver function tests normal
O INR 1.4
O PSA 1.2 ng/mL
O MSU: Klebsiella, sensitive to augmentin
(amoxicillin + clavulanic acid)
Mr. Chau M/66
O Patient was given one week course of
augmentin
O However, symptoms persisted
Uroflowmetry
Mr. Chau M/66
O In view of the significant residual urine
despite repeated voiding, patient was taught
clean intermittent self catheterization (CISC)
O Video urodynamics study was arranged
Bladder diary
VUD
VUD
VUD
VUD
Filling phase (initially 50mL/min down to 10mL/min)
O Decreased bladder compliance with Pdet ~18cmH2O at 208mL O 11.6 mL/cmH2O
O Impaired bladder sensation
O Bladder neck and prostatic channel wide open from beginning
O Urine leakage noted since 50mL infused
O ALPP 25 cmH2O
O Bladder capacity 170mL O Unable to further fill up bladder
VUD
Voiding phase
O No sustained detrusor contraction
demonstrated
O Voided 50mL with valsalvar maneuver only
O Pdet 25cmH2O at Qmax of 4.1mL/s
O BOOI 16.8
O BCI 45.5
O Residual urine 100mL
VUD
Impression:
O Intrinsic sphincter deficiency
O Hypocontractile bladder
O Low bladder compliance
Innervation of the Male Lower Urinary Tract
O Sympathetic innervation (T10-L2) travels as hypogastric nerves
O Parasympathetic innervation (S2-4) travels as nervi erigentes to pelvic plexuses
O Somatic component of the parasympathetic (from the Onuf’s nucleus in S2-4) travels with the parasympathetic nerves
O Somatic innervation (S2-4) travels as the pudendal nerve
Summary
O Intrinsic sphincter deficiency
O Peripheral sympathetic + parasympathetic and/or pudendal nerve injury
O Hypocontractile bladder
O Injury to peripheral parasympathetic nerves
O Low bladder compliance
O Partial injury to peripheral parasympathetic nerves
Summary
O Be wary of LUTS in patients who have history
of pelvic surgery
O When faced with atypical clinical
presentations, important to keep alternative
diagnoses in mind
O And to investigate for these alternative
diagnoses
References
1. Abrams, P. “Bladder outlet obstruction index, bladder contractility index
and bladder voiding efficiency: three simple indices to define bladder
voiding function.” BJUI. 1999; 84: 14-15.
2. Osman et al. “Detrusor Underactivity and the Underactive Bladder: A New
Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology,
Aetiology, and Diagnosis.” Eur Urol. 2014; 65: 389-398.
3. Nitti, V. “Pressure Flow Urodynamic Studies: The Gold Standard for
Diagnosing Bladder Outlet Obstruction.” Reviews in Urology. 2005; Vol
7(supplement 6): S14-S21
4. Seki et al. “Predictives regarding outcome after transurethral resection for
prostatic adenoma associated with detrusor underactivity.” J Urol. 2006;
67: 306-310.
5. Abrams, P. Urodynamics. 3rd ed. 2006.
6. Campbell-Walsh Urology. 10th ed. 2012.
7. The Scientific Basis of Urology. 3rd ed. 2010.
8. Netter, F. Atlas of Human Anatomy. 2nd ed. 1997.