Symptoms versus flow rates versus urodynamics in the selection of patients for prostatectomy

Super early detailed assessment of lower urinary tract symptoms after holmium laser enucleation of the prostate (HoLEP): a prospective study

PURPOSE

To prospectively investigate early and consecutive changes of lower urinary tract symptoms (LUTS), specifically storage symptoms after holmium laser enucleation of the prostate (HoLEP).

METHODS

Patients referred for HoLEP completed the International Prostatic Symptom Score (IPSS) the day before, at discharge, and 1, 2, 3, 4, 6, 8, 12, 16, 20, 24, and 52 weeks after HoLEP. Total IPSS was stratified into mild (score 0-7), moderate (8-19), and severe (20-35) LUTS. Storage symptoms were sub-stratified into storage "negative" and "positive". IPSS changes served as the main postoperative outcome. Mixed linear models identified risk factors affecting postoperative recovery of LUTS.

RESULTS

Between December 2010 and 2012, 144 consecutive HoLEP patients were prospectively included in the study. Preoperatively 57.6% of the cohort reported severe storage symptoms (mean total IPSS: 22.6 ± 5.0). Total IPSS decreased significantly immediately after surgery (p < 0.001). Patients with severe LUTS, storage-positive sub-score, and high maximum urinary flow rate were affected by a rebound of mainly storage symptoms 6-8 weeks after HoLEP and prolonged recovery from LUTS. Of these, about 7.4% presented persisting urge complaints. Finally, 12 weeks following HoLEP, the vast majority of patients were symptom-free. Limitations of this study include missing urodynamic workup and a comparative patient cohort.

CONCLUSION

Immediately after HoLEP, patients experience a significant decrease of LUTS. Continuous symptom recovery seems to be hampered in patients with severe and storage-positive baseline symptoms. (De-novo) storage symptoms slightly affect postoperative recovery. Quality of life is restored to a stable and significantly improved status 3 months after surgery.

Noninvasive Medical Tools for Evaluating Voiding Pattern in Real Life

Voiding dysfunction is a common disease that contributes to a lower quality of life and has an increased prevalence in the elderly population. Noninvasive and objective methods such as uroflowmetry (UFM) and voiding diaries (VDs) are essential for exact diagnosis and effective treatment of this condition because patients with different causes of voiding dysfunction can complain of the same lower urinary tract symptoms. Further, different treatment options can be determined based on the diagnosis made from these symptoms. In order to improve the quality of UFM and VDs and to provide a convenient testing environment, several advances have been made by previous investigators. In this study, we investigate the history and technological mechanisms of UFM and VDs. We also aim to review UFM from the viewpoint of clinical and at-home uses, including the recently proposed toilet-shaped UFM and electronic VDs.

Uroflowmetry in a large population of Brazilian men submitted to a health check up program and its correlation with IPSS and prostate size

PURPOSE

The aim of this study was to assess the uroflowmetry data in a large population of asymptomatic Brazilian men submitted to a health check up program and their correlation to IPSS and prostate size.

MATERIALS AND METHODS

Asymptomatic men underwent a health check-up program between January and December 2012. The inclusion criteria were men between 40 and 70 years, IPSS ≤ 7, without bladder, prostate, urethral surgery, neurological diseases, urinary tract infection, PSA < 4.0 ng/dL and urinary volume higher than 150 mL. Urological assessment consisted of clinical history, IPSS, digital rectal examination (DRE), prostate specific antigen (PSA), urinalysis, ultrasonography and uroflowmetry.

RESULTS

A total of 1041 asymptomatic men were included in this study. The average age was 49 years and average maximum flow rate was 17.4 mL/s. In spite of IPSS and prostate size increase with aging, they had a weak correlation with Qmax cutoffs (10 mL/s and 15 mL/s). A total of 85 men (8.3%) had more than 60 years, and even in this group, Qmax was higher than 15 mL/s. Out of 1041 men, 117 had IPSS less than 8 and Qmax less than 10 mL/s.

CONCLUSIONS

In asymptomatic men there is a weak correlation between IPSS, prostate size and uroflowmetric data. The establishment of different normal cutoffs seems to be complicated and uroflowmetry data should be interpreted with caution in order to avoid misdiagnosis.

