Uso de la uroflujometría en el estudio de síntomas del tracto urinario bajo en pacientes masculinos. Hospital Central Universitario Dr. Antonio María Pineda / Use of uroflowmetry in the study of lower urinary tract symptoms in male patients. Central University Hospital Dr. Antonio María Pineda

La uroflujometría es un estudio no invasivo del tracto urinario inferior que entrega información objetiva del flujo urinario y es ampliamente recomendado por las guías europeas en el estudio de pacientes con sintomatología urinaria baja. Se realizó un estudio descriptivo transversal cuyo propósito fue describir el uso de la uroflujometría en el estudio de síntomas del tracto urinario bajo en pacientes masculinos que acudieron a la consulta de Servicio de Urología del Hospital Central Universitario Dr. Antonio María Pineda de la ciudad de Barquisimeto, estado Lara durante el lapso 2018- 2019. La muestra estuvo conformada por 150 pacientes. Los resultados indican que el 62% de la muestra corresponde a pacientes entre 60 y 70 años de edad de los cuales 52% manifestaron síntomas urinarios leves. La uroflujometría evidenció que 56% de los pacientes tienen un flujo máximo entre 10 y 20 ml/seg lo cual sugiere una probable obstrucción al flujo de salida; 78% de los pacientes presentan un flujo promedio entre 0 a 10 ml/seg. El 53% de los pacientes mostró un volumen de vaciado < 300 ml y 49% un tiempo de flujo máximo entre 30 y 50 segundos. En conclusión, la uroflujometría es un examen simple y rápido que proporciona información útil sobre la salud de las vías urinarias inferiores(AU)

Uroflowmetry is a non-invasive study of the lower urinary tract that provides objective information on urinary flow and is widely recommended by European guidelines for the study of patients with lower urinary tract symptoms. We performed a cross-sectional descriptive study to describe the use of uroflowmetry for the study of lower urinary tract symptoms in males who attended the Servicio de Urología of the Hospital Central Universitario Dr. Antonio María Pineda (Barquisimeto, Lara state) during the 2018- 2019 period. The sample was made up of 150 males. The results show that 62% of the sample included males between 60 and 70 years old and 52% complained of mild urinary symptoms. Uroflowmetry results showed that 56% of patients had a maximum flow between 10 and 20 ml/sec suggestive of urinary tract obstruction; 78% had an average flow between 0 and 10 ml/sec while 53% had a micturition volume < 300 ml and 49% had a maximum flow time between 30 and 50 seconds. Uroflowmetry is a simple and fast test which provides useful information about the health of lower urinary tract(AU)

[Validation of visual prostate symptom score, VPSS, in the evaluation of lower urinary tract symptoms associated with benign prostatic hyperplasia (550 patients)]. / Validation du score visuel prostatique en images SVPI dans l'évaluation des symptômes du bas appareil urinaire associés à une hyperplasie bénigne de la prostate (550 patients).

OBJECTIVES: Our objective was to validate the VPSS (visual prostatic symptom score) score in the French language for the identification and monitoring of BPH-related LUTS in urological practice. METHODS: A prospective observational survey was carried out between September the 15th 2014 and July the 30th 2015 in urology practices. The first 4 consecutive patients aged over 60 years, with BPH-related LUTS requiring prescription of an alpha-blocker, were enrolled. We translated a "visual prostatic symptom score" (VPSS) into French and adapted it slightly. At the first visit and follow-up visit (1-3 months after the first visit), the patient completed 2 questionnaires: the French language version of the IPSS and the VPSS. RESULTS: Of the urologists contacted, 169 enrolled at least one patient and returned information; 550 questionnaires were included in the statistical analysis. The median IPSS and VPSS total scores, subscores and quality of life scores all decreased significantly (P<0.0001) between enrolment and the follow-up visit 1-3 months later. Correlations between the IPSS and VPSS at enrolment and the follow-up visit and their variation were all significant. Total VPSS was significantly correlated with total IPSS, as were the irritative, obstructive and quality of life subscores evaluated on the corresponding pictograms. CONCLUSIONS: This study showed the VPSS to be a simple and useful tool for identifying and monitoring BPH-related LUTS. LEVEL OF EVIDENCE: 4.

