Correlation of intravesical prostatic protrusion with bladder outlet obstruction

OBJECTIVES: To determine the effect of intravesical protrusion of the prostate (IPP, graded I to III) on lower urinary tract function, by correlating it with the results of a pressure-flow study. PATIENTS AND METHODS: In a prospective study men (aged> 50 years) with lower urinary tract symptoms were initially evaluated as recommended by the International Consultation on Benign Prostatic Hyperplasia, together with the IPP and prostate volume, as measured by transabdominal ultrasonography. These variables were then correlated with the results from a pressure-flow study. RESULTS: The IPP was a statistically significant predictor (P < 0.001) of bladder outlet obstruction (BOO) compared with other variables in the initial evaluation. In all, 125 patients had significant BOO, defined as a BOO index of> 40. Of these men, 94 had grade III and 30 had grade I-II IPP. Seventy-five patients had a BOO index of < 40; 69 had grade I-II and six grade III IPP. In patients with BOO confirmed on the pressure-flow study, grade III IPP was associated with a higher BOO index than was grade I-II (P < 0.001). CONCLUSION: The IPP assessed by transabdominal ultrasonography is a better and more reliable predictor of BOO than the other variables assessed.     

Is the short‐term outcome of transurethral resection of the prostate affected by preoperative degree of bladder outlet obstruction,status of detrusor contractility or detrusor overactivity?

AIM: The aim of this study was to investigate whether the preoperative degree of bladder outlet obstruction (BOO), detrusor underactivity (DUA) or detrusor overactivity (DO) affected the short-term outcome of transurethral resection of the prostate (TURP) for patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). METHODS: Ninety-two patients with LUTS/BPH aged 50 years or older who were considered to be appropriate candidates for TURP were included in this study. Pressure-flow study and filling cystometry were performed to determine BOO, DUA and DO before TURP. The efficacy of TURP was determined at 3 months after surgery using the efficacy criteria for treatment of BPH assessed by the International Prostate Symptom Score, QOL index, maximum flow rate and postvoid residual urine volume. RESULTS: On preoperative urodynamics, 60%, 40% and 48% of patients showed BOO, DUA and DO, respectively. After TURP, 76% showed 'excellent' or 'good' overall efficacy, whereas only 13% fell into the 'poor/worse' category. The efficacy was higher as the preoperative degree of BOO worsened. In contrast, neither DO nor DUA influenced the outcome of TURP. However, the surgery likely provided unfavorable efficacy for patients having DO but not BOO. Only 20% of the patients who had both DO and DUA but did not have BOO achieved efficacy. CONCLUSIONS: Transurethral resection of the prostate is an effective surgical procedure for treatment of LUTS/BPH, especially for patients with BOO. DUA may not be a contraindication for TURP. The surgical indication should be circumspect for patients who do not have BOO but have DO.     

Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction

Study Type – Symptom prevalence (prospective cohort) Level of Evidence 1b What’s known on the subject? and What does the study add? Few prevalence studies used current ICS LUTS symptom definitions and to our knowledge no studies exist that estimate total worldwide prevalence of reported LUTS symptoms. One of the primary goals of this analysis was to estimate current and future worldwide prevalence of LUTS among adults. Our estimation model suggests that LUTS are highly prevalent worldwide, with an increasing burden predicted over time.

OBJECTIVE

? To estimate and predict worldwide and regional prevalence of lower urinary tract symptoms (LUTS), overactive bladder (OAB), urinary incontinence (UI) and LUTS suggestive of bladder outlet obstruction (LUTS/BOO) in 2008, 2013 and 2018 based on current International Continence Society symptom definitions in adults aged ≥20 years.

PATIENTS AND METHODS

? Numbers and prevalence of individuals affected by each condition were calculated with an estimation model using gender‐ and age‐stratified prevalence data from the EPIC study along with gender‐ and age‐stratified worldwide and regional population estimates from the US Census Bureau International Data Base.

RESULTS

? An estimated 45.2%, 10.7%, 8.2% and 21.5% of the 2008 worldwide population (4.3 billion) was affected by at least one LUTS, OAB, UI and LUTS/BOO, respectively. By 2018, an estimated 2.3 billion individuals will be affected by at least one LUTS (18.4% increase), 546 million by OAB (20.1%), 423 million by UI (21.6%) and 1.1 billion by LUTS/BOO (18.5%). ? The regional burden of these conditions is estimated to be greatest in Asia, with numbers of affected individuals expected to increase most in the developing regions of Africa (30.1–31.1% increase across conditions, 2008–2018), South America (20.5–24.7%) and Asia (19.7–24.4%).

