Medical evaluation and management of male and female voiding dysfunction: a review.

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

The role of urodynamics in the surgical management of benign prostatic obstruction.

PURPOSE OF REVIEW: Benign prostatic obstruction (BPO) is a common cause of lower urinary tract symptoms (LUTS) in elderly men. However, such symptoms are often caused by primary detrusor overactivity or underactivity. Surgical management where BPO is absent or merely incidental has a lower chance of success, and exposes the patient to the potential complications of surgery. This review discusses the diagnostic challenges facing this common presentation. RECENT FINDINGS: Most evidence comes from small, historical prospective cohort studies. A Cochrane review found only two studies that met the prespecified inclusion criteria. It concluded that urodynamics changed decision-making regarding surgery for LUTS but it was not possible to determine whether this impacted upon outcome. A systematic review of several noninvasive alternatives to urodynamics could not recommend any of them over urodynamic pressure-flow study assessment. Further research is currently in progress, the 'UPSTREAM' study, which is a randomized, multicentre trial. Men are randomized to undergo investigation with clinical evaluation and uroflowmetry, or to additionally receive urodynamics. The primary aim is to determine the impact of urodynamics on the assessment pathway. SUMMARY: Assessment of BPO involves determining whether it has a contributory role in individual patients. This is a crucial factor in outcome, as surgery can give poor results if the symptoms are principally caused by detrusor dysfunction (overactivity or underactivity). Urodynamics can help determine this if undertaken to a suitable standard. Further research will identify the precise role of this test modality.

[Comparative analysis of the effectiveness of various techniques of endoscopic prostate enucleation in a single center]. / Sravnitel'nyi analiz éffektivnosti razlichnykh metodik éndoskopicheskoi énukleatsii prostaty.

AIM: To compare electro- and laser enucleation (thulium, holmium) of prostate hyperplasia. MATERIAL AND METHODS: 693 prostate hyperplasia patients were enrolled. 489 patients underwent holmium enucleation (HoLEP), 51 - monopolar enucleation, 153 - thulium enucleation (ThuLEP). Prostate volume was 91.7 (50-250) cm3. There were no significant differences in preoperative variables between both groups (I-PSS, QoL, Qmax, residual urine volume) (p>0.05). RESULTS: Mean time of HoLEP was 97.0±42.2 min, monopolar enucleation - 112.9±36.3 min, ThuLEP duration was significantly less (77.4±36.3 min, p<0.01). An efficacy of all methods was confirmed in 6 months after surgery by significant (p<0.01) improvement of functional parameters (I-PSS, QoL, Qmax, residual urine volume). CONCLUSION: High efficiency of thulium and holmium enucleation allows to consider them as 'gold standard' of prostate hyperplasia management. Despite higher incidence of complications an efficacy of monopolar enucleation is comparable to that in laser techniques.

Benign Prostatic Hyperplasia - An economic assessment of fixed combination therapy based on a literature review.

FederAnziani Senior Italia and SIU - Italian Society of Urology - have decided to work together to draft a document focussing on Benign Prostatic Hyperplasia (BPH), and to stress the importance of adherence with pharmacological treatment in this setting, from both a scientific and a patient standpoint. Starting from a literature search, the two associations analysed to what extent an increase in treatment adherence amongst these patients influences hospital savings and to what extent therapy persistence levels are affected by monotherapy rather than free drug combinations. These estimates were performed only on patients taking medicinal products belonging to the 5 α-reductase inhibitors (5ARI) class that, although not indispensable, are the compounds that bring the greatest benefits, especially in the elderly and for which we know that every additional 30 days of therapy reduced the likelihood of acute urinary retention (AUR) and surgery by 14% and 11% respectively *. The results show that the use of fixed combination therapy would involve an increase in persistence due to the lower rate of patients abandoning treatment over time. Each 30 day-increment of 5ARI therapy, i.e. for an expenditure of 10.6 million euros extra per year for 5ARI medication, savings of approximately 24.3 million euros in hospital costs could be achieved.

