Voiding Dysfunction
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1. Symptomatology and terminology of voiding dysfunction 2. International prostatic symptom scores (IPSS) 3. Hematuria : definition and causes 4. Investigation for patient with hematuria
Voiding Dysfunction AB CD E E (Sign & Symptom) GH AB GHI J ! JADK KLLCJ G MNOHEDED LUTS (Lower Urinary Tract Symptom) CD E LUTS G Terminology IS GH B T LUIVNE J U MNM NA NE M J B LD W N D LUTS (lower urinary tract symptom Irritative symptom Obstructive symptom Frequency Weak stream Nocturia Urinary hesitancy Urgency Intermittency Dysuria Postvoid dribbling Straining Acute and chronic urinary Retention Interruption of the stream Sense of residual urine
1 Symptomatology and terminology of voiding dysfunction Frequency K JDE IVE GHJJDEGHC ED BH MNa JJ I K NM bD L K 5-6 f DE g D f L G 300-400 cc. K JDE GI C W N D - Polyuria !E K !Bf ID D 2000 ./ L GI C L IJ GH W DW N J T OEW D HUI E OEIJLO (Diabetes Insipidus) OE ELI L GH OH fUM I jW N - Decreased bladder capacity G gGHUM N I K G ID D I K EE J D (Partial cystectomy), g Neurogenic bladder - Decreased functional capacity ! !E I K ELL IDI D GH G J M I K (irritation) ID M cystitis OE N D IG jELUM NI K JDEW N
Nocturia K JDEGHI !BfME O L GHI!NEW N J f MNUD Nocturnal frequency L OHE!Bf K JN W DI 2 f DEO M l Na LUIVNE l I GH J frequency E NI E U - Frequency GHI !BfIS E g W D G nocturia GI CGHI GHIOHE J psychogenic IG - Nocturia without frequency ELI MNaGHIV congestive heart failure G peripheral edema IOHE L ED supine UM N intravascular volume I H !Bf - Nocturia MN EC renal concentrating ability ECGHI H !Bf MNa ECL G K I H !BfE OIOHE L renal blood flow I H !BfMDE Noctruia ELI MGHEJfU m DEE IOHE OH E EnE o I OHEl W DJI C DIJOfE N N nocturia L I L GH G bladder outlet obstruction W N D gDE g (BPH)
2 Urgency E K ED C L JL fW DED L GI C L E IJGHI !BfM I K ID bacterial cystitis UM NIOHEJC !E I K G WDE JGJ !Bf ELI L Neurogenic bladder hyperreflexic urinary urgency ELI L anxiety ED I G g W D GgM JJ I K ED EOHI jW N MNaJ GH GE IVI m L UM NI urgency incontinence OE urinary dribbling IrsE I EDIV f Na ECGH G urgency ELL J NIOHE K GHE (enuresis) IOHE L C L GHE OIOHEI!N NE fUW D
Dysuria E M D ! JADK I MDEK (urethra) IVE MNa - initial dysuria EI H NADK GI CL J IDE I K - terminal dysuria M! ADK M NC GI C L I K DE E dysuria GI CL E IJMDEK (urethritis) DE (prostatitis) HM I K (vesicle calculi)
Weak stream IVL bladder outlet obstruction ID gDE g NaDM bD L W DW N I D G IGH ! !E UK OE !E K IOHE L IGH DI ED N m ELMNIIVt m LB GED IL ID UM NK W D frequency I !Bf DEK GJ (strictured urethra) jIVI C BH GHUM NI Kb GfW N