Establishment and value assessment of efficacy prediction model about transurethral prostatectomy.

OBJECTIVES: To establish and to evaluate discriminant models to predict the outcomes of transurethral prostatectomy. METHODS: Clinical data of patients treated with transurethral prostatectomy between January and December 2013 were collected, including medical history, symptoms, biochemical tests, ultrasonography and urodynamics. Surgical efficacy was evaluated at 6-month follow up. Predictive models were constructed by logistic regression. Receiver operating characteristic curve and diagnostic tests were used to test the accuracy of models before the predictive value between models was compared. RESULTS: A total of 182 patients were included, with 73.6% having an effective outcome. History of recurrent urinary tract infection (OR 1.33), score of storage phase (OR 2.58), maximum flow rate (OR 2.11) and detrusor overactivity (OR 3.13) were found to be risk factors. International Prostate Symptom Score (OR 0.13), transitional zone index (OR 0.58), resistive index of prostatic artery (OR 0.46), bladder wall thickness (OR 0.78), ultrasonic estimation of bladder weight (OR 0.28), bladder outlet obstruction index (OR 0.20) and bladder contractility index (OR 0.83) were found to be protective factors. The areas under the curve of models using factors from ultrasonography and urodynamics were 0.792 and 0.829 respectively, with no significant difference being found between them (P = 0.348). CONCLUSIONS: Surgical efficacy of transurethral prostatectomy is positively correlated to severe voiding phase symptoms, outlet obstruction and better detrusor contractility, and negative correlated with urinary infection, severe storage phase symptoms and excessive detrusor contractibility. Ultrasonography might replace urodynamics in selecting patients for whom transurethral prostatectomy is more likely to be beneficial.

Is the ultrasound-estimated bladder weight a reliable method for evaluating bladder outlet obstruction?

OBJECTIVE: • To evaluate the correlation between ultrasound-estimated bladder weight (UEBW) in patients with different degrees of bladder outlet obstruction (BOO). METHODS: • We evaluated 50 consecutive non-neurogenic male patients with lower urinary tract symptoms (LUTS) referred to urodynamic study (UDS). All patients self-answered the International Prostate Score Symptoms (IPSS) questionnaire. After the UDS, the bladder was filled with 150 mL to determine UEBW. • Patients with a bladder capacity under 150 mL, a previous history of prostate surgery or pelvic irradiation, an IPSS score <8, a bladder stone or urinary tract infection were excluded. • After a pressure-flow study, the Schafer linear passive urethral resistance relation nomogram was plotted to determine the grade of obstruction: Grades I-II/VI were defined as mild obstruction, Grades III-IV/VI as moderate obstruction, and Grades V-VI/VI as severe obstruction. RESULTS: • The UEBW was 51.7 ± 26.9, 54.1 ± 30.0 and 54.8 ± 28.2 in patients with mild, moderate and severe BOO, respectively (P= 0.130). The UEBW allowed us to define four groups: (i) UEBW <35 g; (ii) 35 g ≤ UEBW < 50 g; (iii) 50 g ≤ UEBW < 70 g; and (4) UEBW ≥ 70 g. • We did not find any differences in age, prostate weight, IPSS, PVR, cystometric bladder capacity, presence of detrusor overactive and degree of obstruction in the aforementioned groups. CONCLUSION: • Despite the fact that some studies have emphasized the value of UEBW as an efficient non-invasive method for evaluating lower urinary tract obstruction, our study suggests that UEBW does not present any individual correlation with LUTS or objective measurements of BOO.

The role of invasive and non-invasive urodynamics in male voiding lower urinary tract symptoms.