Clinical significance of prostatic-urethral angulation on the treatment outcome of patients with symptomatic benign prostatic hyperplasia treated with tamsulosin hydrochloride.

OBJECTIVES: To evaluate the impact of the prostatic-urethral angulation (PUA) on the treatment efficacy of selective alpha-1A receptor blocker in male patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: A total of 80 patients with LUTS/BPH and with mean age 53.3 ± 6.3 (range 47-70) were included in our prospective comparative study. The patients were classified into 2 groups as a consecutive cases 40 in each one depending on the PUA either ≤ 35° (group A) or > 35° (group B). PUA and different prostatic parameters were measured using transrectal ultrasound. Prostate-specific antigen (PSA), the International Prostate Symptom Score and quality of life score (IPSS/QoL score), maximum flow rate (Qmax), and postvoid residual (PVR) volume were compared between the groups. The clinical significance of PUA was evaluated after 8 weeks of medical treatment with tamsulosin hydrochloride 0.4 mg daily. RESULTS: Baseline evaluation (pre-treatment) for both groups were comparable to each other with no clinically significant difference regarding age, PSA, IPSS/QoL score, Q(max) and PVR volume (P-value > 0.05). Comparison of parameters after 8 weeks showed that tamsulosin hydrochloride improved the total IPSS and all subscores (P < 0.001), QoL (P = 0.001), Q(max) (P = 0.002), and PVR (P = 0.04) in group A (Table 1). CONCLUSION: Tamsulosin hydrochloride appears to be less effective in improving IPSS/Qol score, Qmax and PVR in patients with lager PUA. The PUA might be a predictor for the treatment efficacy of α-blockers and more studies are warranted in the future before the final conclusion.

Painful Bladder Filling and Painful Urgency are Distinct Characteristics in Men and Women with Urological Chronic Pelvic Pain Syndromes: A MAPP Research Network Study.

PURPOSE: We describe bladder associated symptoms in patients with urological chronic pelvic pain syndromes. We correlated these symptoms with urological, nonurological, psychosocial and quality of life measures. MATERIALS AND METHODS: Study participants included 233 women and 191 men with interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome in a multicenter study. They completed a battery of measures, including items asking whether pain worsened with bladder filling (painful filling) or whether the urge to urinate was due to pain, pressure or discomfort (painful urgency). Participants were categorized into 3 groups, including group 1-painful filling and painful urgency (both), 2-painful filling or painful urgency (either) and 3-no painful filling or painful urgency (neither). RESULTS: Of the men 75% and of the women 88% were categorized as both or either. These bladder characteristics were associated with more severe urological symptoms (increased pain, frequency and urgency), a higher somatic symptom burden, depression and worse quality of life (3-group trend test each p<0.01). A gradient effect was observed across the groups (both>either>neither). Compared to those in the neither group men categorized as both or either reported more frequent urological chronic pelvic pain syndrome symptom flares, catastrophizing and irritable bowel syndrome, and women categorized as both or either were more likely to have a negative affect and chronic fatigue syndrome. CONCLUSIONS: Men and women with bladder symptoms characterized as painful filling or painful urgency had more severe urological symptoms, more generalized symptoms and worse quality of life than participants who reported neither characteristic, suggesting that these symptom characteristics might represent important subsets of patients with urological chronic pelvic pain syndromes.

Evaluation and management of post-transurethral resection of the prostate lower urinary tract symptoms.

Transurethral resection of the prostate (TURP) continues to be the most common treatment in the operative management of benign prostatic hypertrophy (BPH). Several other modalities have shown equivalence to TURP. However, even after surgical treatment, up to one third of patients have bothersome lower urinary tract symptoms (LUTS). This review discusses the pathophysiology, evaluation, and management options for patients with LUTS after TURP.

