The Correlation Between Bladder Outlet Obstruction and Lower Urinary Tract Symptoms as Measured by the International Prostate Symptom Score

Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTS) are common, often bothersome, and have multifactorial aetiology.

OBJECTIVE

To present a summary of the 2023 version of the European Association of Urology guidelines on the management of male LUTS.

EVIDENCE ACQUISITION

A structured literature search from 1966 to 2021 selected the articles with the highest certainty evidence. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

The assessment of men with LUTS should be practical. A careful medical history and physical examination are essential. Validated symptom scores, urine test, uroflowmetry, and postvoid urine residual, as well as frequency-volume charts for patients with nocturia or predominately storage symptoms should be used. Prostate-specific antigen should be ordered if a diagnosis of prostate cancer changes the treatment plan. Urodynamics should be performed for selected patients. Men with mild symptoms are candidates for watchful waiting. Behavioural modification should be offered to men with LUTS prior to, or concurrent with, treatment. The choice of medical treatment depends on the assessment findings, predominant type of symptoms, ability of the treatment to change the findings, and the expectations to be met in terms of the speed of onset, efficacy, side effects, and disease progression. Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection, enucleation, vaporisation, and alternative ablative and nonablative techniques. The choice of surgical technique depends on patient's characteristics, expectations, and preferences; surgeon's expertise; and availability of modalities.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of male LUTS.

PATIENT SUMMARY

A clinical assessment should identify the cause(s) of symptoms and define the clinical profile and patient's expectations. The treatment should aim to ameliorate symptoms and reduce the risk of complications.

A Systemic Review and Meta-analysis of Transabdominal Intravesical Prostatic Protrusion Assessment in Determining Bladder Outlet Obstruction and Unsuccessful Trial Without Catheter

CONTEXT

Urodynamic study (UDS) provides the most objective assessment of bladder outlet obstruction (BOO) but is impractical to be recommended routinely in outpatient services. Intravesical prostatic protrusion (IPP) had been described to obstruct urinary flow by creating an anatomical ball-valve effect, but there remains a lack of pooled evidence that can objectively correlate with BOO in benign prostatic hyperplasia.

OBJECTIVE

To update the current evidence on the predictive role of IPP in determining BOO and unsuccessful trial without catheter (TWOC).

EVIDENCE ACQUISITION

A comprehensive literature search was performed to identify studies that evaluated IPP in diagnosing UDS-determined BOO and TWOC. The search included the PubMed/MEDLINE, EMBASE, and Cochrane Library up to January 2021. An updated systemic review and meta-analysis was performed.

EVIDENCE SYNTHESIS

A total of 18 studies with 4128 patients were examined. Eleven studies with 1478 patients examined the role of IPP in UDS-determined BOO. The pooled area under the curve (AUC) was 0.83 (95% confidence interval [CI]: 0.79-0.86), and at a cut-off of >10 mm, the sensitivity (Sn) and specificity (Sp) were 0.71 (95% CI: 0.61-0.78) and 0.77 (95% CI: 0.68-0.84), respectively. The probability-modifying plot revealed positive and negative likelihood ratios of 3.34 (95% CI: 2.56-4.36) and 0.35 (95% CI: 0.26-0.45), respectively. Seven studies with 2650 patients examined IPP in predicting unsuccessful TWOC, with a pooled AUC of 0.74 (95% CI: 0.70-0.84), with Sn of 0.51 (95% CI: 0.43-0.60) and Sp of 0.79 (95% CI: 0.73-0.84) at an IPP cut-off of >10 mm. Five studies compared prostate volume (PV) and IPP and revealed a lower AUC of PV at 0.71 (95% CI: 0.67-0.75), which was an inferior parameter in diagnosing BOO (p < 0.001).

CONCLUSIONS

This systemic review provided evidence that IPP is a reliable clinical parameter that correlates strongly with underlying BOO and unsuccessful TWOC.

PATIENT SUMMARY

In this review, we comprehensively reviewed all the literature to date on evaluating the clinical utility of intravesical prostatic protrusion (IPP). We have demonstrated that IPP correlates strongly with urodynamic study (UDS)-determined bladder outlet obstruction and failure of trial without catheter (TWOC). Outpatient IPP measurement is a quick, inexpensive, and reproducible clinical parameter that can determine the severity of benign prostatic hyperplasia. The clinical role of IPP in predicting failure of TWOC selects patients who are best treated with aggressive surgical approaches rather than conservative medical therapies. More importantly, IPP can facilitate the discriminatory use of invasive UDS, reserved for patients with a strong suspicion of concomitant detrusor abnormalities.

Non-invasive evaluation of bladder outlet obstruction in benign prostatic hyperplasia: a clinical correlation study

Objectives: To determine the utility of ultrasonography (US)-derived parameters (e.g. prostate volume [PV], bladder wall thickness [BWT], post-void residual urine volume [PVR], and intravesical prostatic protrusion [IPP]) and uroflowmetry for identifying bladder outlet obstruction (BOO) by correlating them with the results of pressure–flow urodynamic studies (UDS).

Patients and methods: In all, 164 patients presenting with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH), from May 2016 to December 2018, were included in this study. All had International Prostate Symptoms Score (IPSS), Quality-of-Life (QOL) index, uroflowmetry (including maximum urinary flow rate [Q_max]) and PVR measured by transabdominal US. Pressure–flow UDS were performed on all men and BOO was defined by a BOO Index (BOOI) >40. Men with a Q_max of ≥12.0 mL/s were considered to have ‘good’ flow.

Results: Amongst the 164 men, the mean (SD) age, PV, BWT and Q_max were 66.72 (9.88) years, 51.91 (13.24) mm, 5.07 (0.91) mm, and 8.46 (3.59) mL/s, respectively. In all, 91 (55.49%) patients had BOO with a BOOI >40 and nine (5.49%) had equivocal BOO with a BOOI of 20–40. The IPP was a statistically significant predictor (P < 0.001) of BOO compared with other variables in the initial evaluation. In patients with BOO confirmed by the pressure–flow UDS, IPP Grade III was associated with a higher BOOI than was Grade I and II (P < 0.001).

Conclusion: BWT, PV and PVR in conjunction with IPP are good predictors of clinically significant BOO due to BPH.

Abbreviations: AUC: area under the curve; BOOI: BOO Index; BPO, benign prostatic obstruction; BWT, bladder wall thickness; IPP: intravesical prostatic protrusion; P_det: detrusor pressure; PV: prostate volume; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; QOL: quality of life; ROC: receiver operating characteristic; (TA)US: (transabdominal) ultrasonography; UDS: urodynamic studies

Is intravesical prostatic protrusion a risk factor for hydronephrosis and renal insufficiency in benign prostate hyperplasia patients?