Hesitancy W D AI H N K W N G MNIE D u I OHE !E NK L EE W NM G (NE D 1 Gg ) DL N MNaGH GKb bladder outlet obstruction ADK M! GH I K G W DAB LC OENGH GJC GH G E IELIVI C!E hesitancy W N
3 Intermittency K EE IV N m IOHE L NaMN N IOfE NNE IJD GHI !BfIE M I K M ADK JJDEMNa bladder outlet obstruction
Postvoid dribbling I OHE fC K D f K GHELL I OEMDEK D bulbous OE prostatic urethra L A G JI!NWM I K MNaGHIV bladder outlet obstruction K GHEDJ IDE bulbous L Ij EE It I DGHL A G JI!NWM I K K IjLNDM bD L I!DIJ m M NK EE DJ f jELL W D W N G IJ m J IvtIjJ U D DEK bulbous M NK EE meatus ELL D NKb dribbling W N Gf W D G U bM LI H I
Urinary Retention K W DEE LNE I!N J K L GI CD m W N D 1. Acute Urinary Retention (AUR) I CGHJJDEGHC OE gDE g (BPH,BPO) Na GE K UJ BH N DW DW N J TED I I OHE D J G E IJ IOfE J !E DE (prostatic congession) ED KLLCJ UWD ADW D K W DEE MGHC Na CD Gf L W J T IOHEK EE ME OG NE SC IS K NI GHA NE L NKb M NNaW N H UM NNaI!N J TIS g N (definitive treatment) IOHE L GfIVlfUW NIj K GHW NM GGfL D !E I K ( D 400 .) fM GGH !E K GHW NNE DELW DAOEIV AUR 2. Chronic Urinary Retention JW N f I b JD JgIOfE GHUM NNa ! J W DW N OEW D ID gE gE y (paraplegia, paraparesis, CVA), Neurogenic bladder, DM with peripheral neuropathy NaELL g J NIOHE E IJ!E I K WE IJ GK IGH IOHE L G overflow incontinence TNa CD GfNE MN U J Neurogenic bladder
4 3. Postoperative Acute Urinary Retention ELJW NMNa b L I acute overdistended bladder ID D GI D MI OE D GHNE MN spinal anesthesia 4. Idiopathic acute urinary retention J MNa b W DJI C D ELJM NaGH G I M fK WN m T N M N intermittent catheterization UM NNa J K W N IjGHC 5. Post Traumatic urinary retention IOHE L ECJ I CI GHDEK (ruptured urethra) ELJ ECJ I C G OEM GGH J ILjJW DC NaEL g J ECJ I C m NIOHE K W DEE IOHE L Strictured urethra NaDM bD AM N W N G UM N LS gW D Strictured urethra ELI IOfEMDEK g IS g IOfE I u (Sexual transmitted disease) M E G!E NaW N NaM CD GfI OHEW N J LS gGH NE SC IS N J Kb M MDK IOHE L DEK GHGJ J ELNE NKb N U Cystostomy IOHEM NK EE H DEGHL D M N JJ I K U TDEW
urinary retention W DI OE J anuria lBH I L EC !E E WM J D I K !BfW NaELL g J NE N OE }K W DEE ~ M N LS gM NW N IOHE L SC IS !E gD LD MNa AUR J full bladder lBH W DJMNa anuria MJ f NE G K IOHEDM LS g L JD Na anuria L W D GK M I K
Incontinence HW !E K g W DN OEJ JW DW N JD IV D m W N D 1. Continuous incontinence W !E K GHJ JW DW NII CDM bDIV iatrogenic I D MI (Pelvic surgery) OE D DE N NE (Transurethral Resection of Prostate gland : TUR-P) IOHE L ND U M NI J ILjJDE External sphincter AOEIV!N IG GHN DEM NI C !
