Transurethral resection in women with lower urinary tract symptoms

BACKGROUND: To evaluate the preliminary safety, efficacy and complications of transurethral resection (TUR) in the management of women with lower urinary tract symptoms. METHODS: One hundred and eight women (mean age, 57.6 years) with moderate to severe lower urinary tract symptoms underwent TUR between September 1998 and December 2002. At preoperative baseline, 6 months and 24 months postoperatively, all patients underwent clinical evaluations including the standardized American Urological Association symptom score, peak urine flow, postvoid residual urine volume and quality-of-life assessments. Operative time, catheter time, hospital stay and incidence of side-effects were also recorded. RESULTS: The total mean operative time was 19.25 +/- 6.70 min. The mean catheter time was 26.2 +/- 12.8 h and the mean hospital stay was 2.08 +/- 0.84 days. No patient needed a blood transfusion or experienced hyponatremia. The total storage and voiding symptom scores and quality of life score had improved significantly 6 months after the surgical procedure (P < 0.01). There were little changes in peak flow rate and residual urine volume. Complications of the procedure included urinary tract infections (n = 4) and stress incontinence (n = 3). Two patients later underwent bladder neck suspension procedure. CONCLUSIONS: In this preliminary study, there was significant clinical improvement maintained at all follow-up intervals and the results were not comparable to TUR of the prostate in men with clinical benign prostatic hyperplasia. The risks associated with TUR in women, especially of stress incontinence, are significant. A multicenter clinical trial is currently underway to determine the long-term efficacy and safety of TUR in women.     

The role of urodynamics in the treatment of lower urinary tract symptoms in women

PURPOSE OF REVIEW: Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women. RECENT FINDINGS: Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations. SUMMARY: In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.     

The role of anticholinergic drugs in men with lower urinary tract symptoms

PURPOSE OF REVIEW: Male lower urinary tract symptoms are often attributed to benign prostatic hyperplasia. However, coexisting overactive bladder may be responsible for storage symptoms in a substantial proportion. Treatment of these symptoms with anticholinergic drugs has been considered hazardous in benign prostatic hyperplasia because of concerns that they may predispose to acute urinary retention. We present recent research evidence on the effectiveness and safety of anticholinergics for male lower urinary tract symptoms. RECENT FINDINGS: Two systematic reviews and a large randomized controlled trial recently evaluated anticholinergic drugs in men with lower urinary tract symptoms. These studies provided good evidence that anticholinergics are effective at improving both urodynamic and patient-reported outcomes. Postvoid residual urine volumes and urine flow rates were not significantly affected, and acute urinary retention was rare. SUMMARY: In men with lower urinary tract symptoms treatment may need to be directed at both the prostate and the bladder, and a pragmatic approach therefore seems appropriate. Men presenting with lower urinary tract symptoms should undergo comprehensive clinical evaluation before benign prostatic hyperplasia is treated, if indicated. Should symptoms fail to resolve, addition of anticholinergic drugs may be considered in the absence of significant postvoid residual urine volumes.     

Cystoscopic findings in women with minimal and maximal lower urinary tract symptoms

BackgroundGlomerulations are not specific for interstitial cystitis/bladder pain syndrome (IC/BPS). Controversy exists about whether cystoscopic findings differ between patients with and without lower urinary tract symptoms. We sought to compare the prevalence of cystoscopic findings in women with “no or minimal” urinary symptoms to those with a “high” symptom burden.MethodsThis is a secondary analysis of a prospective cohort study performed at a University Educational Facility. Participants in this study were part of a larger prospective study, in which female patients scheduled to undergo routine gynecologic procedures were all consented for cystoscopy with hydrodistension (CWHD). We defined the “minimally symptomatic group” as those with ≤1 on each of the O’Leary/Sant Interstitial Cystitis Symptom Index (ICSI) subscores and without history of IC/BPS. The “highly symptomatic” cohort of women had composite ICSI score ≥12 and a Burning/Pain subscore of 4 or 5. All were non-smokers.ResultsA total of 84 women underwent CWHD, with 33 having minimal symptoms and 51 being highly symptomatic. The two groups were not statistically different when assessing for ‘any glomerulations’ compared to ‘no glomerulations.’ However, minimally symptomatic women had an eight-fold lower prevalence of significant glomerulations than highly symptomatic women (3.0% minimally symptomatic vs. 23.5% highly symptomatic, P<0.05.)ConclusionsExtensive glomerulations (≥10 in 3 or 4 quadrants) are rare in women with minimal urinary symptoms. These findings contrast with prior limited prospective data which quoted similar incidence of glomerulations in IC/BPS patients and asymptomatic patients. This study highlights the importance of evaluating objective evidence on CWHD and merits further investigation as part of the ongoing conversation regarding the definition of bladder health and pathology     