BACKGROUND

Some patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms hesitate to undergo surgical treatment until acute urinary retention (AUR) occurs. Some of these patients have been found to have hydronephrosis or even renal insufficiency. This study aimed to analyze the risk factors for hydronephrosis in patients with AUR who needed to receive transurethral resection of the prostate (TURP).

METHODS

We retrospectively analyzed 91 patients from January 2014 to June 2015, who had BPH and received TURP for AUR. Patients with urolithiasis, prostate cancer, bladder cancer, gross hematuria, previous bladder radiation therapy, or urinary tract surgery were excluded. Parameters of intravesical prostatic protrusion (IPP), serum prostatic specific antigen (PSA), total prostate volume (PV), age, body mass index (BMI), hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), and serum creatinine (Cr) were compared between the hydronephrosis and non-hydronephrosis groups.

RESULTS

There were significant differences in IPP (p < 0.001) and Serum Cr (p < 0.001) between the hydronephrosis and non-hydronephrosis groups. For IPP, the cut-off values of the highest risk of hydronephrosis was 1.95 cm. There were no significant differences in age, BMI, DM, HTN, CAD, total PV, and PSA between the two groups. IPP was not correlated with total PV (p = 0.423). Most of the patients with hydronephrosis had renal function improvement after TURP.

CONCLUSION

IPP was a significant risk factor for hydronephrosis in BPH patients. If the patients' IPP exceeded 1.95 cm, they had a higher risk of having hydronephrosis when AUR occurred. Hydronephrosis is a risk factor for renal insufficiency, and Serum Cr levels decreased significantly in the patients of our study.

Voiding urethrocystoscopy: A new concept for benign prostatic obstruction characterization

AIM

To assess the feasibility of voiding urethrocystoscopy (VUC) in males and describe the characteristics of dynamic movements of the prostatic lobes during micturition.

MATERIAL AND METHODS

Patients scheduled for benign prostatic obstruction relief in a tertiary reference center were included in this prospective evaluation. During urethrocystoscopy with a small diameter flexible endoscope, the bladder was filled until desire to void. The patient was asked to void with endoscope in place facing the veru montanum. Movements of the prostatic lobes during micturition were characterized, video-recorded, and categorized based on the dynamics of the lateral lobes, the posterior lobe and the bladder neck.

RESULTS

In all, 192 evaluations were conducted. In 161 cases (84%), the patient was able to void. Among these patients, 126 cases were stated as "closed" (coalescent), without opening of the initial part of the urethra and the bladder neck. In 38 cases, there was no opening of the lateral lobes (type 1A), and in 47 cases a partial opening of the distal parts of the lateral lobes was seen (type 1B). In 31 cases, a fixed posterior bladder neck was seen (type 2A) and in 10 cases a mobile median lobe, with a rolling ball effect, was seen (type 2B). In 25 cases, the lumen was completely open and equivocal in 10 cases.

CONCLUSIONS

This study demonstrates the feasibility of VUC and describes for the first time the dynamics of prostatic lobes during micturition. This evaluation may lead to a new approach for understanding the mechanical aspects of benign prostatic obstruction.

LEVEL OF EVIDENCE

3.

[Fake News BPH - what is really true!]

BACKGROUND

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is the fourth most common and the fifth most costly disease in men aged 50 years or older. Despite the high prevalence of LUTS/BPH in clinical practice and evidence-based guideline recommendations, there are still plenty of misconceptions on the terminology and pathophysiology of the disease, leading to false assumptions and malpractice.

OBJECTIVES

Listing of commonly used false assumptions and clarification of the correct terminology and pathophysiology.

MATERIALS AND METHODS

Critical reflection of 12 selected fake news based on PubMed search.

RESULTS

Average prostate weight in healthy men is 20 g but varies between 8-40 g. The BPH-disease does not progress in stages; therefore, the BPH-classifications according Alken or Vahlensieck should not be used anymore. There is only a weak and inconsistent relationship between bladder outlet obstruction (BOO) and prostate size, diverticula/pseudo-diverticula, postvoid residual, urinary retention or renal insufficiency, which is too unreliable for BOO-diagnosis in the individual patient. Urethro-cystoscopy with grading of the degrees of occlusion of the prostatic urethra and bladder trabeculation is insufficient for BOO-diagnosis. There is no clinically relevant reduction of BOO with licensed BPH-drugs and no convincing data that prostate resection (TURP) has to be complete until the surgical capsule in order to obtain optimal results.

CONCLUSIONS

The reasons for the persistent use of wrong terminology and pathophysiology are diverse. One reason is lack of implementation of evidence-based guidelines into clinical practice due to lack of knowledge, individual beliefs, costs, availability and reimbursement policies. Another reason is the increasing focus on oncology, coupled with underrepresented education and training on BPH.

[How to evaluate BPH-related SBAUs in clinical practice and research?]

OBJECTIVE

To describe the useful explorations in the clinical evaluation of the symptoms of the lower urinary tract symptoms possibly related to BPH (LUTS/BPH), and to list the information necessary to allow an evaluation of an instrumental or surgical intervention in the treatment of the hypertrophy and benign prostatic obstruction.

METHOD

Bibliographic research in English using the European, American and French recommendations on the evaluation of BPH, supplemented by a Pubmed search.

RESULTS AND CONCLUSIONS

A number of systematic investigations into the evaluation of a man with LUTS/BPH include interrogation, clinical examination with rectal examination, urinalysis, flowmeter and post-micturition residual volume. The voiding catalog is necessary to understand the mechanism of a nocturia. PSA has a triple potential of interest: evaluation of the risk of progression, evaluation of the prostatic volume and diagnosis of a cancer of the prostate. Creatinine is needed only when chronic retention is observed and before surgery. Urethrocystoscopy is essential in case of hematuria, suspicion of stenosis of the urethra or bladder tumor. Ultrasound for evaluation of prostate volume is essential before surgery, and may be helpful in guiding the decision to prescribe a 5 alpha reductase inhibitor. No non-invasive technique has proven its possible substitution for pressure flow studies when indicated. When a researcher is considering evaluating a surgical or instrumental treatment for BPH, preoperative, perioperative and follow-up parameters are expected from readers to get a fair idea of the technique being evaluated. LEVEL OF EVIDENCE 5: Consensus d'experts.

Intravesical prostatic protrusion is not always the same shape: Evaluation by preoperative cystoscopy and outcome in HoLEP

AIMS

To examine how morphological differences in intravesical prostatic protrusion (IPP) predict outcome of Holmium laser enucleation of prostate (HoLEP) treatment.

METHODS

We analyzed 173 patients who had undergone HoLEP in our hospital. The protrusion shape was evaluated by outpatient preoperative flexible cystoscopy and classified into five groups: A, no protrusion; B, middle lobe only; C, unilateral lobe only; D, bilateral lobes; and E, B + C or B + D. Paired-match analysis that adjusted for preoperative International Prostate Symptom Score (IPSS) voiding/storage subscores and IPP was performed between the group with middle lobe protrusion (B + E) and the group without it (C + D).