Pharmacological treatment of lower urinary tract symptoms in men: implementation of recommendations in clinical practice.

CONTEXT: Introducing a consensus on pharmacological treatment of male LUTs to be applied to Urology Primary Care. EVIDENCE COMPILATION: The consensus has been created by an expert committee based on the latest recommendations by the European and American Guides for male LUTs treatment. Also, a bibliographic review of the latest advances in the therapeutical approach to these patients has been carried out. EVIDENCE SYNTHESIS: Although the prevalence of both LUTs and overactive bladder is high, and its impact on the quality of life and social cost have been widely described, the number of patients treated is low. On the other hand, current clinical practice doesn't necessarily match the Guides and for this reason false perceptions of the available treatments circulate. For instance, men with storage LUTS are often treated inadequately with α-blockers or 5-α-reductase inhibitors due to underlying obstructive disorders. However, it is known that the incidence of real obstruction tends to be low. Current evidence, though limited, shows that antimuscarinic drugs may be used safely by men with LUTs, and are not associated with an increase in the prevalence of high urinary retention. CONCLUSION: We propose an algorithm for the management of male LUTs in which various levels of clinical evaluation are shown for a specific diagnose, as well as for choosing the most appropriate treatment.

Prostatectomía simple (adenomectomía) por vía laparoscópica: experiencia en 59 pacientes consecutivos / Laparoscopic Simple Prostatectomy (Adenomectomy): Experience in 59 Consecutive Patients

Objetivo: La adenomectomía laparoscópica es una alternativa mínimamente invasiva a la cirugía abierta en próstatas de gran volumen. Nuestro objetivo es dar a conocer nuestra serie de 59 pacientes tratados mediante adenomectomía laparoscópica con control vascular preciso. Material y métodos: Entre junio de 2003 y junio de 2006 un total de 59 pacientes con una edad promedio de 65,5 años (51 a 82) fueron sometidos a adenomectomía laparoscópica extraperitoneal. Todos los pacientes tenían un historial de síntomas del tracto urinario inferior (STUI) y de hiperplasia benigna de próstata (HPB). La mediana del International Prostate Symptom Score (IPSS) fue de 20 puntos (16-22). La información fue recogida de forma prospectiva en una base de datos. El análisis fue realizado a posteriori. Resultados: Todos los 59 adenomas fueron extirpados en su totalidad por vía laparoscópica sin conversión a cirugía abierta. La mediana de volumen prostático preoperatorio medida por ultrasonidos fue de 108,5 cc (75-150). El tiempo operatorio promedio fue de 123 minutos (90-180). La pérdida de sangre promedio fue 415ml (50-1500) y 4 pacientes (14,8%) requirieron transfusión de sangre. Dos (7,4%) de los pacientes presentaron complicaciones perioperatorias. La mediana de estancia hospitalaria y el tiempo de sonda vesical fueron de 3,5 (2-7) y 4,2 (3-7) días respectivamente. Conclusiones: La prostatectomía laparoscópica simple extraperitoneal es un procedimiento efectivo para el tratamiento de grandes adenomas prostáticos. Parece haber menos morbilidad perioperatoria y en nuestra experiencia esta técnica parece factible y reproducible; sin embargo, su curva de aprendizaje es un tema complicado de abordar (AU)