Practical uroflowmetry

• Uroflowmetry is an essential investigation that can assist in the diagnosis of common lower urinary tract dysfunctions. • This article describes key aspects on performing and interpreting the test.

Avoid cruising on the uroflowmeter: evaluation of cruising artifact on spinning disc flowmeters in an experimental setup

AIMS

The aim of our study was to access the variability of maximum flow rate (Q(max)), average flow rate (Q(av)) and flow pattern while varying the point of impact of flow on the flowmeter.

METHODS

Water was delivered through a motorised tube holder in a standardised experimental set up. Flow was directed in 4 different directions on the funnel; 1) Periphery, 2) Base, 3) Centre and, 4) in a cruising motion from the periphery of the funnel to the centre and back again. The variation in the Q(max), Q(av) and the flow pattern were studied at 4 different flow rates. The variables recorded when the flow was directed at the centre of the funnel was taken as baseline.

RESULTS

There was a significant difference in the Q(max) and Q(av)when the point of impact was at the periphery or in a cruising motion compared to the centre. The difference was more marked with cruising motion with a characteristic flow pattern. The maximum percentage difference in Q(av) was 4.1%, whereas the difference in Q(max) was higher at 16.6% on comparing crusing motion with the values from the centre.

CONCLUSION

We have demonstrated a significant variation in Q(max), Q(av) and flow pattern with change in the point of impact on the flowmeter. Though the changes in Q(av) were statistically significant, the alteration in the recorded Q(max) values was more striking. Our study emphasizes the importance of combining Q(av) and flow pattern along with Q(max) in interpretation of results of uroflowmetry.

Benign Prostatic Hyperplasia in Primary Care: What You Need to Know

PURPOSE

We reviewed recent literature and treatment guidelines regarding the prevalence, pathophysiology, and management of BPO related to BPH; and management of lower urinary tract symptoms secondary to BPH.

MATERIALS AND METHODS

Published literature and current treatment concepts were reviewed regarding the diagnosis and treatment options for BPO.

RESULTS

BPH is a histological diagnosis that can contribute to medical problems, including enlargement of the prostate and BPO. These conditions should be treated only if the symptoms are troublesome, there is considerable risk of progression, and/or cancer is suspected. Very effective medical and surgical options are available to treat BPO and improve patient quality of life.

CONCLUSIONS

BPO is highly treatable, but should be managed in close collaboration with the patient. Pharmacological agents and minimally invasive procedures, when appropriate, are generally preferred to more invasive surgery. Patients with mild or moderate symptoms usually can be treated by a primary care physician; more complicated cases should be referred to a urologist for evaluation and management.

Does digital rectal examination affect uroflowmetry measurements?

AIMS

To determine whether digital rectal examination (DRE) would affect uroflowmetry parameters and whether these findings were not due to the circaidan changes.

METHODS

A total of 79 male patients (59 in study and 20 in control group) were included in this study. First uroflowmetry was done at 10:00 am just before the genitourinary physical examination in the study group. Second and third uroflowmetry was performed at the 6th and 24th hour after the first uroflowmetry. The same uroflowmetry tests were done in a control group without DRE. Voided volume and maximum and average flow rate parameters of uroflowmetry were interpreted in our study. The relationship among first, second, and third uroflowmetry parameters were determined in the study and control groups.

RESULTS

There were statistically no difference between the mean first, or 6th- or 24th-hour uroflowmetry parameters of the study and control groups (P > 0.05).

CONCLUSIONS

We could not find any effect of DRE on uroflowmetry parameters. Studies in a larger patient series would be appropriate for recommending DRE before or after uroflowmetry test.

