evaluation of lower urinary tract symptoms (luts) jerry g. blaivas, md clinical professor of urology...

Evaluation of Lower Urinary Tract Symptoms (LUTS)

Jerry G. Blaivas, MD

Clinical Professor of Urology

Weil-Cornell College of Medicine

Adjunct Professor of Urology

SUNY Downstate Medical Center

Lower Urinary Tract Symptoms (LUTS)

• Storage symptoms(irritative symptoms)

• Voiding symptoms (obstructive symptoms)

Storage Voiding

Frequency

Urgency

Incontinence

Nocturia

Pain

Weak stream

Hesitancy

Incomplete emptying

Urinary retention

Post void dribblingStorage & voiding sx may be due to the bladder, the outlet or both bladder and outlet

Storage SymptomsBecause of the Bladder

• Detrusor overactivity- Idiopathic- Non-neurogenic

(pathologic)- Neurogenic

• Low bladder compliance

• Sensory urge

• Fistula

Storage SymptomsBecause of the Sphincter

• Functional classification

• Urethral hypermobility• Intrinsic sphincter deficiency

• Anatomic classification

• Type 0 - 3 SUI

Voiding SymptomsBecause of the Bladder

• Impaired detrusor contractility

neurogenic

myogenic

acquired behavior

• Detrusor overactivity

Emptying Problems Because of the Outlet

• Anatomic:

• prolapse

• prior surgery

• urethral diverticulum

• urethral stricture

• primary bladder neck

• Functional

• dyssynergia

• acquired behavior

• primary bladder neck

Diagnostic Evaluation: Goals

• Define underlying

pathophysiology

• Assess risk factors & co-

morbidities

• Identify remediable

conditions

• Formulate treatment plan

Underlying Pathophysiology

• Detrusor overactivity• Sensory urgency • Urethral obstruction• Sphincter dysfunction • Impaired detrusor contractility• Fistula• Polyuria

Identify Risk Factors

• Detrusor sphincter dyssynergia

• Low bladder compliance

• Significant urethral obstruction

• Grade 3 – 4 POP

Evaluation

• History & physical exam

• Questionnaire

• Urinalysis & culture

• Bladder diary

• Post void residual urine (PVR)

Evaluation (cont’d)

• Uroflow (Q)

• Pad test

• Cystoscopy

• Urodynamics

• Urinary tract imaging

Imaging

• Urinary Tract – Renal Ultrasound

– CT scan

– MRI

– Cystogram & VCUG

• Pelvis– Ultrasound:

• Vaginal

• Perineal

• Abdominal

– CT scan

– MRI

CYSTOGRAM & VCUG

• Cystogram - Radiographjc imaging ofof the bladder during filling

• VCUG (Voiding cysto-urethrogram) - Radiographic imaging of the bladderand urethra during voiding

CYSTOGRAM & VCUG

• Integrity of the sphincter

• Type & degree of urethral mobility

• Site of obstruction (narrowest partof the urethra during voiding)

• Vesico-ureteral reflux

• Bladder & urethral diverticula

Indications for Imaging*

• hematuria• neurogenic bladder• significant post-void residual• flank, abdominal or pelvic pain• untreated grade 3 – 4 POP• extra-urethral incontinence• low bladder compliance

*4th ICI, 2008 (and me)

History

• Questionnaire

• Patient interview

• Each symptom assessed by:• frequency of occurrence• severity• how bothersome

History

• Prior Rx

• Medications

• Review of systems

• Previous surgery

Physical Examination• General

• Neurologic

• Uro - gynecologic

• Neuro - urologic perianal sensation anal sphincter tone anal sphincter control b–c reflex

Bladder Diary

• Essential component of the w/u

• Time & amount of each urination

• Description of symptoms

• +/- Oral intake

• The diary is a snapshot to be

compared to day to day sx

Variable

Mean /MedianDay-time volume (ml) 1261 (721)

Night-time volume (ml) 468 (414)

Frequency Day 6.7 (6.5)

Frequency Night 0.4 (0.3)

Bladder Capacity day 229 (220)

Bladder capacity night 332 (294)

24hr Volume 1729 (1619)

24hr Frequency 7.1 (6.8)

