ISSN: 1305-3876
Hakkında: Özel sayılar şeklinde yayınlanır.
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Differential Diagnosis Of Lower Urinary Tract Sypmtoms In Men:
Dr. Tufan TARCANa
a Üroloji AD, Marmara Üniversitesi Tıp Fakültesi, İSTANBUL
Lower urinary tract symptoms (LUTS) increase with aging in both genders. LUTS of men has been attributed to benign prostatic enlargement and traditionally been referred as "prostatism symptoms". This terminology has been abandoned since it has been found out that LUTS are not necessarily related to prostatic enlargement or bladder outlet obstruction (BOO). The pathophysiology of LUTS is still poorly understood and therefore medical and surgical treatment options for LUTS of elderly male should be considered as empirical. The first step in the differential diagnosis of LUTS of men tries to rule out an underlying infection or tumor of the genito-urinary tract, or stone disease and also tries to discover any morphological deterioration of the urinary tract. These conditions can be diagnosed with the help of history, physical examination, laboratory and radiological methods. However, most men today present with non-complicated LUTS. The challenging problem in such a patient is to understand the causative pathology and plan the appropriate treatment.
LUTS of men can be seen alone or present together with benign prostatic enlargement or BOO. BOO is a diagnosis made by pressure-flow studies. Urodynamic studies in men with LUTS may further reveal detrusor overactivity and/or detrusor weakness. The latter two conditions may be caused by age-related diseases such as some neurogenic diseases or diabetes or may be a result of the "aging bladder". Advanced age, predominant symptoms of filling, detrusor overactivity and especially detrusor weakness predict a poor symptomatic outcome after prostatectomy. The ideal patient who will benefit from prostatectomy most should have no systemic co-morbidity, but have predominantly emptying symptoms with BOO and normal detrusor activity in urodynamic studies. The role of invasive urodynamic studies in the differential diagnosis of LUTS of men is under debate. However, urodynamic studies are very valuable prior to prostatectomy in patients with predominantly filling symptoms, neurogenic or diabetic co-morbidity or when simple uroflowmetric findings are unrevealing or conflicting with symptoms. In the remaining conditions, especially in an ideal patient for prostatectomy as described above invasive urodynamic studies may be by-passed before surgical treatment.
Alfa-1 adrenergic receptor inhibition has become the primary treatment of LUTS suggesting benign prostatic obstruction. The mechanism of action of alfa-1 adrenergic receptor blockade is not completely understood since they improve symptoms without clinically significant changes in urodynamic parameters. Such medical treatment should be considered as empirical and may be applied without invasive urodynamic studies in appropriate cases.
There is no single method in the differential diagnosis of age-related LUTS of men. The physician should plan the differential diagnosis in the light of history, age, physical examination, systemic or neurogenic co-morbidity, characteristics of symptoms, laboratory and radiological findings. It should be kept in mind that the aim of differential diagnosis is first to well understand the underlying pathology and than to predict the success of available treatment options and lastly to discuss it with the patient in an attempt to find the most appropriate treatment modality. In this sense, invasive urodynamic studies may not be necessary in the differential diagnosis of LUTS in all patients, but they predict surgical outcome and enable better patient selection for prostatectomy, when used appropriately.Keywords: Lower urinary tract symptoms, aging, benign prostatic hyperplasia and urodynamicsTurkiye Klinikleri J Surg Med Sci 2005, 1(1):30-37
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