[Techniques and current practice of urodynamics. Problems and traps]

Development of urodynamics particularly during the past decade are highlighted, as well as a number of issues to be faced in the near future: research into the etiopathogenesis of different conditions, finding more sensitive and specific diagnostic procedures to overcome the current ones, establishing more comprehensive indications for urodynamics examinations and, as a result of all the above achieving greater improvement of certain surgical procedures. Both the technique and interpretation of the different urodynamic examinations, as well as the more recent innovations, implementation issues and controversies are detailed to a highly up-to-date level. Neuromodulation and ambulatory urodynamics deserve thoughtful consideration in this paper. Finally, attention is given to the controversies and future challenges such as urodynamic research providing accurate diagnosis of lower urinary tract obstruction in women, establishing the indication of urodynamic studies in women with urinary exertional incontinence, outlining the indications of neuromodulation and ambulatory urodynamics, applicability of artificial intelligence systems, improvement of artificial sphincter materials, tissue growth for bladder enlargement and actual prevention of myelodysplasia.

Comparison of parameters to determine the cause of urinary disturbance in men with prostate volume less than 20 milliliters

BACKGROUND

A pressure-flow study, although a slightly invasive procedure, can evaluate bladder outlet obstruction and detrusor contractility. This study was conducted in men with a non-enlarged prostate to determine the cause of urinary disturbance by less invasive examinations that might eventually replace pressure-flow study.

METHODS

Thirty-six men with lower urinary tract symptoms were enrolled. Their prostate volume, estimated by transrectal ultrasonography, was less than 20 mL. All patients were examined using pressure-flow study, free-flowmetry, transrectal ultrasonography, prostate specific antigen and an interview using the International Prostate Symptom Score and Quality of Life Index. With determination of the cause for urinary disturbance, parameters that correlated with outflow obstruction or impaired detrusor contractility were sought.

RESULTS

Twenty-one (60%) of the 36 men were judged as having outflow obstruction, and 16 of these 21 men had normal detrusor function. Impaired detrusor contractility was observed in 17 men. Only three of these 17 men had no outflow obstruction. Four patients had an unstable bladder. All these four had normal detrusor contractility, but had outflow obstruction. Among the parameters examined, only the maximum flow rate in a flow metrogram (Qmax) correlated significantly with the degree of outflow obstruction (P = 0.04). The positive predictive value of Qmax for outflow obstruction was 65% at a flow rate of less than 10 mL/s, and 100% at that of less than 5 mL/s. No parameter correlated with detrusor contractility.

CONCLUSION

The only parameter that was a clear indicator of outflow obstruction was Qmax. Other indicators of detrusor contractility should be sought.

Computerised assessment of maximum urinary flow: an efficient, consistent and valid approach

OBJECTIVES

To evaluate the relative accuracy of a computerised method to quantitatively assess maximum urinary flow.

METHODS

A total of 1147 uroflows were evaluated by the computerised method and by three experts from different European countries. The sample consisted of uroflows from the respective visits by a 20% sample of randomly chosen patients (n = 223) with lower urinary tract symptoms with participation in two clinical trials in which the efficacy and safety of Permixon was evaluated. The proportions of automated maximum flow values included in the 10% extended range of experts (and their 95% confidence intervals) were assessed, as well as the concordance coefficients between experts and the computerised method and the paired Student's t-test for the average differences between experts and computer.

RESULTS

The rate of agreement between experts and computer varied between about 95 and 100% over factor levels for visit, type of machine and country. Concordance coefficients indicated good agreement between experts and the automated method. When looking at average differences between experts and the computer, the smallest differences were observed between experts 2, 3 and the computer (differences not statistically significant). Statistically significant average differences were observed between expert 1 and the other experts as well as between expert 1 and the computer.

CONCLUSIONS

The computerised assessment decreases the fraction of variability of maximum urinary flow caused by artifacts as well as intra- and inter-expert variation. The computerised assessment of maximum urinary flow is an efficient, consistent and valid approach to quantitatively assess maximum urinary flow in clinical trials.

Pressure-flow studies for patient selection in the treatment of symptomatic BPH--a one-year follow-up study

OBJECTIVE

Many different treatments for lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) are available today. To select the most suitable method for each patient is therefore a delicate task. The aim of this study has been to use a standardised systematic investigation schedule including pressure flow studies (pQS) in order to try to use graded treatment according to obstruction.