Minimum void volume 81 (47)

Maximum void volume 514 (190)

Why did you urinate? (0) Out of convenience (no urge or desire) (1) Mild urge (but can delay urination for an hr) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min)

(4) Desperate urge (must go immediately) Incontinence grade: Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)

Why did you urinate? (0) Out of convenience (no urge or desire) (1) Mild urge (but can delay urination for an hr) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min)

(4) Desperate urge (must go immediately) Incontinence grade: Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)

OAB Bladder Diary Instructions

Time UPS Volume (ml) Incontinence Grade

6 AM 4 120 1

7:30 3 90 0

8:00 4 90 1

9:10 3 90 0

12:30 2 120 0

5:50 1 90 0

8:00 2 60 0

10:00 2 30 0

12:00 4 100 1

3:00 4 100 2

8:40 2 60 0

6:00 4 120 1

OAB Diary

Pad Test

• Useful for quantifying the amount of urine loss – two kinds:

• Stress pad test (20 min – 1 hour)(to provoke incontinence)

• 24 hour – 3 day – 7 day pad test( to mimic typical day)

24 Hour Pad Test

• Patient changes pads PRN

• Put each pad in plastic bag

• Bring pads to next office visit

• Weigh pads (1 gm = 1 ml urine loss)

• normal < 8 gms/24 hours

Post Void Residual Urine

• Assessment of emptying efficiency

• Measured by ultrasound or catheter (when there is a need for catheterization)

• Results may prompt further study

• An elevated PVR only means that the bladder did not contract strongly enough for that urethra during that particular micturition

• It does not necessarily mean there is bladder outlet obstruction

Post Void Residual Urine

Post Void Residual Urine

• A low PVR does not exclude urethralobstruction

• PVR has very larger intra-individual variability

• PVR should be repeated many times before clinical judgments are made

Uroflow (Q)

• Functional evaluation of interactionbetween the bladder & urethra

• Low flow:bladder outlet obstructionimpaired detrusor contractility

• Evaluate Qmax, Qave & shape of curve

ml/S

20

10

UroflowNormal

Seconds

ObstructedImpaired contractilityAcquired voiding dysfunction

Indications for Q & PVR*

• Voiding symptoms

• Elevated PVR

• Results may prompt further

investigation

• I get Q & PVR in all patients

*4th ICI, 2008

Indications for Cystoscopy*

• hematuria

• sterile pyuria

• pelvic/bladder/urethral pain

• vesicovaginal fistula

• extra-urethral incontinence

4th ICI, 2008

Purpose of Urodynamics

• Reproduce symptoms

• Diagnose pathophysiology of underlying symptoms

• Identify risk factors

• Direct treatment

• Prognosticate

Risk Factors

• Detrusor sphincter dyssynergia

• Low bladder compliance

• Significant urethral obstruction

• Grade 3 – 4 POP

Basic Urodynamics

• Cystometry

• Leak point pressure

• Uroflow

• PVR

• Cystogram & VCUG

Advanced Urodynamics• Synchronous Pdet/Q

• Sphincter EMG

• Dynamic & micturitional UPP

• Videourodynamics

• Computer indices of detrusorcontractility & urethral obstruction

Urodynamics

• An interactive test between patient & physician

• The findings must be interpreted at the time of the study

• It is not possible to interpret the study by looking at the tracings afterwardsunless there has been a detailed annotation

Prior to Urodynamics

• What are the symptoms?

• Functional bladder capacity

• Uroflow

• Postvoid residual urine

• Neurologic lesion?