INTRODUCTION: Troublesome voiding lower urinary tract symptoms (LUTS) are a common problem in men, particularly with ageing. Implicitly, management of voiding LUTS can be guided by accurate determination of underlying mechanisms, distinguishing men with voiding symptoms caused by outlet obstruction from those with reduced bladder contractility. METHODS: A PubMed search of the published literature on invasive and non-invasive methods used to assess lower urinary tract function was carried out. RESULTS: A multitude of methods have been applied to assess LUTS. Multichannel pressure flow studies (PFS) are the standard for diagnosing bladder outlet obstruction and underlying mechanisms of LUTS, though their invasive nature can be difficult to tolerate, and improved prediction of treatment outcome is disputed. Uroflowmetry and post void residual measurement are insufficient to make a definitive diagnosis. Ultrasound-derived measurements of bladder wall thickness and estimated bladder weight offer a potential non-invasive alternative to PFS, but their diagnostic parameters are still under evaluation. Non-invasive methods that measure isovolumetric bladder pressure by interrupting the urinary stream can reproducibly measure pressure and urinary flow, but are unable to determine the effects of abdominal straining during voiding and give no insight into urine storage symptoms. Doppler ultrasound during urethral flow is informative, but it is an expensive approach whose clinical utility has yet to be established. CONCLUSION: A variety of non-invasive urodynamic and non-urodynamic techniques have been used to evaluate LUTS and some show great promise. However, there is as yet, insufficient evidence to justify replacement of invasive voiding cystometry by these investigational approaches.

Ultrasound assessment of intravesical prostatic protrusion and detrusor wall thickness--new standards for noninvasive bladder outlet obstruction diagnosis?

PURPOSE: We evaluated the accuracy of detrusor wall thickness and intravesical prostatic protrusion, and the association of each test to diagnose bladder prostatic obstruction in patients with lower urinary tract symptoms. MATERIALS AND METHODS: We enrolled in the study 100 consecutive patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Baseline parameters were International Prostate Symptom Score, prostate volume, urinary flow rate, intravesical prostatic protrusion, detrusor wall thickness, Schaefer obstruction class, minimal urethral opening pressure and the urethral resistance algorithm bladder outlet obstruction index. A ROC curve was produced to calculate AUC and evaluate the diagnostic performance of intravesical prostatic protrusion, detrusor wall thickness and prostate volume for bladder prostatic obstruction. RESULTS: We noted a highly significant correlation between intravesical prostatic protrusion and the bladder outlet obstruction index (Spearman's rho = 0.49, p = 0.001), and Schaefer obstruction class (Spearman's rho = 0.51, p = 0.001). A highly significant correlation was also observed for detrusor wall thickness and the bladder outlet obstruction index (Spearman's rho = 0.57, p = 0.001), detrusor wall thickness and Schaefer obstruction class (Spearman's rho = 0.432, p = 0.02). On multivariate analysis intravesical prostatic protrusion and detrusor wall thickness were the only parameters associated with bladder prostatic obstruction (p = 0.015). The AUC for intravesical prostatic protrusion was 0.835 (95% CI 0.756-0.915) and for detrusor wall thickness it was 0.845 (95% CI 0.78-0.91). The association of intravesical prostatic protrusion and detrusor wall thickness produced the best diagnostic accuracy (87%) when the 2 tests were done consecutively. CONCLUSIONS: Suprapubic ultrasound of detrusor wall thickness and intravesical prostatic protrusion is a simple, noninvasive, accurate system to assess bladder prostatic obstruction in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.

Correlation between prostatic urethral angle and bladder outlet obstruction index in patients with lower urinary tract symptoms.