METHODS

Ninety-nine patients were systematically examined with routine investigations and pQS to select between 3 treatment options, TURP, TUMT 2.0 (low energy) and watchful waiting (WW). Patients with severe BOO were recommended TURP, patients with moderate BOO were treated with TUMT and patients with no or minor BOO were recommended WW.

RESULTS

TURP produced the best improvement in maximum free flow (Q-max), IPS-score and PVR, but only TURP had serious complications. TUMT treatment produced a more moderate improvement in flow rate, IPS-score and PVR, and all of the complications were minor. WW did not improve PVR or Q-max but the IPS-score decreased significantly. One UTI was the only complication in the WW group.

CONCLUSIONS

pQS can be used to allocate patients with LUTS due to suspected BOO into different treatment arms; TURP, TUMT, WW, all with known different effects of BOO and with different severity of complications. Good symptomatic effect in Q-max, PVR and IPS-score with less serious complications and at low failure rate can thereby be obtained.

Predictors of treatment outcome for high-energy transurethral microwave thermotherapy

BACKGROUND AND PURPOSE

Transurethral microwave thermotherapy (TUMT) is an innovative alternative to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) suggestive of bladder outflow obstruction (BOO). Although the results are satisfactory for the majority of the patients, a considerable number of patients have an unfavorable outcome. Thus, the identification of features able to predict efficacy of TUMT for individual candidates is an important issue.

MATERIALS AND METHODS

The available literature in MEDLINE covering the predictive role of various baseline measures for the outcome of high-energy TUMT was reviewed. Direct comparison among various studies was not possible because of differences in thermotherapy devices, treatment protocols, and the definition of a good response to treatment.

RESULTS

Predictive features have been detected only for the Prostatron device. A small prostate volume, a low grade of BOO, and advanced age were independent predictors of poor outcome. The strongest predictive feature was the amount of energy delivered during treatment. Histologic characteristics (epithelial:stromal ratio and microvessel density) have not proved predictive for therapeutic outcome. The role of intraprostatic vascularization, as a regulator of the temperature during treatment, seems to be of the greatest importance, but results have not been presented yet.

CONCLUSION

The value of baseline clinical measures for the selection of the best candidates for TUMT is limited at best. Variations in the internal structure of the individual prostate seem to play the most important role in regulating the amount of energy absorbed during treatment, and further research must focus on this item.

Long-term follow-up of laser treatment for lower urinary tract symptoms suggestive of bladder outlet obstruction

OBJECTIVES

The long-term results of different laser technologies in the management of lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO) are not well known. We studied the durability of the effect of laser prostatectomy and tried to identify the factors predictive of treatment outcome.

METHODS

Between December 1992 and November 1996, 190 patients underwent laser prostatectomy because of LUTS suggestive of BOO. One hundred seven patients received visual laser ablation of the prostate (VLAP), 30 received contact laser vaporization (CLV), and 53 received interstitial laser coagulation (ILC). The baseline evaluation included the International Prostate Symptom Score (IPSS), uroflowmetry (maximum urinary flow rate), postvoid residual urine (PVR), prostate volume measurement, and urodynamic investigation. Patients were followed up until April 1999. Kaplan-Meier plots were constructed to calculate the risk of retreatment, and the log-rank test was used to evaluate the predictive value of clinical parameters for treatment failure.

RESULTS

The median follow-up in the VLAP group was 53 months; the retreatment rate was 14% (95% confidence interval [CI] 6% to 22%). The corresponding numbers for the CLV and ILC groups were 47 months and 14% (95% CI 1% to 26%) and 34 months and 41% (95% CI 23% to 60%), respectively. A high PVR and a high grade of obstruction in the VLAP group, and a younger age in the ILC group, were associated with increased retreatment risk.

CONCLUSIONS

VLAP and CLV have a durable effect, as demonstrated by their low retreatment rate. ILC is a less aggressive procedure, at the expense of a high retreatment rate. Patient selection for VLAP can be based on the grade of obstruction and PVR.

The Streamtest cup: a new uroflow device

OBJECTIVES

To create an inexpensive, simple, accurate, and noninvasive device to evaluate the character of a male's urinary stream.