RESULTS

Type A prostate shape was found in 23 patients, type B in 14, type C in 31, type D in 71, and type E in 34. Groups with middle lobe protrusion (B and E) had better changes in the total IPSS (P < 0.05) and the IPSS storage subscore (P < 0.01). Pair matching identified 37 patients each with or without middle lobe protrusion. The group with middle lobe protrusion had significantly more improved total IPSS (-17.5 ± 7.5 vs -13.5 ± 8.3, P < 0.05) and IPSS storage subscore (-6.9 ± 3.4 vs -4.8 ± 3.3, P < 0.05) than did those without middle lobe protrusion.

CONCLUSIONS

Patients with middle lobe protrusion had greater IPSS improvement after HoLEP than those having comparable-length IPP but without middle lobe protrusion. IPP is not always the same shape and should be clinically divided into at least two groups.

Morphological and clinical evaluation of prostatic urethra using modified sonourethrography with retrograde jelly injection

OBJECTIVE

Using modified sonourethrography (mSUG) with retrograde jelly injection to precisely measure the morphological characteristics of the prostatic urethra, we assessed prostatic urethral morphology associated with clinical parameters of benign prostatic hyperplasia (BPH).

METHODS

BPH patients (n = 43) and control patients with localized prostate cancer (PC; n = 57) were imaged by mSUG before surgery. Using the seminal colliculus as a landmark, prostatic urethral angulation (PUA), sagittal urethral diameter, and anterior or posterior prostatic urethral length were measured. The International Prostatic Symptoms Score (IPSS) was also evaluated in all patients. The Bladder Outlet Obstruction Index (BOOI) was measured in BPH patients that could void in a pressure-flow study. Parameters were compared between BPH and PC patients, and correlations among morphological and clinical parameters were evaluated.

RESULTS

Prostatic urethras were clearly observed in all patients by mSUG. PUA, sagittal urethral diameter, and posterior urethral length were all greater in BPH than PC patients (P < .05). Among all parameters examined, PUA had the strongest correlation with IPSS (r = 0.56). Longitudinal urethral diameter showed the strongest correlation with BOOI, whereas PUA was not correlated with BOOI.

CONCLUSIONS

Prostatic urethral morphology can be imaged precisely by mSUG. Morphometric measurements showed that increased PUA was strongly correlated with problematic urinary symptoms, and a flattened shape of the posterior urethra, such as extension of the sagittal urethral diameter, was correlated with urinary tract obstruction by BPH.

Diagnostic value of urodynamic bladder outlet obstruction to select patients for transurethral surgery of the prostate: Systematic review and meta-analysis

PURPOSE

To investigate the diagnostic value of urodynamic bladder outlet obstruction (BOO) in the selection of patients for transurethral surgery of the prostate.

MATERIALS AND METHODS

We systematically searched online PubMed, Embase, and Cochrane Library databases from January 1989 to June 2014.

RESULTS

A total of 19 articles met the eligibility criteria for this systematic review. The eligible studies included a total of 2321 patients with a median number of 92 patients per study (range: 12-437). Of the 19 studies, 15 conducted conventional transurethral prostatectomy (TURP), and 7 used other or multiple modalities. In urodynamic bladder outlet obstruction (BOO) positive patients, the pooled mean difference (MD) was significant for better improvement of the International Prostate Symptom Score (IPSS) (pooled MD, 3.48; 95% confidence interval [CI], 1.72-5.24; p < 0.01; studies, 16; participants, 1726), quality of life score (QoL) (pooled MD, 0.56; 95% CI, 0.14-1.02; p = 0.010; studies, 9; participants, 1052), maximal flow rate (Qmax) (pooled MD, 3.86; 95% CI, 2.17-5.54; p < 0.01; studies, 17; participants, 1852), and post-void residual volume (PVR) (pooled MD, 32.46; 95% CI, 23.34-41.58; p < 0.01; studies, 10; participants, 1219) compared with that in non-BOO patients. Some comparisons showed between-study heterogeneity despite the strict selection criteria of the included studies. However, there was no clear evidence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis results showed a significant association between urodynamic BOO and better improvements in all treatment outcome parameters. Preoperative UDS may add insight into postoperative outcomes after surgical treatment of benign prostatic hyperplasia.

Ultrasound detrusor wall thickness measurement in combination with bladder capacity can safely detect detrusor underactivity in adult men

PURPOSE

Detrusor underactivity (DU) has lately gained increasing interest because this bladder condition is an important cause of post-void residual urine and lower urinary tract symptoms (LUTS) in adult men. Until now, DU can only be diagnosed by pressure-flow measurement. Therefore, the aim of this study was to search for noninvasive tests which can safely predict DU in adult men.

METHODS

Unselected, treatment-naïve male patients aged ≥40 years with uncomplicated, non-neurogenic LUTS were prospectively evaluated. All men received-after standard assessment of male LUTS-ultrasound detrusor wall thickness (DWT) measurements at a bladder filling ≥250 ml and computer urodynamic investigation. DU was defined as incomplete bladder emptying (>30 ml) in the absence of bladder outlet obstruction or dysfunctional voiding. Classification and regression tree (CART) analysis was used to determine parameters and threshold values for DU.

RESULTS

The study population consisted of 143 consecutive men with medians of 62 years, IPSS 16, and prostate volume 35 ml. In total, 33 patients (23.1 %) had DU. CART analysis showed that all men with DWT ≤ 1.23 mm plus bladder capacity >445 ml had DU. This multivariate model has a sensitivity of 42 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 85 %.

CONCLUSIONS

This study showed that all men with ultrasound DWT ≤ 1.23 mm + bladder capacity >445 ml have DU. Combination of these two tests could help physicians to diagnose DU noninvasively in clinical practice. A prospective independent study should confirm these results.

Relationships between Prostatic Volume and Intravesical Prostatic Protrusion on Transabdominal Ultrasound and Benign Prostatic Obstruction in Patients with Lower Urinary Tract Symptoms

Introduction: The objective of this study is to determine the relationships between prostatic volume (PV) and intravesical prostatic protrusion (IPP) with benign prostatic obstruction (BPO). Materials and Methods: A total of 408 males (aged 50 years and above) who presented with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) were recruited. All had International Prostate Symptoms Score (IPSS), quality of life (QOL) index, urofl owmetry (Qmax) and postvoid residual urine (PVR) measured by transabdominal ultrasonography (TAUS). The PV and the degree of IPP were also measured by TAUS in the transverse and sagittal planes respectively. The PV is classifi ed as Grade a, (20 ml or less), Grade b, (more than 20 ml to 40 ml) and Grade c, (more than 40 ml), while the IPP is graded as Grade 1 (5 mm or less), Grade 2 (more than 5 mm to 10 mm) and Grade 3 (more than 10 mm). Results: There was a fair positive correlation between the PV and IPP (Spearman, rs = 0.62, P <0.001) with important clinical exceptions. There was negative correlation between the PV and Qmax (rs = -0.20, P = 0.022), IPP and Qmax (rs = -0.30, P <0.001). PV and IPP were good predictors of BPO. However, IPP was slightly better (rs of -0.30 vs -0.20) than PV. Conclusion: PV is related to IPP with important clinical exceptions. IPP is a better predictor of BPO than PV. Key words: Benign prostatic hyperplasia, Prostate volume

EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction

CONTEXT

Lower urinary tract symptoms (LUTS) represent one of the most common clinical complaints in adult men and have multifactorial aetiology.