OBJECTIVES: To evaluate the association of prostatic urethral angle (PUA) with bladder outlet obstruction (BOO) index in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). METHODS: A retrospective analysis was made of 260 men with LUTS and/or BPH aged>50 years (median: 65.9, range: 50-87). Patients underwent an evaluation including the International Prostatic Symptom Score, serum prostate-specific antigen levels, transrectal ultrasonography, frequency-volume chart, uroflowmetry, and measurement of postvoid residual, and multichannel video urodynamic study with a pressure-flow study. RESULTS: Patients with higher PUA (PUA>or=35 degrees) had higher prostate-specific antigen levels (P=.043), larger prostate volume (P<.001), higher maximal urethral closure pressure (P=.004), higher detrusor pressure at maximum flow rate (P=.008), and higher BOO index (P=.032), in comparison with those who had lower PUA (PUA<35 degrees). There was no significant difference of PUA values according to the degree of intravesical prostatic protrusion. When we compared BOO index according to PUA, patients with higher PUA had higher BOO index than those with lower PUA (30.6+/-1.8 vs 23.6+/-1.8, P=.006). The area under the curve of PUA was significant for BOO (area, 63.0%; 95% confidence interval, 55.1%-70.9%; P=.002). CONCLUSIONS: PUA may be one method to asses the presence of BOO in men with LUTS and/or BPH. Our findings suggest that PUA may help in the treatment of individuals by better predicting their likely classification from a pressure-flow study.

The comparative pressure-flow plot properties of radiological bladder neck and prostatic obstruction.

OBJECTIVES: To test the hypotheses that: (i) significant differences should exist in pressure/flow data between radiologically determined bladder neck and prostatic obstruction; (ii) these differences should inform understanding of the pathophysiology of male outflow obstruction. The biomechanics of the voiding/pressure/flow plot imply that a urodynamic assessment trace should identify outflow obstruction and characterise the urethral viscoelastic properties. Micturating cystourethrograms (MCUG) images might provide a useful diagnostic dichotomy for testing these assumptions. MATERIALS AND METHODS: The pressure/flow data from 71 men who also provided video-urodynamic imaging data that a radiologist could classify unequivocally as showing bladder neck obstruction (42) or prostatic obstruction (29) were analysed. The following variables were recorded: the detrusor pressure at initiation of voiding (P(det.open)); the detrusor pressure at the end of voiding (P(det.close)); the detrusor pressure at maximum flow rate (Q(max)), (P(det.)Q(max)), and Q(max). The urethral resistance relation (URR) was drawn onto the pressure-flow plot and the gradient of the URR, DeltaP(det)/DeltaQ, was calculated. RESULTS: There were significant between group differences in P(det.open) (95% confidence interval of the difference 5.2-28.6, U = 352, P = 0.003); P(det.close) (0.2-15.0, U = 428, P = 0.034); P(det).Q(max) (0.0-18.9, U = 439, P = 0.05); Q(max) and DeltaP(det)/DeltaQ did not distinguish between the MCUG groups (95% confidence interval of the difference 2.3-18, U = 111; P = 0.004). The best-fit model from linear combinations of the data achieved an area under the receiver operator curve of 0.72 for discriminating between the MCUG groups. CONCLUSIONS: The urodynamic assessment identified interesting and coherent biomechanical differences, and could distinguish between the obstructions with a moderate degree of accuracy.

Invited commentary: Lower urinary tract symptoms and inflammation--weighing the evidence.

Lower urinary tract symptoms (LUTS) are a common condition, particularly among older men. The etiology of these symptoms is often obscure and not always clearly related to prostatic enlargement or benign prostatic hyperplasia. St. Sauver et al. (Am J Epidemiol. 2009;169(11):1281-1290) hypothesized that systemic inflammation may be associated with LUTS and benign prostatic hyperplasia. Using a well-defined cohort, they found that, in general, inflammation was not related to LUTS or to benign prostatic hyperplasia progression. However, men with the highest amount of systemic inflammation, as measured by C-reactive protein levels, were at increased risk of a rapid change in irritative voiding symptoms and decreased urinary flow but not obstructive voiding symptoms or prostate size. To what degree systemic inflammation relates to inflammation within the urinary system and specifically the bladder and/or prostate is unclear. Furthermore, to what degree inflammation within the urinary system contributes to LUTS is unclear. Given that clinical trials of antiinflammatory drugs for LUTS have been largely unsuccessful, the role of inflammation as a contributor to LUTS remains an interesting hypothesis that requires further study.