METHODS

The results of a formal in-office uroflow study performed on 50 symptomatic men were compared with those of the same men using the Streamtest cup.

RESULTS

All men with a urine flow of 12 mL/s or greater reached or exceeded the red line on the Streamtest cup. No patient whose stream was less than 11 mL/s was able to reach the red line.

CONCLUSIONS

Uroflowmetry is an excellent study in diagnosing, managing, and monitoring the treatment of urinary obstructive disease secondary to benign prostatic hyperplasia. The Streamtest cup can provide both the patient and the physician with a clinically accurate visual assessment of an individual's urine flow at a significant cost savings over other testing means. The Streamtest cup when compared with a formal in-office uroflow study provided clinically similar results in separating obstructive uropathy from a normal urinary flow.

Pathophysiological relationships between lower urinary tract symptoms and the prostate do not strengthen over time

BACKGROUND

The aim of this survey was to examine the relationships among baseline prostate gland volume and changes in urinary symptomatology 3 years later.

METHODS

A Scottish community-based cohort of 193 men aged 40-79 years who had prostate volume measured by transrectal ultrasound (TRUS) were followed-up at 3 years.

RESULTS

Only baseline nocturia correlated with prostate volume (r = 0.202, P = 0.0057), although some relationships existed for the antero-posterior dimension of the prostate gland. More statistically significant relationships were evident for adenoma volume rather than prostate volume, but they still had relatively low correlations (range, 0.19-0.31).

CONCLUSIONS

This study demonstrates the lack of relationships between prostate gland variables and lower urinary tract symptoms (LUTS). Those relationships that are statistically significant (at the P < 0.01 level) are weak, and only explain at most 9% of the total variation of prostate or adenoma volume or their dimensions.

Predictability of conventional tests for the assessment of bladder outlet obstruction in benign prostatic hyperplasia

BACKGROUND

The degree of bladder outlet obstruction (BOO) in benign prostatic hyperplasia (BPH) is most accurately quantified by pressure flow studies (PFS), although these studies are more invasive and complicated than conventional tests. We examined how precisely conventional tests predicted the PFS-assessed degree of BOO.

METHODS

The study population consisted of 232 BPH patients who had undergone routine conventional tests and PFS. Correlation of the conventional test results with the degree of BOO assessed by PFS was examined by Spearman's correlation coefficients. Regression and subgroup analyses were performed to predict the degree of BOO using the conventional test results as the explanatory variables.

RESULTS

The degree of BOO correlated with prostate volume, the degree of endoscopic obstruction, and to a lesser extent, with the maximum flow rate (Qmax) and age. The predictability of conventional tests alone, or in combination, for BOO, was approximately 60% to 70%, which is not acceptable for investigational use. However, almost all patients with a prostate volume larger than 30 mL, or with severe obstruction on urethroscopic findings, had an obstructed bladder outlet.

CONCLUSION

PFS is mandatory when the precise evaluation of the degree of BOO is required, and patients are highly likely to have an outlet obstruction when they have a prostate larger than 30 mL, or severely obstructed posterior urethra on endoscopy.

Clinical outcome at 3 months after transurethral vaporization of prostate for benign prostatic hyperplasia

OBJECTIVES

To evaluate the clinical outcome of transurethral vaporization of the prostate (TUVP) for the management of benign prostatic hyperplasia (BPH).

METHODS

Between March and June 1995, 30 patients with symptomatic BPH treated by TUVP were enrolled in this study. Transrectal ultrasonography (TRUS) was done preoperatively. American Urological Association (AUA) symptom score determination, pressure flow study, and questionnaire (for evaluating potency) were done preoperatively and 3 months postoperatively.

RESULTS

The average age was 70.5 years (range 60 to 83) and estimated prostate size by TRUS before surgery was 33.8 +/- 14.0 g. The average AUA symptom score decreased significantly 3 months after TUVP (6.2 +/- 7.8 versus 18.2 +/- 9.0; P < 0.01). The maximum urine flow rate (Qmax) was 11.1 +/- 3.7 mL/min before TUVP (mean +/- SD) and 17.0 +/- 6.5 mL/min 3 months after TUVP, whereas the detrusor pressure at maximum urine flow (Pdes at Qmax) was 61.0 +/- 23.9 and 41.2 +/- 15.2 cm H2O, respectively. Qmax increased and Pdes at Qmax decreased significantly 3 months after TUVP. Of the 30 patients, 3 (10%) developed bladder neck contracture. Of the 24 patients who were potent sexually before operation, 3 (12.5%) developed impotence 3 months after surgery.