OBJECTIVE

To develop European Association of Urology (EAU) guidelines on the assessment of men with non-neurogenic LUTS.

EVIDENCE ACQUISITION

A structured literature search on the assessment of non-neurogenic male LUTS was conducted. Articles with the highest available level of evidence were selected. The Delphi technique consensus approach was used to develop the recommendations.

EVIDENCE SYNTHESIS

As a routine part of the initial assessment of male LUTS, a medical history must be taken, a validated symptom score questionnaire with quality-of-life question(s) should be completed, a physical examination including digital rectal examination should be performed, urinalysis must be ordered, post-void residual urine (PVR) should be measured, and uroflowmetry may be performed. Micturition frequency-volume charts or bladder diaries should be used to assess male LUTS with a prominent storage component or nocturia. Prostate-specific antigen (PSA) should be measured only if a diagnosis of prostate cancer will change the management or if PSA can assist in decision-making for patients at risk of symptom progression and complications. Renal function must be assessed if renal impairment is suspected from the history and clinical examination, if the patient has hydronephrosis, or when considering surgical treatment for male LUTS. Uroflowmetry should be performed before any treatment. Imaging of the upper urinary tract in men with LUTS should be performed in patients with large PVR, haematuria, or a history of urolithiasis. Imaging of the prostate should be performed if this assists in choosing the appropriate drug and when considering surgical treatment. Urethrocystoscopy should only be performed in men with LUTS to exclude suspected bladder or urethral pathology and/or before minimally invasive/surgical therapies if the findings may change treatment. Pressure-flow studies should be performed only in individual patients for specific indications before surgery or when evaluation of the pathophysiology underlying LUTS is warranted.

CONCLUSIONS

These guidelines provide evidence-based practical guidance for assessment of non-neurogenic male LUTS. An extended version is available online (www.uroweb.org/guidelines).

PATIENT SUMMARY

This article presents a short version of European Association of Urology guidelines for non-neurogenic male lower urinary tract symptoms (LUTS). The recommended tests should be able to distinguish between uncomplicated male LUTS and possible differential diagnoses and to evaluate baseline parameters for treatment. The guidelines also define the clinical profile of patients to provide the best evidence-based care. An algorithm was developed to guide physicians in using appropriate diagnostic tests.

Defining the degree of intravesical prostatic protrusion in association with bladder outlet obstruction

Purpose

The present study was done to define the degree of intravesical prostatic protrusion (IPP) causing bladder outlet obstruction (BOO) in patients with benign prostatic hyperplasia (BPH)/lower urinary tract symptoms.

Materials and Methods

We retrospectively evaluated 239 patients with BPH, analyzing age, IPP, prostate volume, International Prostate Symptom Score (IPSS), and the results from a pressure-flow study. Urethral resistance was quantified by using the BOO index (BOOI), according to the formula BOOI=PdetQmax-2×Qmax (where Pdet is detrusor pressure at the peak flow rate and Qmax is peak flow rate). BOO was defined by a BOOI above 40. Patients with a BOOI below 20 were excluded. Patients were classified into two groups (obstructed and unobstructed groups) by the BOOI. Correlations were determined by logistic regression analysis, and receiver operating characteristic curves were plotted to estimate the optimal cutoff for IPP.

Results

There were significant differences in total prostate volume, postvoiding residual urine (PVR), IPP, and Qmax (p<0.001, p<0.001, p<0.001, and p=0.026, respectively) between the obstructed and unobstructed groups, but there were no significant differences in age (p=0.653), IPSS total score (p=0.624), or quality of life score (p=0.138). IPP had a significant prognosis (p<0.001) but was weakly correlated with prostate volume (p=0.026). The correlation coefficients between IPP and Qmax, PVR, prostate volume, and BOO were 0.551, -0.159, 0.225, and 0.391, respectively. For IPP, the area under the curve was 0.759 (95% confidence interval, 0.657 to 0.861) and the cutoff to indicate BOO was 5.5 mm with 66.7% sensitivity and 80.5% specificity.

Conclusions

An IPP exceeding 5.5 mm was significantly associated with BOO.

The value of measuring the prostatic resistive index vs. pressure-flow studies in the diagnosis of bladder outlet obstruction caused by benign prostatic hyperplasia

Objective

To compare the prostatic resistive index (RI) and measurements from pressure-flow studies (PFS) for the diagnosis and follow-up of bladder outlet obstruction (BOO) in patients with benign prostatic hyperplasia (BPH).

Patients and methods

In all, 338 men (aged 55–82 years) presenting with lower urinary tract symptoms were evaluated prospectively for BOO secondary to BPH. In all patients, the prostatic RI was measured by transrectal power Doppler ultrasonography. PFS were assessed in all patients and depending on the results the patients were divided into an obstructive and an unobstructive group. The receiver operating characteristic (ROC) curve was used to determine the prostatic RI threshold value for predicting BOO secondary to BPH. Patients who were confirmed to have BOO secondary to BPH received either medical or surgical treatment, and they were re-evaluated after 3 and 6 months with prostatic RI measurements.

Results

According to the PFS the obstructive group included 158 patients and the unobstructive group 180 patients. The mean (SD) prostatic RI was significantly higher in the obstructive group, at 0.73 (0.04), than in the unobstructive group, 0.65 (0.05) (P < 0.001). Using the ROC curve a prostatic RI of ⩾ 0.71 predicted BOO secondary to BPH, with 84.6% sensitivity, 78.4% specificity and 83.8% overall predictability. After management, the prostatic RI of the obstructive group, 0.69 (0.08), was significantly lower than before treatment, 0.73 (0.04) (P < 0.05).

Conclusions

The prostatic RI can predict BOO with high specificity and sensitivity. We believe that the prostatic RI could be a useful variable for the diagnosis and follow-up of patients with BPH.

The role of nocturia in the quality of life of men with lower urinary tract symptoms

OBJECTIVES

To determine the role of treatment-associated improvement in nocturia in health-related quality of life (HRQL) in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia, and secondarily to confirm the role of nocturia in HRQL at baseline and to compare the effects of watchful waiting, transurethral microwave treatment (TUMT) and transurethral resection of the prostate (TURP) to those of α1-adrenoceptor antagonists (α-blockers) on nocturia.