CONCLUSIONS

? This model suggests that LUTS, OAB, UI and LUTS/BOO are highly prevalent conditions worldwide. Numbers of affected individuals are projected to increase with time, with the greatest increase in burden anticipated in developing regions. ? There are important worldwide public‐health and clinical management implications to be considered over the next decade to effectively prevent and manage these conditions.     

The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic follow-up of untreated bladder outlet obstruction

OBJECTIVES: To assess the long-term outcomes of untreated bladder outlet obstruction (BOO), assuming that, if there is little or no deterioration, a conservative approach to management is justified, as there is little information on the natural history of untreated BOO and lower urinary tract symptoms (LUTS) in men, and studies to date suggest that neither BOO nor LUTS inevitably progress to a stage at which prostatectomy is required. PATIENTS AND METHODS: Men aged >45 years who were investigated in our department between 1972 and 1986, diagnosed with BOO, and who initially opted for no specific treatment were invited for repeat symptomatic and urodynamic evaluation. Identical methods of assessment were used, allowing results to be compared directly. RESULTS: In all, 1068 men were initially diagnosed with BOO; 428 (40%) of these died. Of the 170 men who initially opted for a conservative approach and attended for repeat assessment, 141 (83%) remained untreated, with a mean follow-up of 13.9 years. The only significant urodynamic changes were a reduction in detrusor contractility and an increased prevalence of detrusor overactivity. Most patients reported no change in their symptoms but a significant minority experienced a gradual deterioration. Of the 29 men in whom the conservative approach failed, 22 proceeded to surgery for LUTS, and seven for acute urinary retention. CONCLUSIONS: Patients with untreated BOO do not significantly deteriorate urodynamically in the long term, with only a minority deteriorating symptomatically. These findings justify a conservative approach to men with LUTS associated with BOO.     

Effects of chronic treatment with vardenafil,a phosphodiesterase 5 inhibitor,on female rat bladder in a partial bladder outlet obstruction model

OBJECTIVES

To investigate whether vardenafil, a phosphodiesterase 5 (PDE‐5) inhibitor, would protect the bladder from decompensatory changes in a 4‐week rat bladder outlet obstruction (BOO) model, as evidence has been accumulating that PDE‐5 inhibitors improve lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

In all, 50 12‐week‐old female Sprague‐Dawley rats were divided into five equal groups; group 1, sham operated vehicle control rats; group 2, BOO vehicle rats; group 3–5, BOO rats given oral vardenafil at 5, 20, 80 mg/L, respectively. Vardenafil was given in drinking water from the day of surgery. At 4‐weeks after the introduction of BOO, vardenafil was washed‐out by giving water for 24–48 h, and then the bladder was excised and dissected into four longitudinal strips for isometric organ‐bath assay. Contractile responses of bladder strips to electrical field stimulation (EFS), carbachol and KCl was determined for each group.

RESULTS

BOO induced a significant increase in bladder weight in group 2 compared with group 1. Bladder weights of groups 3–5 were not significantly different from that of group 2. The contractile forces in response to EFS, carbachol and KCl in group 2 were 30.7–51.7% of those in group 1. Vardenafil treatment in groups 3–5 generally did not block the BOO‐induced reduction of contractile force in the bladder strips. However, treatment with a high dose of vardenafil resulted in a significant increase in the contractile response to carbachol (78.4% group 5 vs 51.7% group 2).

CONCLUSION

Chronic treatment with a high dose of vardenafil protected the rat bladder from BOO‐induced contractile dysfunction to carbachol.     