CONCLUSIONS

TUVP is an effective alternative surgical procedure to relieve obstruction for patients with symptomatic BPH. However, cautious attitude on its usage is advocated based on our preliminary results indicating the occurrence of late complication such as impotence and bladder neck contracture.

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 terazosin therapy in symptomatic patients with and without bladder outlet obstruction: a stratified analysis

OBJECTIVES

To evaluate clinical and urodynamic changes in patients with and without bladder outlet obstruction (BOO) and to compare the clinical and urodynamic results of terazosin treatment between patients with and without BOO.

METHODS

In a prospective study, 97 patients who completed a full screening program including urodynamic investigation with pressure-flow study analysis started treatment with terazosin. A total of 60 patients completed 6 months of treatment and were re-evaluated with International Prostate Symptom Scores (IPSS), uroflowmetry, and urodynamic investigation with pressure-flow study analysis. Patients were stratified using the linear passive urethral resistance relation (lin-PURR) classification according to Schäfer. Patients with a lin-PURR of 3 or more were classified as patients with BOO and patients with a lin-PURR of 2 or less were classified as patients without BOO. The clinical and urodynamic changes within and between the groups with and without BOO were evaluated.

RESULTS

Terazosin resulted in significant symptomatic relief (9 points on the IPSS scale; P < 0.01) and a significant improvement of free urinary flow (3.0 mL/s; P < 0.01). In patients with BOO, a statistically significant improvement of all urodynamic obstruction variables (P < 0.01) was shown. In patients without BOO, a significant improvement of free urinary flow (4.4 mL/s; P < 0.01), a statistically significantly improved bladder capacity (increase of 70 mL; P = 0.01), and no statistically significant changes in urodynamic obstruction variables (P > 0.05) were shown. Patients with a hypoactive detrusor were more prone to early dropout. When comparing the changes of symptoms (P = 0.89), quality of life (P = 0.85), and the number of patients with improvements of free uroflow of at least 30% (P = 0.15), there appeared to be no significant difference between the groups with and without BOO.

CONCLUSIONS

Although there is a statistically significant difference in urodynamic response to terazosin treatment between patients with and without BOO, we cannot recommend the use of pressure-flow studies in the selection of patients for terazosin treatment because the clinical results of treatment appear not to be significantly different between patients with and without BOO. It seems more useful, and certainly less expensive and less invasive, to start alpha 1-blocker therapy if, on clinical grounds, the urologist considers the patient to be a candidate for alpha 1-blocker therapy, and to continue therapy in those who respond.

Reproducibility of uroflow measurement: experience during a double-blind, placebo-controlled study of doxazosin in benign prostatic hyperplasia

OBJECTIVES

To evaluate the interindividual and intraindividual variation of uroflow measurements in men with benign prostatic hyperplasia (BPH).

METHODS

A total of 147 men with clinical evidence of BPH underwent two uroflow measurements at each of two screening visits prior to recruitment into a placebo-controlled study of doxazosin in the treatment of BPH. The maximum and mean flow rates were determined on each occasion. Differences in the mean value of both parameters for the cohort were examined. The intraindividual variability was evaluated using intraclass correlation coefficients and differences in maximum uroflow at each visit were examined.

RESULTS

Uroflow measurements for the cohort were reproducible and there was no clinically significant difference in maximum and mean flow rate on each occasion. However, the intraclass correlation coefficients for the mean and maximum flow rate varied between 0.70 and 0.82, indicating that intraindividual variation accounted for a substantial component of the total variation in uroflow observed among these patients. For many individuals, test-retest differences were clinically relevant.