PATIENTS AND METHODS

We retrospectively analysed using multiple regression a large single-centre database of patients receiving routine care for treatment-associated alterations of symptoms and HRQL (assessed at baseline, 2611 men) and 6-12 months after initiation of treatment (1258 men).

RESULTS

Among the symptoms assessed using the International Prostate Symptom Score, nocturia (together with urgency and weak stream) had the strongest correlation with HRQL at baseline and after treatment. Watchful waiting, α-blockers, TUMT and TURP reduced nocturia episodes by a mean (sd) of 7 (53)%, 17 (40)%, 32 (47)% and 75 (23)%, respectively. The treatment-associated improvements in nocturia (together with those of weak stream) had the strongest association with those of HRQL.

CONCLUSIONS

We conclude that among all LUTS assessed in the IPSS, nocturia has one of the strongest associations with HRQL, and that treatment-associated improvements in nocturia contribute considerably to overall improvements in HRQL.

Urethral Sensations are Related to the Development of Detrusor Overactivity

Urgency is the core symptom of the overactive bladder symptom complex, but the underlying mechanisms are not fully understood. Clinical findings have led to the assumption that bladder outlet obstruction (BOO) caused by benign prostatic enlargement (BPE) induces storage symptoms and detrusor overactivity. Presumably, BOO by BPE accounts for urgency; however, urgency is not always caused by BOO. Sensory nerves in the wall of the urethra fire in response to urethral fluid flow, and this activity initiates bladder contractions in the quiescent bladder and augments ongoing contractions in the active bladder. In humans, prostatic urethral anesthesia results in significant increases in bladder capacity among BPH patients without neurological diseases, therefore sensory stimuli from an anatomically altered prostatic urethra has the possibility to induce urgency and detrusor overactivity. Studies in animals demonstrate the basis for an excitatory urethra to bladder reflex. Urethral stimulation by prostaglandin E2 induces an excitatory effect on micturition reflex by activation of C-fiber afferent nerves. α1A -adrenoceptor blocker has an inhibitory effect on the micturition reflex, suggesting excitatory urethra to bladder reflex is mediated by α1A -adrenoceptor. Even if there is no obstruction, increase in urethral sensory due to BPE may induce the development of the detrusor overactivity.

Clinical and urodynamic significance of morphological differences in intravesical prostatic protrusion

Purpose

The objectives of this study were to evaluate whether morphologic differences correlated with urodynamic and clinical characteristics in patients with benign prostatic hyperplasia (BPH) with intravesical prostatic protrusion (IPP) of trilobar or bilobar adenoma.

Materials and Methods

Between January 2008 and June 2009, 72 male patients who had undergone transurethral resection (TUR) owing to BPH with IPP were included in this study. They underwent preoperative urodynamic studies, the International Prostate Symptom Score (IPSS)/quality of life (QoL), maximal flow rate (Qmax), post-voiding residual urine volume (PVR), transrectal ultrasonography (TRUS), and serum prostate-specific antigen (PSA) measurement. The patients were classified into 2 groups (the trilobar and bilobar adenoma groups) on the basis of video findings during the TUR operation.

Results

The trilobar and bilobar adenoma groups consisted of 37 patients and 35 patients, respectively. The Mean±SD IPP, prostate volume (PV), and transition zone volume of the trilobar and bilobar adenoma groups were 11.8±5.2 mm and 9.0±3.8 mm (p=0.014), 81.1±25.8 g and 59.3±22.5 g (p<0.001), and 49.6±20.6 g and 34.8±19.4 g (p=0.003), respectively. The Mean±SD PSA, bladder contractility index (BCI), and bladder outlet obstruction index (BOOI) were 4.6±2.5 ng/ml and 3.5±1.7 ng/ml (p=0.042), 119.8±33.4 and 87.7±24.4 (p<0.001), and 62.6±29.5 and 44.6±20.4 (p=0.005), respectively. There were no significant differences in IPSS/QoL, Qmax, PVR, acute urinary retention, or detrusor overactivity in the 2 groups.

Conclusions

IPP has two morphologic types of trilobar or bilobar enlargement. The PV, BOOI, and BCI were significantly smaller in the bilobar adenoma group than in the trilobar adenoma group.

Staging of Benign Prostate Hyperplasia is Helpful in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostate Hyperplasia

Introduction: We prospectively evaluated the staging of benign prostate hyperplasia (BPH) to decide transurethral resection of prostate (TURP) therapeutic modality and the final outcomes in patients with lower urinary tract symptoms (LUTS) suggestive of BPH. Materials and Methods: Male patients above 50 years old presented with LUTS suggestive of BPH were included in this study. The initial assessment included the International Prostatic Symptoms Score (IPSS) and the Quality of Life (QOL) index, digital rectal examination (DRE). Transabdominal ultrasound was done to measure the prostate volume, intravesical prostatic protrusion (IPP) and the post void residual (PVR) urine. BPH was classified according to the degree of IPP using grades 1 to 3. The staging of BPH was performed according to the presence or absence of bothersome symptoms (QOL ≥3) and significant obstruction (PVR >100ml). Patients with stage I BPH with no bothersome symptoms and no significant obstruction were generally observed. Those with stage II BPH, bothersome symptoms but no significant obstruction, received pharmacotherapy in the first instance, and were offered TURP if symptoms persisted or worsened. Patients with significant obstruction, persistent PVR >100ml, irrespective of symptoms would be classified as stage III, and were advised to undergo TURP as an option. Lastly, those with stage IV (complications of BPH) were strongly recommended to undergo TURP. Results: A total of 408 patients were recruited in this study and after a mean follow-up of 30 months (range, 6 to 84), 96 (24%) eventually had TURP. Sixteen (13%), 50(21%), 28(64%) and 2(100%) patients who underwent TURP were initially diagnosed as stage I, II, III and IV, respectively. Eighty-seven (91%) of the 96 patients significantly improved to stage I BPH post TURP. Conclusions: These results showed that the staging of BPH can assist in the tailoring of treatment for patients with LUTS suggestive of BPH, with good outcome in 91% post TURP. Key words: Intravesical prostatic protrusion, Post void residual urine, Quality of life, Symptoms score

A 2-year prospective follow-up study of lower urinary tract symptoms in patients treated with clozapine

Urinary incontinence and enuresis are well-known side effects of clozapine. However, clinical experience has shown that patients also suffer from diverse lower urinary tract symptoms (LUTS). The natural course of clozapine-related LUTS is unclear. Thus, a longitudinal follow-up study is needed. A total of 101 subjects who were taking clozapine initially participated. Their LUTS were evaluated using the International Prostate Symptom Score (IPSS), other questionnaires, and a medical records review. After 2 years, 87 of the original subjects could be contacted, and the status of their LUTS was re-evaluated. The average IPSS total was 7.4 +/- 5.9 at the initial evaluation. Although only 11 subjects (10.9%) reported actual incontinence, 42 subjects (41.6%) were found to have clinically significant LUTS (IPSS total score > or =8). No influencing factors could be found among the demographic and clinical variables. At the follow-up, the average IPSS total (7.9 +/- 6.0) and the percentage of subjects with clinically significant LUTS (43.7%) had both increased, although the change was not statistically significant. The prevalence of LUTS in clozapine-medicated patients was higher than in the general population of the same age. However, the prevalence of incontinence was only a quarter of that of LUTS. If clinicians focus only on incontinence, distress from LUTS will not receive appropriate attention. Furthermore, contrary to literature observations, clozapine-related LUTS did not remit easily but rather persisted even into the long-term maintenance phase. More concern should be directed at these troublesome and often neglected side effects.