Effect of bladder outlet obstruction on detrusor smooth muscle cell: an in vitro study

BACKGROUND: Although relieving obstruction is generally curative on bladder outlet obstruction (BOO), bladder dysfunction persists in some patients. Repetitive stretch and relaxation applied to cultured bladder smooth muscle (SM) cells in vitro have been used to mimic increases in urodynamic load experienced by the detrusor muscle under conditions of BOO. We first clarified the relationship between phenotype transformation and biomechanical properties of detrusor smooth muscle cell (DSMC) subjected to the cyclic mechanical stretch. MATERIALS AND METHODS: Cultured rat DSMC were grown on collagen-coated silicone membranes and subjected to continuous cycles of stretch-relaxation. All experiments were performed on cells between passages 2 and 4. Each cycle consists of 5 seconds of stretch and 5 seconds of relaxation. The computer controlled vacuum induced 10% (1), 20% (2), and 30% (3) maximum elongation of the plate membrane at different designed pressures. The deoxyribonucleic acid synthesis rate was assessed by performing tritiated thymidine incorporation assay. The expression of SM-alpha-actin and proliferation of DSMC were analyzed by immunofluorescent assay and flow cytometry. The image analysis and micropipet aspiration systems were used to investigate the single cell contraction and viscoelasticity. Using the 3-element standard linear solid model, the elastic modulus K(1), K(2), and viscoelastic coefficient mu were determined, which show the passive deformation ability of detrusor cells. RESULTS: As the basic structural changes to mechanical stretch, DSMC undergo phenotypic modulation from their normal contractile phenotype to a "synthetic" phenotype: the DSMC become more proliferative and the actin less organized along the cell's long axis. The cell proliferation index of control and stretched group (10%, 20%, 30% elongation) are 0.24, 0.43, 0.58, and 0.65, respectively. The actin filaments in unstimulated cells were evident and orientated along the major axis of the cell. After mechanical stretch, the well-spread filaments changed their orientation. The function, such as contraction, and viscoelasticity of a single DSMC subjected to stretch both decreased significantly compared with control. The maximum contractile velocity and maximum cell length shortening rate of group 3 (30% elongation) showed significant decreases compared with unstretched control (P < 0.01). K(1) and K(2) were decreased with the increase of mechanical overload. However, there was no statistic difference between groups 2 and 3. CONCLUSIONS: Functional abnormalitie of BOO have the structural basis: phenotype transformation (i.e., remodeling) of the detrusor cells. Cyclic stretch and relaxation applied to DSMC in vitro can be used to model increases in urodynamic load experienced by the bladder detrusor muscle under conditions of BOO. Phenotype transformation is the structural basis of functional changes of DSMC subjected to periodic overload mechanical stretch.     

经尿道双极等离子前列腺电切术联合内分泌治疗晚期前列腺癌并膀胱出口梗阻

目的：探讨经尿道双极等离子前列腺电切术（TuPKVP）联合内分泌治疗在晚期前列腺癌并膀胱出口梗阻（BOO）治疗中的应用。方法：对38例诊断为晚期前列腺癌合并BOO的患者行TUPKVP术及内分泌治疗。结果：本组38例患者手术均获得成功,术后并发症少,术后3个月IPSS评分、QOL评分、剩余尿量、最大尿流率及PSA较术前均有明显改善,差异有统计学意义（P〈0．01）。结论：TUPKVP联合内分泌治疗可有效缓解晚期前列腺癌所致的膀胱出口梗阻,提高患者生存质量。     

经尿道前列腺切除术治疗晚期激素非依赖性前列腺癌可行性分析

目的:探讨经尿道前列腺切除术(TURP)在晚期前列腺癌并下尿路症状(LUTS)治疗中的作用。方法:对2004～2009年诊断为晚期前列腺癌合并LUTS的43例患者进行总结,分析TURP术前及术后3、12个月患者的IPSS评分、最大尿流率、以及疾病相关危险因素。结果:术后3个月,非雄激素依赖性前列腺癌患者的IPSS[(9.58±0.33)分]、最大尿流率[(8.96±0.47)ml/s]与术前[(19.60±0.41)分、(4.93±0.68)ml/s]存在显著差异(P<0.05)。随访12个月后IPSS[(15.73±0.66)分]、最大尿流率[(15.67±0.44)ml/s]与术前相比无显著性差异。多因素分析提示术前表现为急性尿潴留的患者术后预后相对较好,激素非依赖前列腺癌患者预后差。结论:TURP治疗晚期激素非依赖前列腺癌合并LUTS的患者,在短期内可以迅速降低IPSS评分,改善生活质量;远期效果不理想。同时,手术本身也可能带来相关并发症,降低患者生存质量。     

女性膀胱颈口梗阻33例诊治分析

目的 探讨女性膀胱颈口梗阻（FBOO）的诊断依据和手术适应证.方法 回顾性分析33例FBOO患者的临床资料.应用尿动力学检查、膀胱镜、B超,从门诊难以用药物治疗的反复下尿路刺激症状女性患者中,确诊出FBOO患者33例,用奥林帕斯等离子电切镜行膀胱颈后唇切除,5点、7点、12点切开.平均手术时间20 min,术后留置尿管2 d左右.结果 手术均获成功,无1例并发症.30例术后效果满意,3例术后效果不满意.结论 把握好女性膀胱颈口梗阻诊断依据、产生膀胱颈口梗阻的原因及手术适应证是取得手术满意疗效的关键.     