CONCLUSIONS

For a group of patients, maximum and mean uroflow measurements are reproducible. However, for an individual, these parameters are subject to clinically significant variation and a single measurement may not be representative. This may be important when considering the need for therapeutic intervention.

Uroflowmetry

Uroflowmetry is a widely used noninvasive screening modality for patients who present with symptoms of lower urinary dysfunction. However, it should be recognized that uroflowmetry represents the compound effect of bladder and urethral function because it may easily be misinterpreted. In elderly men with "prostatism", uroflowmetry is often sufficient to indicate treatment, while the value in women is less prominent. In pediatrics, more sophisticated urodynamic testing is crucial.

Differential diagnosis of prostatism: A 12-year retrospective analysis of symptoms, urodynamics and satisfaction with therapy

PURPOSE

We determined the incidence of voiding symptoms, urodynamic etiology and satisfaction with therapy in a large cohort of men with prostatism during a 12-year period.

MATERIALS AND METHODS

We retrospectively analyzed the records of 2,845 consecutive men who underwent urodynamic evaluation between January 1982 and December 1994. Patients were divided into groups 1 and 2 according to the years of study (between 1982 and 1988, and between 1989 and 1994, respectively). Parameters of evaluation included prevalence and distribution of voiding symptoms, urodynamic etiology of symptoms and satisfaction with therapy (medical or surgical).

RESULTS

There was 843 evaluable patients 50 to 94 years old (mean age 63.2) Group 2 patients were younger, and had a 22% higher prevalence of nocturia and a 12% higher prevalence of daytime frequency. The prevalence of all other symptoms was the same in both groups. On urodynamics 523 patients (62%) had demonstrable evidence of bladder outlet obstruction of whom 345 (66%) had concomitant detrusor instability. Of the 843 patients 647 (77%) had detrusor instability, which was the sole diagnosis in 199 (24%). We noted low pressure/low flow in 137 patients (16%) and impaired detrusor contractility in 152 (17%), including 57 (7%) in whom the latter condition was the only diagnosis. Urodynamic findings remained the same during the entire 12-year period. Global satisfaction and symptomatic improvement were better with surgical than medical therapy, although the degree of satisfaction was independent of the urodynamic etiology of symptoms.

CONCLUSIONS

Symptomatic men with prostatism are presenting with a greater prevalence of significant nocturia and daytime frequency than in the past with no change in urodynamic findings. In addition, patient level of satisfaction remains greater with surgical than medical therapy regardless of the urodynamic presence of bladder outlet obstruction.

Does anamnestic symptom evaluation or clinical examination give enough information to evaluate the severity of obstruction in benign prostatic hyperplasia?

In this study we have investigated 70 men fulfilling the usual criteria accepted for transurethral resection of the prostate (TURP). The anamnestic evaluation included the Madsen-Iversen symptom score and a quality of life questionnaire. The clinical examination included suprapubic pressure flow measurement, free urinary flow, the determination of residual urine and the ultrasound evaluation of the size of the prostate. The clinical data were correlated with the grade of obstruction according to Schäfer calculated from the pressure/flow studies. No correlation was found between the grade of obstruction and anamnestic symptom data, the size of the prostate or residual urine. A slight correlation was found between the Schäfer grade of obstruction and the flow curve pattern or peak flow.

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a pathologic disorder that develops in response to the action of dihydrotestosterone on the aging prostate and to changes in stromal and epithelial cells in this exocrine gland. The current therapies for this disorder are chosen after other causes for irritative and obstructive symptoms have been excluded and the status of the urinary tract has been assessed. This evaluation includes a detailed medical history, a thorough genitourinary and neurological examination, assessment of serum prostate specific antigen and creatinine levels, as well as a urinalysis. A urodynamic evaluation consisting of a combined pressure-flow study is required if the diagnosis of obstruction is to be made. Patients with minimal symptoms and normal test results require no therapy. Mild to moderate symptoms can be controlled, at least temporarily, with alpha-adrenergic blockers such as terazosin or doxazosin. A subset of BPH patients with obstructive symptoms respond to the 5 alpha-reductase inhibitor finasteride. Early results with minimally invasive treatments such as laser prostatectomies, hyperthermia, and ultrasonic and radiofrequency ablation appear encouraging for those with moderate symptoms of prostatism. Severe symptoms, urinary retention, gross hematuria, recurrent urinary tract infections, bladder calculi, and hydronephrosis or renal insufficiency warrant transurethral incision, resection, vaporization, or open prostatectomy (for very large neoplasms). Although the morbidities of these latter surgical therapies are not insignificant, these treatments offer the best and most durable results for relief of obstruction and amelioration of symptoms.

