Hashim Hashim: Thank you, Professor Wein, for this kind introduction, and thank you for inviting me today on UroToday to talk about urodynamics and male lower urinary tract symptoms. So, this was based on a review we just published a few months ago. And essentially, when we looked at the literature, we tried to look and see where urodynamics sit. And as you mentioned, we are a well-established urodynamics unit, and we tend to do about 1,000 urodynamics a year on male and female patients. But with regards to the male lower urinary tract symptoms, a lot of symptoms tend to be attributed to the prostate. Everyone says, "Well, it's the prostate that's causing the problem, so let's just operate on the patient and see what happens." And actually even looking at the AUA guidelines specifically, even flow tests are not mandatory. They look and say, "Well, you can do it if you need to and check the residual as a main initial assessment." But what we found is that actually, not every patient has LUTS due to BPO or BPE or even BPH. And we note that a lot of patients... Well, we know that BPH or histological BPH, which is based on the fact that it is confirmed on biopsy, and technically, we should be using the term BPE, which is benign prostatic enlargement. 25 to 50% of men who have BPH will experience lower urinary tract symptoms or LUTS. And only 50% of symptomatic men actually have bladder outflow obstruction.
So, there's another 50% who may end up having surgery unnecessarily. So, the way to assess these patients is by measuring the pressure on the flow with urodynamics and assess them adequately, or at least even non-invasive urodynamics such as flow tests as an initial screening. But once we're coming up to surgery, we would tend to look at using urodynamics because it gives you the additional benefit of measuring the pressure and the flow. So, what are the indications for video urodynamics in this case? Well, we tend to limit it to patients who are men younger than the age of 60. And the reason we use 60... Some of the literature uses 50, which is what we used to use in the past, but we decided to go up to 60 because men under the age of 50 or even 60 are less likely to be obstructed from the prostate. And actually, if you look at the data for prostate surgery, at least from the UK, the majority are done in patients over the age of 60. So, although BPH histologically starts at the age of 40, the obstruction probably doesn't start until the age of 60, unless someone has a very large prostate at a younger age. So, younger men, we tend to do video urodynamics on. Men who have symptoms such as chronic prostatitis and voiding symptoms, we would do video urodynamics on as well, and those with a high residual. So, patients with a high residual. We'll talk about the indications for each later on. Patients who've had stress urinary incontinence following a radical prostatectomy, and those who've had surgery or radiotherapy in the pelvis, and complex cases such as those who've had transplant, and obviously, neurogenic patients, we would do video urodynamics rather than standard urodynamics because we get that anatomical sort of information. So, why young men?
Well, young men, data suggests that about 30 to 50% of young men can have primary bladder outflow obstruction or dysfunctional voiding, and there isn't really a test that would be able to diagnose these accurately other than video urodynamics or as good as can be better than video urodynamics. So, I don't think any middle-aged man, let's say, in their 40s, 50s would want an operation unnecessarily, and they would want more information. So, the urodynamics would tend to give you that information. It will tell you whether they are obstructed or not. Now, what is important, why do we need to use videos and rather than just standard in these cases, is because it can tell you the level of the obstruction. If they have a primary bladder neck obstruction, then the bladder neck would not open at voiding or it would be narrowed, and there won't be funneling or opening of the proximal prostatic urethra. Equally, if they have dysfunctional voiding, then that's poor relaxation of the external sphincter. And in those cases, you would get opening of the bladder neck, opening of the prostatic urethra and with the narrowing of the sphincter. And you can combine that with EMG, but EMG, electromyography, is sphincter EMG with needles is painful, and the surface EMG tends to measure pelvic floor activity rather than sphincter activity. And urethral pressure profiles can also be helpful in these patients because they can give us an idea about the sphincter pressure, as well as the pressure at the bladder neck and in the prostatic urethra. So, young men definitely would need video urodynamics.
What about those with high post-void residuals? Again, that's probably a more difficult one. You can do an ultrasound, but ultrasound doesn't pick up grade one and possibly not even grade two ureteric reflux, and therefore, video urodynamics would be better at that. So, why not do a micturating cystourethrogram and urodynamics separately? Well, you can do that, but then you won't be able to assess pressures if there is, for example, reflux and assess compliance accurately. However, with urodynamics, you can look at reflux. That reflux would siphon the pressures in patients who have a poor compliance, and you may then be able to say, "Well, actually, this patient has reflux, and even though the compliance looks normal on the urodynamic traces, it may be due to the reflux." So, again, gives you that added benefit. And you can also look for bladder diverticula and trabeculations. And if you have large diverticula, you can see if they're actually emptying or not after they've had or during micturition and after micturition. And what about patients with chronic prostatitis or pelvic pain syndrome? Well, again, data suggests that many of these patients, so 20 to 30% of these patients will have another diagnosis giving them the chronic prostatitis or pelvic pain syndrome, such as bladder neck obstruction, overactivity, or even dysfunctional voiding. And so video urodynamics can reveal these pathologies. What about the post-prostatectomy incontinence? Again, the guidelines are variable on this. However, we've recently presented our data last year actually at the ICS, suggesting that not every man who presents with incontinence following a radical prostatectomy has stress incontinence, and there's a percentage of men who have overactivity incontinence and those who have poorly-compliant bladders as well.