Vulvar lichen sclerosus in women is associated with lower urinary tract symptoms

Introduction and hypothesis

Lichen sclerosus (LS) is thought to be primarily a disease of postmenopausal women. Little is reported about lower urinary tract symptoms (LUTS) in association with LS. The aims of this study were to evaluate the odds of having LS-associated LUTS and to identify the predominant type of LS-associated bladder dysfunction.

Methods

This was a cross-sectional study with two cohorts investigating the association between LS and LUTS and the predominant type of LS-associated bladder dysfunction.

Results

The odds of LUTS in women with LS were more than four times higher than in women without LS (OR 4.5, 95% CI 2.6–8.0; p < 0.0001). There was no significant difference in the occurrence of LUTS between women who experienced the first LS symptoms before and after the age of 50 years (36% and 53%, respectively, p = 0.14), or in the occurrence of the different types of LUTS between women with and without LS (p = 0.3). The most common type of LUTS was overactive bladder (OAB) in both women with LS (67.3%) and without LS (60%). The most prevalent type of LS-associated LUTS was OAB.

Conclusions

The odds of developing LUTS (self-reported) are four times higher in women with LS than in those without. The predominant type of LUTS in women with and without LS is OAB.

     

前列腺增生症患者C反应蛋白与下尿路症状关系的临床研究

目的探讨前列腺增生患者血C反应蛋白(CRP)与下尿路症状的关系。方法共141例在我院就诊的前列腺增生并有下尿路症状患者,所有患者行IPSS评分、体格检查、最大尿流率测定、尿量、残余尿、前列腺体积、血PSA和CRP测定。计算排尿期评分(IPSS-V)与储尿期评分(IPSS-S)的比值(用IPSS-V/S表示),当IPSS-V/S≥1时给予患者α-受体阻断剂口服,当IPSS-V/S1时给予患者抗毒蕈碱剂口服。比较血CRP水平与各参数之间的关系及服药后各参数的变化。结果所有患者平均血CRP值为(3.43±2.30)mg/L,单因素相关分析提示血CRP与年龄、PSA、排尿量相关,与残余尿、前列腺体积无关,与总IPSS、IPSS-S正相关,与IPSS-V/S负相关。多因素分析血CRP与年龄、总IPSS和IPSS-S相关。IPSS-V/S1患者给予托特罗定治疗3月后血CRP明显下降。结论前列腺增生患者血CRP与储尿期症状及膀胱功能障碍相关,表明慢性炎症是储尿期症状为主的下尿路症状的原因之一。     

Comparison of voiding parameters in men and women with lower urinary tract symptoms

AIM: The aim of this study was to compare voiding parameters by using urodynamic investigations in men and women with lower urinary tract symptoms (LUTS). METHODS: A total of 164 individuals (76 men and 88 women) completed the International Prostate Symptom Score (IPSS) and underwent a detailed urodynamic investigation. Patients were stratified by voiding function, which included bladder voiding efficiency (BVE) of < 80% and of >or= 80%. RESULTS: IPSSs were similar in the men and women except for voiding symptoms for those with a BVE of >or= 80% (12 for men vs. 9 for women, P=0.016). When voiding parameters were compared according to BVE in men and women, respectively, maximum flow rate (Q(max)) (P=0.002), average flow rate (Q(ave)) (P=0.003), voided volume (P=0.037), post-void residual (PVR) (P<0.001), and bladder outlet obstruction index (P=0.016) were different for men with a BVE of < 80% and men with a BVE of >or= 80%. However, for women with a BVE of < 80% or >or= 80%, PVR (P<0.001), detrusor pressure at maximum flow rate (P=0.022), and opening detrusor pressure (P=0.024) were different. CONCLUSIONS: The voiding parameters of women differ from those of men according to voiding function. The present results show that a pressure-flow study may represent a difference according to BVE in women as well as in men. Our findings suggest that opening detrusor pressure in women reflects the urethral and detrusor during voiding phase accurately as detrusor pressure at maximum flow rate does.     