Reliability and Validity of the Incontinence Quality of Life Questionnaire in Patients With Neurogenic Urinary Incontinence

OBJECTIVE

To assess the reliability, validity, responsiveness, and minimally important difference (MID) of the Incontinence Quality of Life (I-QOL) questionnaire in patients with urinary incontinence due to neurogenic detrusor overactivity.

DESIGN

Randomized, double-blind, multicenter, placebo-controlled study.

SETTING

Eight centers across Belgium, France, and Switzerland.

PARTICIPANTS

Patients with urinary incontinence due to neurogenic detrusor overactivity inadequately managed on oral anticholinergics. Fifty-nine patients (spinal cord injury, n=53; multiple sclerosis, n=6) were enrolled.

INTERVENTION

Single dose of botulinum toxin type A (Botox) (200 or 300 U) or placebo.

MAIN OUTCOME MEASURES

I-QOL questionnaire completed at screening and over a 24-week post-treatment period.

RESULTS

The Cronbach alpha ranged from .79 to .93, indicating that I-QOL is a reliable measure of QOL in neurogenic urinary incontinence patients. No item had more than 5.1% missing or out of range values. With the exception of 2 items, questions showed acceptable item-scale correlation and scaling success results varied by domain. Post-treatment correlations indicated acceptable construct validity. The I-QOL was responsive to improvements in symptoms. MID values ranged from 4 to 11 points.

CONCLUSIONS

Results suggest that I-QOL is a reliable, valid, and responsive measure of incontinence-related QOL in neurogenic patients.

Home and office uroflowmetry for evaluation of LUTS from benign prostatic enlargement

A group of 107 patients with lower urinary tract symptoms (LUTS) from benign prostatic enlargement (BPE) participated to the HOUSE Study (Home and Office Uroflowmetry Specific Evaluation). Patients received routine investigation, consisting of medical history taking, physical examination including digital rectal examination, prostate-specific antigen (PSA), assessment of symptoms listed both on the International Prostate Symptom Score and on ICS-male questionnaire. We examined the results of uroflowmetry evaluation in this population; data were analysed to observe if any circadian changes of parameters obtained with home uroflowmetry could be detected. We searched a correlation between Q(max), Q(ave) and ICS-benign prostatic hyperplasia symptom score: a significantly inverse correlation was found only for Q(max), confirming Q(max) as a reliable parameter to quantify subjective symptoms. When examining the multiple flow curves recorded in the same patient with home uroflowmetry, voided volume and flow time had usually higher values during night-time: the existence of circadian changes of uroflowmetry parameters in patients with LUTS from BPE was confirmed, and lower values of average and maximum flow rates during sleep hours were recorded in the same patient. In conclusion, when evaluating the natural history or treatment outcome of individual patients or group of patients in clinical trials for evaluation of BPE and LUTS, an assessment including multiple measurements may be useful and of value.

Urodynamic studies in the surgical treatment of benign prostatic hyperplasia

OBJECTIVE

We compared the clinical and urodynamic outcome of men with lower urinary tract symptoms with and without previous urodynamic evaluation submitted to transurethral resection of the prostate.

MATERIALS AND METHODS

A prospective and randomized study was performed in 315 patients who underwent transurethral resection of the prostate. In 151 patients (group A) with a mean age of 63 years, transurethral resection of the prostate was performed without a prior urodynamic study, and group B, 164 patients with a mean age of 61 years, underwent a urodynamic study prior to surgical procedure. In group B, only obstructed patients were selected for surgery. All patients had I-PSS higher than 15 and underwent at least 2 uroflowmetry and flow was lower than 10 ml/sec. At 6-month follow up, patients in both groups underwent the I-PSS questionnaire and pressure / flow study.

RESULTS

The symptomatology and uroflowmetry did not display different behavior between the groups. The mean postoperative score for group A was 8.87 + 3.27 and for group B was 9.32 + 3.14 (p = 0.22). The mean postoperative uroflow for group A was 17.0 + 2.1 mL/s and for group B was 16.6 + 2.2 mL/s (p = 0.15).Postoperative, in group A, 27 patients (17.8%) were obstructed and in group B, 16 patients (9.75%) were obstructed (p = 0.03).

CONCLUSION

The study suggests that the previous urodynamic study is not the only factor related to the success of surgical outcome; and therefore, the symptomatology and uroflowmetry associated would be enough during the preoperative routine studies for BPH patients.

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.

Questionnaires for women with urinary symptoms

AIMS

To identify the characteristics of optimal symptom questionnaires in women with lower urinary tract symptoms (LUTS).

METHODS

Literature review.

RESULTS

Although numerous questionnaires have been developed for the evaluation of female LUTS, no one instrument has emerged as that preferred for collecting and reporting subjective information about LUTS in women. Questionnaires currently available range widely in intended purpose, extent and style, and in the quality of testing used to validate them.

CONCLUSIONS

Questionnaires should be constructed based on scientifically sound validation techniques that reflect disease and/or symptoms in the target population. They should be concise, easily administered and scored, discriminant between sphincter and bladder causes of incontinence, and able to measure severity and the effect of the symptom on the patient.

Home uroflowmetry: improved accuracy in outflow assessment

To study home uroflowmetry and to compare this method to free or "traditional" uroflowmetry in the evaluation of the patient with symptomatic benign prostatic hyperplasia (BPH), and the relationship between the values of home uroflowmetry parameters and bladder outlet obstruction (BOO). Twenty-five patients (mean age, 67 years) with symptomatic BPH were examined with home uroflowmetry, free uroflowmetry, and pressure-flow measurement. The patients were assessed using the International Prostate Symptom score; digital rectal examination; routine blood chemistry, including serum prostate-specific antigen level; urinanalysis; transrectal ultrasonography; and post-void residual urine. The 24 hr were divided into "active time" (AT) and "sleep time" (ST). AT home uroflowmetry parameters were compared to ST ones. The home uroflowmetry parameters were compared to respective ones of the free uroflowmetry as well and those obtained by pressure-flow measurement. The patients were asked about their opinion of home uroflowmetry. Home uroflowmetry was found to be a simpler and more acceptable method than free uroflowmetry. The mean Qmax of AT was significantly greater than the mean Qmax of ST, but the mean voided volume and mean voiding time of ST were significantly larger than those of AT. There was a close relationship between the mean Qmax at home and the Qmax in hospital, but the voided volume and voiding time measured in hospital were significantly larger than those at home. Home uroflowmetry provided an estimation of BOO for 46% of the patients as low if the home mean Qmax was >14 ml/sec, and as high if the home mean Qmax was <10 ml/sec. Home uroflowmetry was well accepted by the patients and gave more information than free uroflowmetry. In 46% of the cases, an estimation of BOO was obtained with home uroflowmetry.