Objective: Laparoscopic adenomectomy 150 is a minimally invasive alternative to open surgery in large prostates. Our aim is to discuss our series of 59 patients treated by means of laparoscopic adenomectomy with precise vascular control. Materials and methods: Between June 2003 and June 2006, a total of 59 patients with a mean age of 65.5years (51 to 82), underwent laparoscopic extraperitoneal adenomectomy. All the patients had a history of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). The mean International Prostate Symptom Score (IPSS) was 20 points (16-22). The information was collected prospectively in a database. The analysis was performed subsequently. Results: All 59 adenomas were completely removed laparoscopically without conversion to open surgery. The mean preoperative prostate volume by ultrasound was 108.5 cc (75-150). The average operating time was 123minutes (90-180). The mean loss of blood was 415ml (50-1500) and 4 patients (14.8%) required a blood transfusion. Two (7.4%) of the patients presented perioperative complications. The mean hospital stay and the bladder catheterization time were 3.5 (2-7) and 4.2 (3-7) days respectively. Conclusions: Laparoscopic extraperitoneal simple prostatectomy is an effective procedure for the treatment of large prostatic adenomas. There seems to be less perioperative morbidity and, in our experience, this technique seems to be feasible and reproducible; however, its learning curve is a complicated matter to deal with (AU)

Benign prostatic hyperplasia evaluation and management by urologists and primary care physicians: practice patterns from the observational BPH registry.

PURPOSE: We examined the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia by physician specialty (urologist vs primary care physician). MATERIALS AND METHODS: The BPH Registry and Patient Survey is a longitudinal, observational, disease registry cohort of patients enrolled from January 2004 to February 2005 in the United States. The survey examines patient outcomes and physician practice patterns in the management of lower urinary tract symptoms associated with clinical benign prostatic hyperplasia. It includes 402 urologist and primary care physician practices throughout the United States. Included in this study were 6,924 men with lower urinary tract symptoms/benign prostatic hyperplasia managed by watchful waiting or medical therapy. Data were collected on demographics, clinical characteristics and lower urinary tract symptoms/benign prostatic hyperplasia management using physician and patient completed forms. Multivariate analysis was done by physician specialty. RESULTS: Based on multivariate analysis urologists were more likely than primary care physicians to perform urinalysis (OR 3.9), serum prostate specific antigen (OR 1.2) and post-void residual urine (OR 18.9) measurement, uroflowmetry (OR 17.3), prostate ultrasound (OR 7.7) and biopsy (OR 3.5), renal ultrasound (OR 4.0) and cystoscopy (OR 4.6) but less likely to measure creatinine (OR 0.1). Men seeing urologists were twice as likely as men seeing primary care physicians to be treated with benign prostatic hyperplasia medical therapy vs watchful waiting. Significant differences by physician specialty were also observed for specific benign prostatic hyperplasia medical therapies. CONCLUSIONS: Significant differences in practice patterns were observed between primary care physicians and urologists in the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia. These data establish valuable benchmarks and identify possible interventions that may improve the standard of care.

Prospective comparison of a new visual prostate symptom score versus the international prostate symptom score in men with lower urinary tract symptoms.

OBJECTIVE: To evaluate the correlation between the International Prostate Symptom Score (IPSS) and a new Visual Prostate Symptom Score (VPSS) using pictures rather than words to assess lower urinary tract symptoms (LUTS). METHODS: Four IPSS questions related to frequency, nocturia, weak stream, and quality of life (QoL) were represented by pictograms in the VPSS. Men with LUTS were given the IPSS and VPSS to complete. Peak (Qmax.) and average (Qave.) urinary flow rates were measured. Statistical analysis was performed using Student's t, Fisher's exact, and Spearman's correlation tests. RESULTS: The educational level of the 96 men (mean age 64, range 33-85 years) evaluated August 2009 to August 2010 was school grade 8-12 (62%), grade 1-7 (28%), university education (6%), and no schooling (4%). The IPSS was completed without assistance by 51 of 96 men (53%) and the VPSS by 79 of 96 men (82%) (P<.001). Comparing education grade<7 vs grade>10 groups, the IPSS required assistance in 27 of 31 men (87%) vs 9 of 38 men (24%) (P<.001), and the VPSS required assistance in 10 of 31 men (32%) vs 3 of 38 men (8%) (P=.014). There were statistically significant correlations between total VPSS, Qmax. and Qave., total VPSS and IPSS, and individual VPSS parameters (frequency, nocturia, weak stream and QoL) vs their IPSS counterparts. CONCLUSIONS: The VPSS correlates significantly with the IPSS, Qmax. and Qave., and can be completed without assistance by a greater proportion of men with limited education, indicating that it may be more useful than the IPSS in patients who are illiterate or have limited education.

