When a man complains of voiding problems--urinating too frequently, difficulty starting or maintaining the flow of urine, or not feeling relieved after voiding--the urologist must determine the cause of these complaints. The symptoms of prostatism are not always due to bladder outlet obstruction from an enlarged prostate (BPH-benign prostatic hyperplasia). Voiding difficulties can be due to
neurologic diseases--Parkinson's disease, multiple sclerosis, stroke, dementia, diabetes mellitus
urinary tract infection
bladder cancer
bladder stone
excess fluid intake--including diuretics such as coffee and tea
medications
an aging bladder
urethral stricture--that is, scar tissue within the urethra
The challenge that faces the urologist is to determine the cause of the man's complaints. In other words, are the voiding symptoms due to an enlarged prostate (BPH).
The first step is to obtain a thorough history of the problem. This will determine to what degree the symptoms are affecting the patient's quality of life. It will establish a baseline set of symptoms which can be used to assess the impact of future treatments. Most importantly, a good history will determine the general health of the patient and give an idea how fit he is to undergo further evaluation and treatment.
The physical examination can provide clues as to the condition of a man's urinary system. For example:
examination of the abdomen may disclose
a distended bladder representing urinary retention
surgical scars representing previous prostate or bladder surgery
examination of the back over the kidneys may disclose
tenderness representing infection of the kidneys or blockage of the kidneys
surgical scars representing previous kidney surgery
examination of the prostate may disclose
the size of the prostate
irregularity, nodularity, or hardness, representing possible prostate cancer
examination of the nervous system and spine may disclose neurologic disorders that may be responsible for the man's voiding difficulties
There are several laboratory tests that are helpful in defining the health of a man's urinary tract. These include:
urinalysis--examination of the urine. This test can give information reflecting the patient's fluid intake (dilute or concentrated urine), the health of the kidneys (degree of protein present in the urine), whether diabetes mellitus may be present (amount of sugar in the urine), whether blood is present, and whether infection is present.
serum blood urea nitrogen (BUN) and creatinine--blood tests which measure kidney function. When bladder outlet obstruction progresses to the point where the bladder is unable to empty itself of urine, the kidneys may begin to fail.
PSA blood test--screening test for prostate cancer. If a man with bladder outlet obstruction is found to have prostate cancer, the treatment for this man may be dramatically altered.
uroflow examination--This test measures the flow rate and flow pattern of urine leaving the bladder.
bladder ultrasound--This noninvasive test measures the amount of urine in the bladder. If performed immediately after a patient voids, the amount of urine left in the bladder is the residual urine, which may reflect the degree of obstruction to the bladder or the degree of bladder weakening.
intravenous pyelogram (IVP)--This test is an x-ray of the urinary tract. It gives information as to whether the prostate obstruction has caused damage to the kidneys. It also can visualize the bladder, demonstrating bladder diverticuli (weak areas of the bladder wall which pouch outward from the bladder, empty poorly, and are often the result of bladder outlet obstruction) and bladder wall thickening (also a result of bladder outlet obstruction).
urodynamic studies--This is a series of tests that do not give a picture of the bladder, but instead show how the bladder is functioning. It gives information on how well the bladder can store urine, whether the bladder is obstructed when it empties itself of urine, and the strength of the bladder. If a man has difficulty voiding and is not emptying his bladder well, the problem may be bladder outlet obstruction from an enlarged prostate or a weak bladder without obstruction. Urodynamic studies are used to differentiate these two conditions, which have vastly different treatments.
cystoscopy--This procedure involves looking in the prostate and bladder with a telescope. It allows the urologist to assess the size of the prostate (which may influence the choice of treatment), look for bladder stones, check for urethral strictures (scar tissue within the urethra), and check for any unsuspected lesions within the bladder. Cystoscopy also allows inspection of the bladder wall, and changes secondary to bladder outlet obstruction, such as bladder wall thickening (trabeculation), can be identified. Bladder wall thickening is evident in the picture below.