Associations between C-reactive protein and benign prostatic hyperplasia/lower urinary tract symptom outcomes in a population-based cohort.

Inflammation may play a role in the development of benign prostatic hyperplasia and/or lower urinary tract symptoms (LUTS). Higher levels of C-reactive protein (CRP) may therefore be associated with the development of these outcomes. The authors examined the association of CRP levels measured in 1996 with rapid increases in prostate volume, prostate-specific antigen levels, and LUTS as well as rapid decreases in peak flow rates (through 2005) in a population-based cohort of men residing in Olmsted County, Minnesota. Men with CRP levels of > or =3.0 mg/L were more likely to have rapid increases in irritative LUTS (odds ratio (OR) = 2.14, 95% confidence interval (CI): 1.18, 3.85) and rapid decreases in peak flow rates (OR = 2.54, 95% CI: 1.09, 5.92) compared with men with CRP levels of <3.0 mg/L. CRP levels were not significantly associated with rapid increases in prostate volume, obstructive LUTS, or prostate-specific antigen levels. Associations were attenuated after adjusting for age, body mass index, hypertension, and smoking history (irritative LUTS: OR = 2.00, 95% CI: 1.04, 3.82; peak flow rate: OR = 2.45, 95% CI: 0.73, 8.25). These results suggest that rapid increases in irritative LUTS and rapid decreases in peak flow rates may be due to inflammatory processes.

Presumed circle area ratio of the prostate in a community-based group of men.

OBJECTIVE To determine the normal values for the presumed circle area ratio (PCAR) in a group of community-based men, and to determine whether PCAR is associated with specific urological outcomes. PATIENTS AND METHODS The study was a cross-sectional analysis among 328 Caucasian men (94% participation) residing in Olmsted County, Minnesota, USA. The PCAR was measured during prostatic ultrasonography. Lower urinary tract symptoms (LUTS) were measured using the American Urologic Association Symptom Index. The peak urinary flow rate was measured by a uroflowmeter, and the postvoid residual volume (PVR) was assessed using the BladderScan(TM) BVM 6500 (Verathon, Bothell, WA, USA). Correlations between PCAR and presence of LUTS, peak urinary flow rate, and PVR were determined using Spearman correlation coefficients. Unadjusted and adjusted odds ratios (ORs) were calculated using logistic regression to determine the associations between PCAR thresholds and categorical urological outcomes. RESULTS The median (interquartile range) PCAR was 0.85 (0.81-0.88). After adjusting for age and total prostate volume, men who had PCARs of >0.90 were more likely to have elevated overall and obstructive symptom scores (OR 2.95, 95% confidence interval 1.39-6.25, and 3.47, 1.63-7.39, respectively). CONCLUSION PCAR might add further information beyond total prostate volume when predicting the development of obstructive LUTS.

Association of lower urinary tract symptoms and chronic ischaemia of the lower urinary tract in elderly women and men: assessment using colour Doppler ultrasonography.

OBJECTIVES: To investigate, using transrectal colour Doppler ultrasonography, (TRCDUS) whether perfusion of the bladder and prostate is reduced in elderly patients with lower urinary tract symptoms (LUTS), common in later life, as experimental data suggest that chronic ischaemia has a key role in the development of LUTS. PATIENTS, SUBJECTS AND METHODS: In 32 elderly patients with LUTS (12 women, mean age 82.3 years, group 1; and 20 men, 79.4 years, group 2) perfusion of the bladder neck (in women) and of the bladder neck and prostate (in men) was measured using TRCDUS and the resistive index (RI) and colour pixel density (CPD) determined, assessed by a TRUS unit and special software. To assess the age-related effect two control groups of 10 young healthy women (mean age 42.3 years, group 3) and 10 age-matched healthy men (mean age 41.5 years, group 4) were also enrolled. RESULTS: Irrespective of gender, there was markedly lower bladder perfusion in elderly patients with LUTS than in the younger subjects. The mean (SD) RI of the bladder neck in group 1, of 0.88 (0.06), and group 2, of 0.80 (0.08), was higher than in control groups 3, of 0.62 (0.05), and group 4, of 0.64 (0.09). The results were similar for the CPD measurements. The frequency of daily and nightly micturition showed a strong negative correlation with perfusion in the urinary bladder. CONCLUSION: In elderly patients with LUTS there was decreased perfusion of the bladder neck and prostate when assessed using TRCDUS. Therefore, decreased perfusion in the urinary bladder might be responsible for the development of LUTS with advancing age.