前列腺增生致膀胱出口梗阻后逼尿肌功能改变对尿动力学参数的影响

目的探讨良性前列腺增生症（BPH）致膀胱出口梗阻（BOO）后逼尿肌功能改变对尿动力学参数的影响。方法109例具有完整尿动力学结果的BPH患者根据有无B00分为梗阻组和非梗阻组;梗阻组根据梗阻级别分Ⅲ、Ⅳ、Ⅴ、Ⅵ级4组;逼尿肌收缩力分为逼尿肌收缩力减弱（DCA）与收缩力正常组;逼尿肌不稳定（DI）分DI与非DI;膀胱顺应性（BC）分高、正常、低顺应性三组;28例患者行经尿道前列腺切除术（TURP）术前及术后尿动力参数对比。结果BOO组的前列腺体积（PV）、国际前列腺症状评分（IPSS）、DI、急性尿潴留（AUR）发生率明显高于非BOO组（P〈O．05）;BOO组的最大尿流率（Qmax）、BC值、DCA发生率明显低于非BOO组（P〈0．05）;逼尿肌收缩力正常组的残余尿（RV）与BC值明显低于减弱组（P〈0．05）,而BOO和DI的发生率明显高于减弱组（P〈0．01）;DI组的年龄、BC值及DCA的发生率明显低于非DI组（P〈0．05）,而B00级别和AUR的发生率明显高于非DI组（P〈0．01）;低BC组IPSS、BOO级别、AUR发生率明显高于正常及高BC组（P〈0．05）,而DCA发生率明显低于正常及高BC组（P〈0．01）;术后Qmax、BC值较术前明显升高（P〈0．05）,RV、IPSS、DI发生率较术前明显减小（P〈0．01）。结论①BOO常与低顺应性膀胱、DI、AUR合并存在;②IPSS评分不能提示是否存在DI,DI的存在不影响IPSS评分;③TURP是治疗前列腺增生的金标准;④尿动力检查能全面了解有无BOO及BOO所致逼尿肌功能改变情况,对BPH的临床鉴别诊断、预后估计及选择恰当治疗方案都具有重要意义。     

Urgency of micturition and detrusor contractility in men with prostatic obstruction and overactive bladders

AIMS: In men with prostatic obstruction and detrusor overactivity (DO), to ascertain whether urgency of micturition affects bladder contractility. MATERIALS AND METHODS: We urodynamically assessed five groups of 20 men each who had bladder outflow obstruction (BOO) from benign prostatic enlargement-Groups 1 (with no DO and no urgency), 2 (with DO and no urgency), 3A (with DO and moderate urgency), 3B (with DO and severe urgency), and 4 (with DO, severe urgency and chronic ischemic cerebral lesions). Urgency was graded as moderate or severe by the ability to avert an urgent void at cystometry for > or =2 or <2 min, respectively. BOO was assessed by the "Abrams-Griffiths number" (AG) and bladder contractility by the parameters PIP and WF(max). RESULTS: AG did not differ significantly in Groups 2, 3A, and 3B, proved higher in such groups than in Group 1, and was nearly the same in Groups 1 and 4. PIP and WF(max) were significantly higher in Groups 2, 3A, and 3B than in Groups 1 and 4, had the highest levels in Group 3B, and did not differ significantly in Groups 1-4 and 2-3A. CONCLUSIONS: In DO patients with prostatic obstruction there seems to be a DO-related facilitation of bladder contractility. In the same patients, severe urgency of micturition might over-amplify (i.e., enhance a DO-related facilitation of) bladder contractility, provided there are no neurogenic (chronic ischemic cerebral) lesions.     