• Formulate questions to be

answered by the study

Indications for Urodynamics

• Low uroflow

• High PVR

• Uncertain diagnosis

• Finding that requires further evaluation

• Persistent symptoms despite apparently appropriate treatment

Indications for Urodynamics

• Empiric treatment associated with risk • Irreversible or potentially morbid

treatment is planned• Risk of renal or bladder damage from

pre-existing conditions (radiation, NGB)• Harmful sequelae can occur in the absence

of symptoms

Storage Phase Urodynamics

• Cystometrogram (CMG)

• Leak Point Pressure

• Urethral Pressure Measurements

• EMG

• Cystogram

Emptying Phase Urodynamics

• Detrusor pressure – uroflow study

• Micturitional urethral pressure profile

• Sphincter electromyography (EMG)

• Post void residual

• Voiding cystourethrogram

Cystometry (CMG)

• Measurement of bladder pressure and volume bladder filling; records:

• Bladder sensations

• Bladder pressure

• Involuntary bladder contractions

• Bladder compliance

• Bladder capacity

• Control over micturition

Idealized CMG

pdet

Volume

Storage Voiding

• Gravity filling• Talk to patient• Observe height of water column• Account for every rise in pressure:

• detrusor contraction• increase in abdominal pressure• low compliance

• Observe for incontinence

Caveats

• CMG only assesses the bladder’s response to filling

• Many CMG abnormalities are caused by voiding dysfunction

• If CMG alone is done, underlying problem may be missed

(Voiding) Detrusor PressureUroflow Study

• Urethral obstruction = high detrusor pressure & low uroflow

• Impaired detrusor contractility = low or poorly sustained detrusor pressure& low flow

Urethral Obstruction

• Normal or high voiding pressure• Decreased uroflow

Qmax < 12 mL.S

pdet@Qmax > 20 cm H20

Blaivas - Groutz Nomogram

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50Free Qmax (ml/ sec)

pdet

.max

(cm

H2O

)

Moderate obstruction (2)

Severe obstruction (3)

Mild obstruction (1)

Unobstructed (0)

Impaired Detrusor Contractility

• Decreased voiding pressure• Decreased uroflow

Qmax < 12 mL.S

pdet@Qmax < 20 cm H20

2Strss

High pressure

Low flow

JK

Low pressure

Low flow

Videourodynamics• Combines urodynamics with fluoroscopic imaging

of the LUT during

–bladder filling

–provocative maneuvers

–voiding

• Most accurate means of assessment

• Each parameter serves as a check against the others

Evaluation of Stress Incontinence

• HX, PE (observation of SUI, prolapse)

• UA

• Q-tip test

• Bladder diary (incontinence episodes)

• Q & PVR (straining pattern)

Conditions Causing Incontinence

• Bladder problems Detrusor overactivity Low bladder compliance Fistula

• Sphincter problems Urethral hypermobility Intrinsic sphincter deficiency

Q-tip test

• Place lubricated Q-tip into meatus

• Record resting angle

• Record maximum deflection during cough and strain

• Hypermobility > 30O deflection

A measure of urethral mobility

Q-tip Test

> 30O = hypermobility

Cough or strain

50O

Vesical Leak Point Pressure(VLPP)

• The bladder is filled with 150 ml • The patient coughs or strains• VLPP = Pves at leakage• Low VLPP = intrinsic sphincter

deficiency• A means of quantitating intrinsic

sphincter strength

RwnNo leak

Cough

Rwn

VLPP

leak

Cough

VLLP = 45 cm H20Qtip = 0 > 10O

VLPP

AGAGAG

VLLP = 92 cm H20Qtip = 0 > 60O

AG

Urethral Hypermobility vs ISDFleischmann et al J Urol 169:999, 2003

• No correlation of ALPP with hypermobility:

–ALPP < 60 24% hypermobile

–ALPP 60-90 31% hypermobile

–ALPP > 90 41% hypermobile

Fleischmann et al, J. Urol 169(3): 999-1002, 2003

Urethral Hypermobility vs ISDFleischmann et al J Urol 169:999, 2003

• LPP & mobility do not correlate with incontinence episodes or pad weight

• ISD and hypermobility do not define discrete classes of patient

• Use LPP & mobility parameters to characterize not classify

Fleischmann et al, J. Urol 169(3): 999-1002, 2003.