Relationships between lower urinary tract symptoms and bladder outlet obstruction: results from the ICS-"BPH" study

Despite the lack of evidence in the literature for close relationships between lower urinary tract symptoms and bladder outlet obstruction, the majority of urologists rely on symptomatology when selecting patients for prostatic surgery. We investigated the relationships between a wide range of lower urinary tract symptoms from the ICSmale questionnaire and the results of urodynamic pressure and flow studies. We evaluated 933 patients with lower urinary tract symptoms suggestive for bladder outlet obstruction from 12 countries who participated in the ICS-"BPH" study with the ICSmale questionnaire and urodynamic pressure and flow studies. Spearman rank correlation coefficients were obtained between symptoms and measures of bladder outlet obstruction. There was little or no correlation between a wide range of symptoms and the results of free uroflowmetry and pressure and flow studies. From symptoms alone, it is not possible to diagnose bladder outlet obstruction. Pressure and flow studies and symptom profiles measure different aspects of the clinical condition that should be viewed separately in the evaluation and treatment decision of the patient presenting with lower urinary tract symptoms.

Intra- and inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms

The objective of this study was to assess the intra- and inter-investigator variation in the analysis of pressure-flow studies that were performed in men with lower urinary tract symptoms. Two hospitals were involved in this study. In each hospital 100 PFS were selected. Photocopies of printouts of all PFS were analyzed manually by six experienced investigators, including determination of P(detQmax) and Q(max). Afterward, all 200 PFS were analyzed again in a different order. For each P(detQmax) and accompanying Q(max) the AG-number was calculated. With these AG numbers, the intra-investigator SD, the inter-investigator SD and the intra- and inter-investigator SD combined were calculated. The intra- and inter-investigator SD combined was 10.7. This implies that if one investigator analyzes a PFS once and determines an AG number of 40, another investigator may determine an AG number between 40 +/- 2. 77*10.7 = 10-70, using a 95% confidence interval. The inter-investigator SD was 10.0 and the intra-investigator SD was 3.7. The reproducibility of the manual analysis of urodynamic studies is moderate owing to a considerable intra- and inter- investigator variation. This is mostly caused by the substantial intra-investigator variation.

Is bladder outlet obstruction normal in elderly men without lower urinary tract symptoms?

The aim of the present study was to correlate basic voiding parameters, including uroflowmetry, symptom score, and residual urine volume with the results of pressure-flow studies applying the Abrams/Griffith nomogram, in a series of urologically asymptomatic elderly men. Twenty-nine consecutive male volunteers (median age, 66 years) without past or present urological complaints participated. Fifteen (52%) of the 29 subjectively normal men proved to have bladder outlet obstruction (BOO). Qmax <10 mL/s had a positive predictive value of 100% in diagnosing obstruction, whereas the predictive information of higher flow rates proved very modest. No significant difference existed between obstructed and unobstructed persons at any cutoff value concerning symptom score. The sensitivity as well as the positive predictive value of a residual urine volume >50 mL was zero. It is concluded that a surprisingly high prevalence of BOO in asymptomatic elderly men was demonstrated and that the correlation between pressure flow investigations and alternative diagnostic tests, i.e., flow rate, symptom score, and residual volume was weak in this group of men. It is suggested that a possible explanation for the high frequency of BOO observed in the evaluated asymptomatic men could be that the values defining obstruction have been set too low. Neurourol. Urodynam. 18:545-552, 1999.

The tolerability of urodynamic studies and flexible cysto-urethroscopy used in the assessment of men with lower urinary tract symptoms

OBJECTIVE

To determine the overall tolerability of urodynamic studies used in the assessment of men with lower urinary tract symptoms (LUTS), by assessing the objective and subjective morbidity experienced during and after urodynamic studies, and to assess the voiding complaints caused by the combination of urodynamic studies with flexible cysto-urethroscopy.

PATIENTS AND METHODS

A total of 103 men with LUTS, who underwent a urodynamic study combined with flexible cysto-urethroscopy, completed a questionnaire designed to assess objective and subjective symptoms and degree of bother, with emphasis on the urodynamic study. In addition, a urine specimen was analysed and cultured. In all, 78 patients who underwent a second urodynamic study completed the questionnaire twice.

RESULTS

The results of the first questionnaire showed that more than half of the patients experienced some urge after the urodynamic study and cysto-urethroscopy (56%); 35% of the patients experienced little and 19% experienced severe voiding discomfort after the combined investigations, compared with 24% and 5%, respectively, after a urodynamic study alone. Three patients (3%) had a symptomatic urinary tract infection. Haematuria, increased voiding frequency and increased nocturia occurred occasionally. Most of the patients found the urodynamic study less bothersome than they had expected (64%) and only 9% found it worse than expected. The overall degree of discomfort, experienced during and after the urodynamic study combined with cysto-urethroscopy, was low, and after a second urodynamic study was even lower.

CONCLUSION

In contrast with earlier results, this clinic-based urodynamic investigation was associated with a low proportion of urinary tract infection, and low objective and subjective morbidity. The combination of a urodynamic study with a flexible cysto-urethroscopy does not cause significant additional voiding complaints. Most patients find urodynamic studies tolerable and not very bothersome.

Sexual function following high energy microwave thermotherapy: results of a randomized controlled study comparing transurethral microwave thermotherapy to transurethral prostatic resection

PURPOSE

We evaluate changes in sexual function in patients treated with high energy transurethral microwave thermotherapy compared to transurethral resection of the prostate.

MATERIALS AND METHODS

A total of 147 patients randomized to undergo transurethral microwave thermotherapy or transurethral resection of the prostate were asked to complete a self-administered questionnaire evaluating sexual function before, and 3 and 12 months after treatment. The questionnaire dealt with such items as social status, libido, quality of erection, ejaculation and overall satisfaction of sexual functioning.

RESULTS

There was a statistically significant improvement of micturition in both groups. The improvement in the transurethral prostatic resection group was significantly better than in the transurethral microwave thermotherapy group. Antegrade ejaculation occurred at 3 months following treatment in 27% of the transurethral prostatic resection group compared to 74% of the transurethral microwave thermotherapy group and at 1 year in 37 and 67%, respectively. Significantly more patients undergoing transurethral prostatic resection (36%) had changes in sexual function compared to the transurethral microwave thermotherapy group (17%). The transurethral microwave thermotherapy group was more satisfied with the sex life. Of these patients 55% graded sex as very satisfying compared to 21% in the transurethral prostatic resection group. The severity of symptoms was not correlated with sexual function in this study. In general, older patients had sexual dysfunction more often, while younger patients had pain during sexual activities more frequently.