Age-associated changes in detrusor sensory function in women with lower urinary tract symptoms

This study examined changes in bladder sensation which occur with age in women. 1381 women (age range 20–95 years, mean 54.9) with symptoms of lower urinary tract dysfunction underwent urodynamic study. The bladder capacity at which they first became aware of the desire to void was taken as a quantitative measure of bladder sensation. Maximum bladder capacity fell in the eighth and ninth decades (H=95.84, df=7,P=0.00), but by contrast bladder capacity at first desire to void rose progressively in association with age, both in the group as a whole (H=17.13, df=7,P=0.017) and in a subgroup with detrusor instability (n=952, H=15.42, df=7,P=0.032). This rise in capacity points to a decrease in bladder sensation in association with age. This is not due to neurological disease, antimuscarinic drugs or oestrogens, as the median capacity at first desire to void of these three subgroups did not differ significantly from that of the group as a whole.     

Voiding patterns in men and women with lower urinary tract symptoms combined with nocturia

AIM: We evaluated differences between men and women with lower urinary tract symptoms (LUTS) combined with nocturia. METHODS: A total of 71 age-matched female-male pairs (median 58, range 20-81 years) who had moderate to severe LUTS and nocturia of more than once per night were enrolled in this study. RESULTS: In the younger group (<50 years), the International Prostate Symptom Score (I-PSS) results of the sexes were not significantly different. However, although total I-PSS results in the elderly group (> or =50 years) were not significantly different, quality of life index scores for women were higher (P = 0.002). On frequency-volume (FV) charts, mean total daytime voided volume (DVV) was significantly higher in younger men than in younger women (P = 0.017), but the mean nocturnal polyuria index (NPi) for women was higher than that for men (P = 0.047). However, maximum DVV (P = 0.009), mean DVV (P < 0.0001), total DVV (P < 0.0001), and mean nocturnal urine volume (P = 0.009) were significantly higher in elderly men than in elderly women. However, numbers of daytime voids were not different. CONCLUSION: Elderly women with LUTS have lower functional bladder capacities than elderly men, as suggested by their smaller mean voided volumes. However, no significant differences were observed between numbers of daytime voids, which was probably due to the smaller total daytime voided volumes of elderly women. In addition, although NPi for younger women and nocturnal urine volume for elderly men was higher, no other differences were observed in terms of other night-time parameters.     

alpha-Blockers improve chronic ischaemia of the lower urinary tract in patients with lower urinary tract symptoms

OBJECTIVE

To investigate whether a mechanism of action of α‐blockers on lower urinary tract symptoms (LUTS) involves improved perfusion of the LUT.

PATIENTS, SUBJECTS AND METHODS

The accuracy of perfusion measurements using transrectal colour Doppler ultrasound (TRCDUS) and colour pixel density (CPD) was initially confirmed in a porcine model. Following this confirmation, measurements were taken from four healthy male volunteers and 19 patients with LUTS. The urinary bladder was filled slowly (50 mL/min) with 0.2 m KCl, which resembles the osmolarity of concentrated urine, and evaluated by cystometry. In parallel, TRCDUS and measurement of the CPD of the LUT were performed. The patients with LUTS were then treated with daily α‐blocker (0.4 mg tamsulosin) for 5 weeks and urodynamic variables as well as perfusion were evaluated again.

RESULTS

In the healthy men, perfusion of the LUT increased considerably (157%) during filling of the bladder to a mean (sd ) maximum cystometric capacity (C_max) of 481 (28.9) mL. All the patients with LUTS had a reduced mean C_max during filling with KCl at 322.4 (58.5) mL. The mean CPD in the urinary bladder and the prostate were only increased by 58.4% during filling with KCl. After α‐blocker therapy the mean C_max during filling with KCl rose to 382.5 (42.9) mL; furthermore, perfusion of the LUT measured by CPD was significantly increased (132.8%).

CONCLUSIONS

The present data strongly suggest that LUTS are associated with chronic ischaemia of the prostate and urinary bladder. α‐blockers increase perfusion in the LUT and C_max. These results might explain the therapeutic effects of α‐blockers on LUTS.