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

OBJECTIVE: To investigate whether a mechanism of action of alpha-blockers on lower urinary tract symptoms (LUTS) involves improved perfusion of the LUT. PATIENTS, SUBJECTS AND METHODS: The accuracy of perfusion measurements using transrectal colour Doppler ultrasound (TRCDUS) and colour pixel density (CPD) was initially confirmed in a porcine model. Following this confirmation, measurements were taken from four healthy male volunteers and 19 patients with LUTS. The urinary bladder was filled slowly (50 mL/min) with 0.2 m KCl, which resembles the osmolarity of concentrated urine, and evaluated by cystometry. In parallel, TRCDUS and measurement of the CPD of the LUT were performed. The patients with LUTS were then treated with daily alpha-blocker (0.4 mg tamsulosin) for 5 weeks and urodynamic variables as well as perfusion were evaluated again. RESULTS: In the healthy men, perfusion of the LUT increased considerably (157%) during filling of the bladder to a mean (sd) maximum cystometric capacity (C(max)) of 481 (28.9) mL. All the patients with LUTS had a reduced mean C(max) during filling with KCl at 322.4 (58.5) mL. The mean CPD in the urinary bladder and the prostate were only increased by 58.4% during filling with KCl. After alpha-blocker therapy the mean C(max) during filling with KCl rose to 382.5 (42.9) mL; furthermore, perfusion of the LUT measured by CPD was significantly increased (132.8%). CONCLUSIONS: The present data strongly suggest that LUTS are associated with chronic ischaemia of the prostate and urinary bladder. alpha-blockers increase perfusion in the LUT and C(max). These results might explain the therapeutic effects of alpha-blockers on LUTS.

Sustained beneficial effects of intraprostatic botulinum toxin type A on lower urinary tract symptoms and quality of life in men with benign prostatic hyperplasia.

OBJECTIVE: To present a comprehensive experience with intraprostatic botulinum toxin-type A (BoNT-A) injection in men with symptomatic benign prostatic hyperplasia (BPH) and to assess the efficacy on lower urinary tract symptoms (LUTS) and quality of life (QoL). PATIENTS AND METHODS: In all, 41 men (mean age 69.1 years, sd 7.1 ) with an International Prostate Symptom Score of > or = 8, peak flow rate of < 12 mL/s, and who were refractory to medical treatment were injected with BoNT-A (Botox, Allergan, Inc., CA, USA) at 100 U (21 men, for prostate volume < 30 mL) or 200 U (20, for prostate volume > 30 mL) into the prostate transperineally under transrectal ultrasonography guidance. Study exclusion criteria were confirmed or suspected malignancy, previous pelvic surgery or trauma and previous invasive treatment for BPH. The clinical effects were evaluated at baseline and at 1, 3 and 6 months after treatment. RESULTS: There were no significant local or systemic side-effects in any men. LUTS and QoL indices improved by > 30% in 31 of the 41 men (76%), and four of five men with urinary retention for > 1 month could void spontaneously at 1 week to 1 month after the BoNT-A injection. In 12 of 41 men (29%) there was no change in prostate volume, yet seven of these men still had a > 30% improvement in maximum flow rate, LUTS and QoL. The efficacy was sustained at 12 months. CONCLUSION: BoNT-A injected into the prostate is safe and effective for men with symptomatic BPH. The mechanisms of relief of symptoms might not depend totally on the volume shrinkage; the inhibitory effect on the smooth muscle tone and aberrant sensory function might also be important.