And therefore, the video urodynamics would allow you to assess for strictures, look for leakage, and look for bladder neck abnormalities, as well as rule out overactivity and reflux, and therefore, may help the decision-making process and the counseling of the patient. So, to summarize, really, yes, video urodynamics is for selective cases, especially the ones we've mentioned, the young men, those with a higher post-void residual, those with pelvic pain symptoms, post-prostatectomy stress incontinence, and complex patients such as transplant and those who've had pelvic surgery or radiotherapy, because it can combine anatomy with function, it can tell you the level of the obstruction in those who have obstruction. And combining that with physiology, you'll get the best of two worlds. And therefore, our message really is to be selective, but these are the main groups of patients to use video urodynamics in that we would recommend. So, I hope that's given an overview of the use of urodynamics and video urodynamics in male LUTS. And hopefully, the guidelines can also be updated in the future to look at video urodynamics as an investigation tool. Thank you very much.
Alan Wein: That was a terrific overview of video urodynamics, particularly useful in those instances that you described. Of all the urodynamic studies that are done in your unit in Bristol, what percent would you say have videos as opposed to regular pressure-flow studies?
Hashim Hashim: That's a very good question. So, if we look historically starting in 2011, about 30 to 40% were video urodynamics and about 60 to 70% were standard urodynamics. With the pickup of standard urodynamics around our unit and in other cities, we've seen a shift, and because we are a tertiary center and there's lots of centralization of these complex cases, we have seen a big shift. So, the latest figures suggest that about 60 to 70% is video urodynamics now, and about 30% is standard urodynamics. Majority of the men get video urodynamics. Very few actually get standard urodynamics, but those who get standard urodynamics are usually the ones who, let's say, a 70-year-old man who has a flow test suggestive of bladder outflow obstruction and has no residual.
Alan Wein: And the videos, are they done by you, by the staff people, or are they done by what we would call advanced practice providers? I think you call them continence nurses. In other words, who actually does the video? Who actually places the catheters and operates the fluoro machine?
Hashim Hashim: So, we are probably a bit unique in Bristol because we have our own unit, and let's say, we're not at the mercy of radiology. So, our clinical scientists and senior nurses operate the fluoro machine, but it always has to be done with a doctor in the room. So, usually, a fellow or a consultant also is putting the catheters in and being there. So, we always have two people in the room, and it is done by the two people jointly, but our team presses the fluoro machine. And we have our own C-arm, so we don't have to get a radiographer to come in and press the button for us.
Alan Wein: And when you do videos, is it ever necessary to do EMGs? I've always felt the patch EMGs are pretty worthless.
Hashim Hashim: No, we don't really do EMGs at all. So, the only time we tend to do a surface EMG, which is the patch EMG, is in young men who have difficulty voiding and can't void at all, and especially with us in the room or even after we've left the room, then we would bring them back and do a flow test with EMG. So, just a flow with EMG to actually just assess their pelvic floor. But in general, we don't really use, and that's probably... I'm talking about less than 1% have surface EMG. But the majority gets urethral pressure profiles because that assesses the bladder neck pressure. It can assess the prostatic urethral pressure and the sphincter pressure.
Alan Wein: And when you say, "Urethral pressure profiles," it's the standard side hole catheter and constant rate pulling the catheter through the urethra?
Hashim Hashim: Yeah. So, we use a single-lumen catheter with two eye holes rather than a dual lumen because in the dual lumen, the eye holes are not opposite each other, and one is measuring pressure, one is exerting fluid at different points while with a dual lumen. So, the standard, the original Brown-Wickham technique with one catheter with two eye holes opposite to each other.
Alan Wein: Got it. Well, that's been really informative. We thank you for sharing your expertise with us and hopefully, the viewers on UroToday will have a better idea of when to call for videos and when not to call for videos. So, thanks so much. Hope to see you at one of the meetings soon.
Hashim Hashim: Thank you very much, Professor Wein, and see you soon.
Alan Wein: Take care, my friend.
Hashim Hashim: Thank you. Thank you. Take care.