Diagnostic value of International Prostate Symptom Score voiding-to-storage subscore ratio in male lower urinary tract symptoms.

AIMS: To investigate the diagnostic value of the International Prostate Symptom Score (IPSS) voiding-to-storage subscore ratio (IPSS-V/S) in male lower urinary tract symptoms (LUTS). METHODS: A total of 253 men with LUTS were enrolled from January 2005 to July 2010. The voiding (IPSS-V) and storage IPSS (IPSS-S) subscores were recorded separately by the patients themselves. The IPSS-V/S was calculated and compared among various aetiologies based on videourodynamic studies. Receiver operating characteristics (ROC) curves were constructed for comparing the diagnostic value of various non-invasive methods for predicting failure to voiding and storage lower urinary tract dysfunction (LUTD). RESULTS: Patients with failure to voiding LUTD, including benign prostatic obstruction (n = 72), bladder neck dysfunction (n = 19), urethral stricture (n = 3) and poor relaxation of the urethral sphincter (n = 32), had mean IPSS-V/S scores > 1. In contrast, patients who were urodynamically normal (n = 2) or had failure to storage LUTD, including idiopathic detrusor overactivity (n = 84), increased bladder sensation (n = 37), and detrusor overactivity and impaired contractility (n = 4), had IPSS-V/S scores ≤ 1. When IPSS-V/S was used to differentiate male LUTS, failure to voiding LUTD was found in 81.2% of patients with IPSS scores > 1, while failure to storage LUTD was found in 75.7% of patients with IPSS-V/S ≤ 1. The area under ROC curve of IPSS-V/S was higher than for other non-invasive methods for predicting failure to voiding and storage LUTD. CONCLUSION: Measuring IPSS subscores and calculating IPSS-V/S is a simple and useful method to differentiate failure to voiding and failure to storage LUTD in men with LUTS. IPSS-V/S may provide a guide for the initial treatment, especially for primary care physicians without access to urological studies.

Change in International Prostate Symptom storage subscore after long-term medical therapy in BPH patients: finasteride and alpha-blocker combination therapy in men with moderate-to-severe LUTS/BPH in Korea.

OBJECTIVE: To evaluate the efficacy and the change of International Prostate Symptom Score (IPSS) storage subscore after combination therapy (α-blocker and finasteride) in patients with lower urinary tract symptoms (LUTS) consistent with moderate-to-severe benign prostatic hyperplasia (BPH) and compared with α-blocker-only treatment. METHODS: A total of 1315 patients seen in 5 urology centers in Korea from January 2001 to August 2007, with LUTS secondary to BPH were enrolled. Patients were divided into 4 groups according to treatment pattern (α-blocker monotherapy vs combination therapy) and IPSS storage subscores (≥6 vs <6). The changes from baseline in prostate volume, prostate-specific antigen concentration, IPSS, and Q(max.) were analyzed. We also determined the statistical differences among 4 groups in the IPSS, Q(max.), quality of life score (QoL), and prostate volume. RESULTS: Of the 1315 men, 217 (16.5%) completed the month 48 visit. All groups showed significant improvements in the IPSS total score, IPSS voiding subscores, and QoL at 1 year. However, the high storage subscore group at baseline showed a significantly higher improvement in IPSS total scores and IPSS voiding subscores compared with the low storage subscore group at year 4. IPSS storage subscores were improved only in patients with high storage subscores at baseline, especially in combination treatment group. The mean change in QoL score from baseline to year 4 was significantly improved in high storage subscore groups. CONCLUSIONS: Data from this retrospective analysis suggest that long-term combination treatment would be beneficial, especially to patients with severe storage symptoms at baseline.