5 DNa ECJ DE!N HU W DAOEDIVKb M D TUR-P M J NaJ g ID Na high spinal cord paralysis, Quadriplegia GHNE JC K D endoscopic external sphincterotomy IV UM NI continuous incontinence lBH L UM NW D GK N JC IOfEMNaW N G!Bf ANU K MNaGHIV continuous incontinence W DDIM j L JDW D GK M I K I AOEIV A GHD L incontinence EOH 2. Stress incontinence G Ij !E K M! GH G I H IJD MDE NE ID M! WE L !BfJ W H MGHC L HM! I N JJDEMNa b ECGH G DE!E pelvic diaphragm lBH IVM NDEK DEK (sphincter unit) IOHE HUUM NW D AN I H !E GHI !BfW NE LGHU bOE U stress test GfELJW NM f m D DE NE MNa 3. Overflow incontinence LD MNa CD GfL J full bladder lBH ELL LAB J OE Na J NKb IOHE K IGH E I W D AJC W N J f D J persistent bacteriuria and pyuria J NE MNNENE I j DEWNE I I L neurogenic bladder hyporeflexia UM NW D G propioceptive sensation WD E J IOHE CNM N I K JGJ JMNa paraplegia GHI L sacral cord lesion lBH IVU D !E micturition center ELJMNaIJ GH G sensorineuropathy OEI j GHIVg myelomeningocoel LS gGHU bOE continuous incontinence g K IOHE !E K GH N 4. Urgency incontinence JW NJDEGHC Na GE W DC IV H J f IG UbID f G D m GHUM NI urgency incontinence W N D cystitis, CVA with hemiparesis, parkinsonism, post operative TUR-P, overactive bladder, bladder stone etc. LS DM bDMN l LD LK NaJ GH G l JlNEELNE MN L N urodynamics N
6 Enuresis AB K GHE L E JW N Enuresis MI j I OEJ f I L delay maturation !E JJ JC K I j GH G L JC ADK W NIE ME I OHEEC 1-2 !J E O 2-3 !J OJN (investigation) W D G LUIVMI j ECNE D 7 !J LS TUJD Wg INGH behavioral change ID fU DEE C M N!Bf ADK JN v M NI!N NE fU DEEC O IOHE D IG !E I j L EE M IOHE enuresis W NJDE m ID Wg IG A DE D GH IOHENEIGMIOHE K GHE M N U ML DI j g DE D UM NI j I Kb NE WMGHC M J I j GH GKb Gf W DW N J MDMLIDGH L WDJC GHI jJ G NEM! I!ND CD Enuresis MNM bD IVL gMGHW N J L LS ED IEG
Pneumaturia G HEE M! K AB GE H DE J JJ I E OE UWN M bD ELIV!N IG D I OE C !E Ij L UWNM bD E HGfELJGH E W OE I K GHU bOE IOfEED IOfE !E JJ I K NE m ELEE AE K OE L DE NE !E JJ K (cystoscope) W N lBH IV f m W DI 48 Hg
International prostatic symptom scores (IPSS) IOHE L E D ED GH D EL GfU M GH D LB GN N M ND GHIG D International Prostate Symptom Score (IPSS) lBH MKLLCJ E L L MN JNaDE g N U MNMNa LUTS EG g KLLCJ MN symptom score LB IVGHE J ED N ! M M N LS g I T U JNa LUTS
7 IPSS 0 1 2 3 4 5 W D GE GE m GE JDE GE JDE GE JDE GE I f NE D DNE D E D 5 JDE 2 f MAD 5 f M 5 f M I OEJC f K 10 ADK f M ADK f 10 f ADK 10 f 10 f 1. NB ADK W DC OEI OEN 0 1 2 3 4 5 L ADIjL N 2. ADK JDE m D W DAB 0 1 2 3 4 5 2 Hg 3. ADK J EOE ADm 0 1 2 3 4 5 C m f 4. I OHE K N fW DW NNE GJ 0 1 2 3 4 5 I!N NE fU 5. K W DCD UK EDE 0 1 2 3 4 5 6. NE IJD OEE DEL AD 0 1 2 3 4 5 K EE W N 7. I OHEE J NNE C !BfAD -----0 -----1 -----2 -----3 -----4 -----5 K B GH f DEOHE f f f f f f EIN
0 7 AB E NE 8 19 AB I H GE !Bf 20 35 AB E C I H T
