Videourodynamic findings of lower urinary tract dysfunctions in men with persistent storage lower urinary tract symptoms after medical treatment

RESEARCH ARTICLE Videourodynamic findings of lower urinary tract dysfunctions in men with persistent storage lower urinary tract symptoms after medical treatment Yuan-Hong Jiang1, Chung-Cheng Wang2,3, Hann-Chorng Kuo1* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan, 2 Department of Urology, En Chu Kong Hospital, College of Medicine, National Taiwan University, New Taipei, Taiwan, 3 Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan * Abstract Objective OPEN ACCESS Citation: Jiang Y-H, Wang C-C, Kuo H-C (2018) Videourodynamic findings of lower urinary tract dysfunctions in men with persistent storage lower urinary tract symptoms after medical treatment. PLoS ONE 13(2): e0190704. https://doi.org/ 10.1371/journal.pone.0190704 Editor: Peter F.W.M. Rosier, University Medical Center Utrecht, NETHERLANDS Received: April 8, 2017 Accepted: December 16, 2017 Published: February 20, 2018 Copyright: © 2018 Jiang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. To analyze the underlying lower urinary tract dysfunctions by video-urodynamic studies in men who have persistent storage symptoms after initial drug therapy for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Methods The medical records of 614 men 40 years of age with LUTS and an International Prostate Symptom Score of 8 were retrospectively analyzed. All patients had persistent storage symptoms after medical treatment for at least 6 months. A video-urodynamic study was done to investigate the underlying bladder or bladder outlet dysfunction. Predictors of bladder outlet obstruction (BOO) by baseline urine flow metrics and prostate parameters were investigated. Results Data Availability Statement: Data contain potentially identifying participant information and cannot be shared publicly. The Buddhist Tzu Chi General Hospital Research Ethics Committee has restricted these data. Interested, qualified researchers can request the data by contacting . The final results revealed bladder neck dysfunction (BND) in 137/614 (22.3%), benign prostatic obstruction (BPO) in 246/614 (40.1%), detrusor overactivity (DO) in 193/614 (31.4%), and DO with detrusor underactivity (DO+DU) in 38/614 (6.2%) patients. Among the patients, 221/281 (78.6%) with a total prostatic volume (TPV) 40 ml had BOO, including 43/281 (15.3%) with BND and 178/281 (63.3%) with BPO. If we combined TPV 40 ml and Qmax <12 ml/s as predictors of BOO, BOO was found in 176/215 (81.8%) patients including 34/215 (15.8%) with BND and 142/215 (66.0%) with BPO. BOO was also found in 48.8% of men with a TPV <40ml, and in 36.3% of men with TPV< 40 ml and Qmax  12 ml/s. In 102 men with TPV <40 ml and Qmax 12 ml/s, 64 (62.7%) had DO. Funding: The authors received no specific funding for this work. Conclusion Competing interests: The authors have declared that no competing interests exist. BOO, including BND and BPO, comprise 62.4% (383/614) of men with persistent storage symptoms after initial medical treatment for LUTS/BPH. In men who have persistent storage PLOS ONE | https://doi.org/10.1371/journal.pone.0190704 February 20, 2018 1 / 10 Lower urinary tract dysfunction in men with storage symptoms after treatment symptoms after medical treatment for LUTS/BPH, BOO should be carefully investigated and appropriate management being given to improve LUTS. Introduction Lower urinary tract symptoms (LUTS) are highly prevalent in aged men [1]. AUA and EAU guidelines recommend to treat LUTS in men with an alpha-blocker alone or in combination with an alpha-reductase inhibitor when the total prostate volume (TPV) is greater than 30–40 mL [2,3]. About three-quarters of men with symptomatic bladder outlet obstruction (BOO) have LUTS improved with alpha-blocker monotherapy. The residual storage LUTS after alpha-blocker treatment is usually attributable to bladder dysfunction such as detrusor overactivity (DO) and an antimuscarinic is advised to add [2,4]. Recently, bladder dysfunction in men such as DO and detrusor underactivity (DU) have been shown to play important roles in LUTS [5]. The initial medical treatment with a combination of an alpha-blocker and an antimuscarinic or beta-3 adrenoceptor agonist has been recommended in treating men with LUTS suggestive of benign prostatic hyperplasia (LUTS/ BPH) with predominantly storage symptoms [6,7]. It is likely that storage symptoms may exist primarily or secondarily to BPH or BOO; therefore, combined treatment is beneficial and can relieve LUTS after the initial medical treatment [4,8]. In clinical practice, it is common to encounter a group of men with mixed voiding and storage LUTS. After initial treatment for LUTS/BPH, the voiding symptoms improve, but storage symptoms persist. Recent studies have proven combined alpha-blocker and antimuscarinic drugs, or an antimuscarinic drug alone, often provide improvement for these patients [6,8]. Use of the IPSS voiding to storage subscore ratio has been proposed as a guide for initial treatment of men with mixed voiding and storage symptoms [9]. For patients in whom the initial treatment fails to improve the storage LUTS, it is possible that the initial diagnosis might be incorrect or the initial medication not powerful enough, leading to a suboptimal treatment outcome. In order to obtain the actual pathophysiology for the persistent storage LUTS, a urodynamic study is mandatory to identify the underlying pathophysiology and optimize a therapeutic strategy [5,10,11]. The role of urodynamic studies in men with LUTS and BPH is still controversial because the procedure is considered invasive and the results lack clinical significance [10]. Although several non-invasive tests have been proposed to replace urodynamic studies, measuring urodynamic pressure flow remains the gold standard test for the diagnosis of BOO [11]. The AUA and EAU guidelines recommend pressure flow studies as an optional test if patients with LUTS and BPH and are planning to undergo surgery [12,13]. Transurethral resection of the prostate (TURP) is not usually recommended unless BOO is proven by urodynamic pressure flow studies [14]. The aim of this retrospective study was to analyze the underlying lower urinary tract dysfunctions by video-urodynamic studies in men who have persistent storage symptoms after initial drug therapy for LUTS/BPH. We also investigated the possible relationship between TPV and the maximum flow rate (Qmax) and the diagnosis of bladder dysfunction and BOO such as bladder neck dysfunction (BND) and benign prostatic obstruction (BPO). The results can provide evidence for physicians to select appropriate men wit (...truncated)