Comparative study of laser versus electrocautery prostatic resection: 18-month followup with complex urodynamic assessment

A total of 25 patients with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia was entered into a prospective, randomized trial comparing prostatectomy done with the Urolase right angle firing neodymium:YAG laser fiber and standard transurethral electroresection of the prostate. Efficacy of treatment, as assessed by standardized American Urological Association symptom scores, patient assessment of symptom improvement, peak urinary flow rates, post-void residual urine volumes and complex urodynamic evaluation, including assessment of opening pressure and maximum detrusor voiding pressure, was equivalent for the 2 treatment groups through 1 year. Ultrasonic assessment of prostatic volumes at 1 year showed a mean decrease in total volume of 59% for standard electrocautery resection compared to 28% for laser prostatectomy. Symptom scores and peak urinary flow rates remained equivalent for both groups through 18 months.

Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

Is pre-operative imaging of the urinary tract worthwhile in the assessment of prostatism?

The reports of routine pre-operative imaging investigations performed on patients presenting with symptoms of uncomplicated benign prostatic hypertrophy were compared with management decisions and clinical outcome. In 175 patients with prostatism no urological abnormality which altered management was discovered on plain films of the abdomen and pelvis and ultrasound of the urinary tract which were performed routinely. Post-micturition residual volume (PMRV), estimated by ultrasound, was compared with the maximum urine flow rate (Q max) in 57 patients. PMRV showed negative correlation with Q max. Both high PMRV and low Q max were associated with the urologist's decision to operate, but multiple logistic regression revealed that ultrasound residual volume was not a significant predictor of operation when adjusted for Q max. Urologists in this hospital therefore use flow rates as the primary indication of the need to operate. We suggest that no routine pre-operative imaging need be performed in patients presenting with prostatism.

Survey of urological centres and review of current practice in the pre-operative assessment of prostatism

A survey of 24 urological centres has shown a wide variation in the routine pre-operative assessment of patients being considered for prostatectomy. Imaging of the urinary tract by intravenous urography (IVU) or ultrasound (US) is performed in 21/24 centres (79%) and plain films in 16/24 (67%). Post-micturition residual volume (PMRV) is estimated quantitatively in 10/24 centers (42%). Although there is little agreement on what constitutes a significant PMRV, a large PMRV leads to increased likelihood of operation, and earlier operation. Peak urine flow rate (Q max) is measured in 19/24 centres (79%). The significance of these findings is discussed.

Dilatation of the prostatic urethra with 35 mm balloon

A series of 54 men, 25 with acute urinary retention and 29 with cytometrically proven bladder outflow obstruction (BOO), underwent dilatation of the prostatic urethra using a 35 mm fixed diameter, low compliance balloon. In 42 patients this was performed under cystoscopic guidance and in 12 patients under fluoroscopic control. Three months following dilatation, 13/27 patients (48%) with BOO who returned for review were rendered unobstructed and 19/27 (70%) were symptomatically improved. By 6 months only 3 remained unobstructed but 15 remained symptomatically improved. Nine months after dilatation 14 patients retained symptomatic improvement but only 2 remained unobstructed. Of the 25 patients treated for acute retention only 6 voided spontaneously, 1 of these relapsing into retention at 2 months and another at 4 months. No patient was rendered unobstructed but 2 patients (who declined prostatectomy) noted an improvement in their obstructive symptoms at both 3 and 6 months. No patient developed retrograde ejaculation following dilatation. Balloon dilatation to 35 mm has no role in acute urinary retention but may have a role in younger men with BOO who wish to avoid prostatectomy and the risk of retrograde ejaculation. In these patients careful follow-up is required.