Evaluation of OAB

• HX, PE (prolapse, urethral tic, NGB, UTI, bladder cancer)

• UA

• Bladder diary (voiding frequency, urge voids, maximum voided volume)

• Q & PVR (urethral obstruction, impaired contractility retention)

Urodynamic Evaluation of OAB

• Etiology

–detrusor overactivity

–sensory urgency

• Classification (based on control

mechanisms)

Detrusor Overactivity (DO)

• Idiopathic (detrusor instability)

• Pathologic (detrusor instability)

• Neurologic (NDO, detrusor

hyperreflexia)

Idiopathic Detrusor Overactivity

BA

Involuntary Contraction

Trying to hold

incontinent

Can’t hold any longer

Pathologic DO

• Urinary tract infection

• Genital prolapse

• Sphincteric incontinence

• Urethral obstruction

• Bladder cancer

• Bladder stones

Pathologic Detrusor Overactivity

Grade 3 prolapse

Grade 1 urethral obstruction

FK

Involuntary detrusor contraction

Incontinent

Urethral catheter

Urethral meatus

cystocele

Pathologic Detrusor Overactivity

Bladder cancer

Involuntary detrusor contractions

Bladder tumor(filling defects)

Remediable Causes of DO

• Urinary tract infection

• Urethral obstruction

• Stress incontinence

• Urethral diverticulum

Remediable Causes of DO

• Foreign body

• Genital prolapse

• Bladder stones

• Bladder cancer

Sensory Urgency

• An uncomfortable urge to void unassociated with detrusor overactivity

• Synonymous with hypersensitive bladder and painful bladder syndromes

Sensory Urgency

• Severe urge to void

• Low bladder volume

• Stable bladder

Sensory UrgencyEtiology

• Urinary tract infection

• Bladder outlet

obstruction

• Idiopathic

• Bladder stones

• Acquired behavior

• Bladder cancer

Evaluation of NGB

• HX, PE (extent of neurologic deficit, urinary retention, febrile

UTI)

• Urinalysis

• +/- Bladder diary & pad test

• +/- Q & PVR

• Videourodynamics

• +/- upper tract imaging

Neurogenic DO

• Stroke

• Parkinson's disease

• Multiple sclerosis

• Spina bifida

• Transverse myelopathy– spinal cord injury

– transverse myelitis

– tumor

Detrusor Hyperreflexia

• Synergy

–Stroke

–Parkinson’s

–MS(supraspinal)

–Spina bifida

• Dyssynergy

–SCI

–MS (spinal)

–Spina bifida

Involuntary Contraction

Can’t hold any longerPR

No flow

Trying to hold

incontinent

PS

Involuntary detrusor contraction

Involuntary sphincter contraction

Obstruction due to sphincter contraction

BLADDER COMPLIANCE• The ratio of a small change in bladder

volume to a small change in detrusor pressure

• bladder vol. = bladder compliance pdet

• A measure of bladder wall "stiffness”

• High filling pressures are more clinically relevant

Causes of Low Bladder Compliance

• Myelodysplasia

• Thoracolumbar SCI

• Indwelling catheter

• Bladder surgery

• Urethral obstruction

DS

Steep rise in pressure

Vesico-ureteral reflux

DS

Stop filling

Involuntary detrusor contraction

Vesico-ureteral reflux

Detrusor Leak Point Pressure(DLPP)

• Fill bladder until leakage occurs

• DLPP = Pdet at leakage

• For any bladder, the higher the DLLP, the higher the urethral resistance

• Untreated, a high DLPP poses high risk for renal damage

• DLPP is related to bladder compliance & urethral resistance

DS

DLPP

2

Evaluation of Voiding Symptoms

• HX, PE (prolapse, urethral tic, NGB)

• Urinalysis

• Bladder diary

• Q & PVR (urethral obstruction,

impaired contractility, retention)

• Patient: 51 y/o woman

• History: “pot belly” > plastic surgeon for abdominoplasty > palpable bladder > PVR = 2100 ml

SSTRS

• Exam: palpable bladder, normal neurologic

• Uroflow: 4 ml/S , interrupted pattern, voided volume = 150 ml

• PVR: 810 ml

• Cystoscopy: 3+ trabeculation, two large bladder diverticula

SSTRS

2Strss

• Treatment: Transurethral resection of vesical neck (2 gms)

• Pathology: fibromuscular tissue lined with urothelium with squamous metaplasia

• Uroflow: 31 ml/S , normal pattern, voided volume = 400 ml

• PVR: 95 ml

SSTRS

50

Flow

0

Ml/S

SSTRS

SS Post -op