经尿道前列腺切除联合去势治疗伴膀胱出口梗阻的晚期前列腺癌

目的探讨经尿道前列腺切除术（TURP）联合去势治疗伴膀胱出口梗阻（BOO）的晚期前列腺癌的临床疗效。方法回顾性分析2001年6月~2007年8月我院采用经尿道前列腺切除术与双侧睾丸切除术及内分泌治疗26例晚期前列腺癌患者的临床资料。结果经尿道前列腺切除手术时间35～125min，平均75min，切除前列腺重量15～55g，平均26g，出血量40～200mL，平均90mL，均未输血；随访2～5年，2年内死亡2例．5年内死亡10例，9例生存至今，失访5例。结论对于全身情况较差、伴有膀胱出口梗阻的晚期前列腺癌患者，经尿道前列腺切除术联合去势治疗是安全有效的方法之一。     

Age and bladder outlet obstruction are independently associated with detrusor overactivity in patients with benign prostatic hyperplasia

Background

Detrusor overactivity is one known cause of lower urinary tract symptoms and has been linked to bladder storage symptoms (urgency, frequency, or urge incontinence).

Objective

To determine clinical and urodynamic parameters associated with detrusor overactivity in patients with suspected benign prostatic hyperplasia.

Design, Setting, and Participants

During 1993–2003, urodynamic investigations were performed in patients aged 40 yr or older and with lower urinary tract symptoms, benign prostatic enlargement, and/or suspicion of bladder outlet obstruction (maximum flow rate < 15 ml/s or postvoid residual urine > 50 ml).

Measurements

Detrusor overactivity was defined according to the new International Continence Society classification (2002) as involuntary detrusor contractions during cystometry, which may be spontaneous or provoked, regardless of amplitude. The Schäfer algorithm was used to determine bladder outlet obstruction.

Results

In total, 1418 men were investigated (median age: 63 yr) of whom 864 men (60.9%) had detrusor overactivity. In univariate analysis, men with detrusor overactivity were significantly older, more obstructed, had larger prostates, higher irritative International Prostate Symptoms Score subscores, a lower voiding volume at free uroflowmetry, and a lower bladder capacity at cystometry. The prevalence of detrusor overactivity rose continuously with increasing bladder outlet obstruction grade. Multivariate analysis showed that only age and bladder outlet obstruction grade were independently associated with detrusor overactivity. After age adjustment, the odds ratios of detrusor overactivity compared to Schäfer class 0 were 1.2 for class I, 1.4 for class II, 1.9 for class III, 2.5 for class IV, 3.4 for class V, and 4.7 for class VI.

Conclusions

In patients with clinical benign prostatic hyperplasia, detrusor overactivity is independently associated with age and bladder outlet obstruction. The probability of detrusor overactivity rises with increasing age and bladder outlet obstruction grade.     

Clinical diagnosis of bladder outlet obstruction in men with lower urinary tract symptoms: reliability of commonly measured parameters and the role of idiopathic detrusor overactivity

AIMS: There is no generally accepted consensus how to evaluate patients with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO). We have tried to determine whether the most frequently used objective variables as prostate volume, IPS-score, maximum flow rate, residual urine volume, functional bladder capacity, and pressure-flow study are reliable for diagnosis of BOO and we investigated the influence of idiopathic detrusor overactivity (IDO) on this condition. METHODS: A total of 153 men with LUTS and suspected BOO were systematically examined with routine investigation including digital rectal examination, transrectal ultrasound (TRUS), post-void residual urine volume measurement, uroflowmetry, and pressure-flow study. All patients completed IPS-score. Patients were divided into groups based on Sch?fer's grade of obstruction and incidence of IDO and clinical and urodynamical variables were compared. RESULTS: At baseline, 45.8% of the patients were urodynamically moderately obstructed and 37.9% were found to be severely obstructed. The grade of obstruction did not correlate with age. Prostate volume, post-void residual volume (PVR), and maximum flow rate correlated significantly with the degree of obstruction. The mean IPS-score remained almost unchanged throughout all obstruction groups. The incidence of IDO was 40.5% and increased from 16% in the minor obstruction group to 38.6% and 53.4% in the moderate and severe obstruction group, respectively. The patients with IDO were older, had larger prostates and were more obstructed. There was no impact of IDO on symptomatology of BOO. CONCLUSIONS: These data indicate that IPS-score does not achieve sufficient diagnostic accuracy and its role in the assessment of BOO is limited. The grade of obstruction is more related to prostate volume, PVR, and maximum flow rate. BOO and IDO seem to be related and have numerous mutual interactions.