CONCLUSIONS

Although clinically less effective, high energy transurethral microwave thermotherapy is a better therapeutic option than surgery for patients who want to preserve sexual function. In particular ejaculation is often preserved after transurethral microwave thermotherapy while there is significant deterioration following transurethral prostatic resection. In general, older patients have greater sexual dysfunction.

Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting

OBJECTIVES

To examine the variability of bladder outlet obstruction and mild lower urinary tract symptoms in patients with benign prostatic hyperplasia (BPH) followed up by watchful waiting.

METHODS

The International Prostate Symptom Score (IPSS) has four questions related to voiding symptoms and three related to filling symptoms. Scores of 0 to 7, 8 to 19, and 20 to 35 represent mild, moderate, and severe symptoms, respectively. Over a period of 36 months the IPSS questionnaire was administered to 479 patients 50 to 81 years old (mean age 63) with BPH. A pressure-flow study was used to determine the presence of bladder outlet obstruction. On the basis of their scores, the patients were classified into 50 with mild, 227 with moderate, and 202 with severe symptoms. In the present study only patients with a mild score were analyzed.

RESULTS

Of 50 patients with mild symptoms, 16 (32%) had bladder outlet obstruction. After a period of 9 to 22 months (mean 17) of watchful waiting, these 16 patients were reviewed. Twelve (75%) of the 16 had bladder outlet obstruction reconfirmed by pressure-flow studies, and 3 (18.8%) of 16 had increased symptoms (moderate symptomatic) and underwent treatment (1 began pharmacologic treatment, and 2 chose transurethral resection). A total of 4 (25%) of 16 patients still had mild voiding disturbances and refused the second urodynamic evaluation. The remaining 34 patients with no obstruction had annual routine follow-up and had persistent mild symptom scores and normal uroflowmetric results. These patients did not undergo another pressure-flow evaluation.

CONCLUSIONS

A pressure-flow study is routinely avoided in patients with a mild IPSS. From symptoms alone it was not possible to diagnose bladder outlet obstruction in these patients. Pressure-flow studies and symptom profiles measure different aspects of the clinical condition. After a mean follow-up of 17 months of watchful waiting, 13 (81.2%) of 1 6 patients were clinically stable. Because the need for therapy is dictated by quality of life, it is difficult to propose treatment for patients with minimal symptoms, even in the presence of bladder outlet obstruction.

The predictive value of baseline variables in the treatment of benign prostatic hyperplasia using high-energy transurethral microwave thermotherapy

OBJECTIVE

To evaluate the combination of patient age, prostate size, grade of outlet obstruction and total amount of energy, all independent predictive variables of treatment outcome in patients with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) treated with high-energy transurethral microwave thermotherapy (HE-TUMT), and thus provide nomograms for predicting treatment outcome after HE-TUMT.

PATIENTS AND METHODS

Between October 1993 and July 1996, 247 patients with LUTS and BPH were treated with HE-TUMT using the Prostatron device, software version 2.5 (EDAP Technomed, Lyon, France). The World Health Organisation Response Evaluation Criteria were used to evaluate the outcome. Patient age, prostate volume, total amount of energy and grade of outlet obstruction were categorized using the Akaike information criterion (AIC). The probabilities of a good/intermediate vs a poor response at 26 weeks according to the AIC were calculated.

RESULTS

Nomograms are presented providing the estimated probability (95% confidence interval) for a good/intermediate response of the evaluation of the International Prostate Symptom Score at 26 weeks by categories of prostate volume, total amount of TUMT energy and age, and of maximum urinary flow rate by categories of bladder outlet obstruction (linear passive urethral resistance ratio, linPURR) and total amount of energy, and of linPURR by categories of prostate volume and total amount of energy. The total amount of energy appeared to have the most impact in the prediction of good/intermediate and poor response in all three response evaluation criteria.

CONCLUSIONS

These nomograms may assist urologists in making clinical recommendations for the treatment of men with LUTS and BPH using HE-TUMT.

Quantitative assessment of uroflow: is there a circadian rhythm?

OBJECTIVES

To investigate if the circadian rhythm of urinary flow values varies within groups of patients with varying degrees of bladder outlet obstruction.

METHODS

A total of 170 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction used a home-based uroflowmeter and produced a total of 1670 correctly measured flows at home. These patients also underwent a screening program with free urinary flowmetry in the hospital and a urodynamic pressure and flow study.

RESULTS

There is a circadian variability in urinary flow values in men with higher grades of obstruction. These men have a higher peak urinary flow with a smaller voided volume and thus a shorter flow time in the early afternoon when compared with late evening, early morning, and the midnight to morning periods.

CONCLUSIONS

This significantly greater maximum flow in the afternoon in men with higher grades of obstruction can be an important bias in studies where the primary end point is to assess a small improvement in maximum flow. Therefore, the circadian rhythm of uroflow has to be taken into account in the evaluation of the efficacy of treatment. Patients participating in clinical research studies should produce their urinary flow in the clinic always during the same time period, either in the morning or in the afternoon, and should not switch their appointment time.

Urodynamic and clinical effects of noninvasive and minimally invasive treatments in elderly men with lower urinary tract symptoms stratified according to the grade of obstruction

OBJECTIVES

We investigated the symptomatic and urodynamic effects of several noninvasive and minimally invasive treatment modalities to quantify these effects and to compare subjective and objective results within groups with various degrees of obstruction.

METHODS

In a prospective study at one center, 487 patients who completed a full screening program including urodynamic investigation started treatment with watchful waiting, terazosin, transurethral microwave thermotherapy, or laser treatment of the prostate; they were re-evaluated symptomatically and urodynamically after 6 months of therapy. The symptomatic and urodynamic results of 87 patients from another center who underwent transurethral resection of the prostate and who had their second urodynamic evaluation 6 months after surgery were also included.

RESULTS

In patients without bladder outlet obstruction (BOO), improvement in maximum flow and symptom scores with little change in the degree of obstruction was most apparent, whereas a decrease of detrusor pressure at maximum flow was observed mainly in patients with BOO. The urodynamic effect but not the symptomatic effect of treatments depended on the initial grade of BOO. Urodynamic changes were more marked in the minimally invasive treatment groups compared with the noninvasive treatment groups.

CONCLUSIONS

In symptomatic patients with benign prostatic hyperplasia, symptomatic improvement in the short term does not seem to depend on changes in urodynamic parameters. Future well-controlled studies focusing on the durability of symptomatic and urodynamic effects will be needed to illustrate the relative potential of urodynamic and other clinical parameters to predict a favorable response to current and innovative treatments.