Hematuria : definition and causes Definition Microscopic hematuria Macroscopic hematuria (gross hematuria) Initial hematuria Terminal hematuria Homogeneous hematuria Painful or painless hematuria Pseudohematuria
8 Microhematuria When will be considered abnormal? Microhematuria Reference 1. More than 2 RBCS per high power field Campbells urology 1986 2. More than 40,000 RBCS per hour Scientific foundation of Urology 1982 3. More than 5 RBCS per HP. or more than Evaluation of hematuria 500,000 red cells in 12 hours urine Urology; 21: 215-225, 1983 4. More than 1 RBC per HP. on A spun The evaluation of hematuria J specimen Uro; 138: 1189-1190, 1987 5. More than 3 RBCS per HP. on 3 urinalysis The significance of adult Hematuria J. Uro; 141: 350-355; 1989
Table 3 Degress of hematuria versus diagnostic yield (Evaluation of 1000 adults) RBCS/HPF Total No. Significant Lesion (%) Life threatening lesion (%) 0-3 12 2(16.7) 0(0) 4-10 69 8(11.6) 2(2.9) 11-50 507 100(19.7) 16(3.2) >50 103 31(30.1) 9(8.7) Microhematuria all 691 141(20.9) 27(3.9) Gross hematuria all 309 178(57.6) 64(20.7) (Mariani AJ. The significant of adult hematuria. J Uro; 141: 350-355, 1989.
9 Table 4 Frequency of more common causes of hematuria Children (study) Adults (Study) Severity of hematuria G G G or M G or M M M M Mostly G or Mostly G M G No. of patients 80 150 164 488 200 246 500 163 237 1,878 Neoplasms 1 1 1 0 13 10 2 2 11 18 Urinary infection 24 26 1 4 25 2 4 9 3 14 Stones 0 2 1 7 16 3 4 5 49 22 Obstruction 5 1 1 0 3 2 1 2 0 1 Trauma 0 7 7 0 0 0 0 6 5 3 Glomerulonephritis 41 5 68 59 0 2 0 0 5 3 Urethritis 5 0 0 0 0 6 21 31 4 8 Urethrotrigonitis 0 0 0 0 18 12 3 6 0 0 Berging prostatic hypertrophy 0 0 0 0 20 8 23 0 9 6 No diagnosis made 15 9 17 22 19 50 44 5 5 10 (Abuelo JG. Evaluation of hematuria. Urology; 21: 225, 1983) G = gross hematuria M = micro hematuria
Investigation for patient with hematuria Urine analysis M G!E microhematuria ELNE G LlfU IOHEO !E I j IOE AB NDLU!E RBC W DW NDM I C!E LC IOE EE DUM N JE C W N proteinuria GHI 2+ ELUWD LS g glomerular disease NaM CD sport hematuria excrcise hematuria (K GIOE EE U ED ) G L K GH M 3 ED W j Na gross hematuria ELW D GIOE EE C AN GHW NL Na IL IOHEAOEW N L M N OJNM! fEDEWAB N L UA L W DJI j IOE N Plain KUB and IVP IV LGH G g AJE U D LC IOE EE W N IL g IS GHIV life threatening disease ID IOfE E !E W E W I K g HM U D D m !E JJ I K AMN M D W NM GGHJEg IOfE E !E I K GH G! Ij EL LS W NW D IEG L IVP D J L N DE NE DEW
10 Ultrasound IV L screening GH G gIOHEJE EgED N m W N G MD !E W I K (full bladder) Cystoscope IV L lower urinary tract W ND IEG MJ f AM N T JDWW N ID vesical calcull IOHE L IV LIS ELL UW DW NMC J f ELNE D DENa CT scan DM LS EgGHWg IS solid mass IOfE E GH W W D G gM G!E g HM JJ I K Angiography D LS A-V malformation gGHI GH J E IOE NaGHLW DJEgM m L OJNGH D !N NL EDM CD ldiopathic hematuria OE essential hematuria L W N IV m DEW
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