© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
6
Rosenberg ET AL.
The physical examination should focus on detecting
abnormalities that couldcontribute tothesymptomology.
The neurological examination could start by observing
the patient’s gait as theywalk into the roomor down the
hall. Noting a limp, poor coordination, dysarthria, facial
asymmetry or other findingsmay indicate neurological
conditions such as a stroke or multiple sclerosis. A
brief mental status examination can be performed by
observing the patient’s general appearance and their
response to questions. Alertness, orientation, memory
and thought content can be useful parameters in
assessing the patient.
Body mass index (BMI) should be noted as there is
a strong relationship between increasing BMI (> 30)
and the likelihood of female UI.
11
Identifying this
correlation provides an opportunity for the PCP to
discuss lifestyle changes for the patient as moderately
obese women who undergo even a small weight loss
can decrease their LUTS.
The abdomen should be checked formasses, hernias
or a distended bladder. In the female, the genitalia is
assessed for vaginal abnormalities such as a prolapse of
the bladder or uterus, atrophic vaginitis or urogenital
atrophy and rectal sphincter tone. Having the patient
cough during the pelvic exam may help identify SUI.
In a male, it is important to assess the prostate for
enlargement, nodules, asymmetry or tenderness. The
penis should be examined for scars lesions or meatal
stenosis. If a foreskin is present it should be checked
to verify that it can retract over the glans and is not
phimotic. The rectum should also be assessed for tone.
Aurinalysis performed by dipstick or microscopic
examination is strongly recommended to check for
blood, protein, glucose or any signs of infection.
Although hematuria or pyuria are not always
found in conditions such as bladder cancer, stones or
infection, a normal urinalysis makes these diagnoses
less likely.
1
It is not adequate to use the urinalysis to
rule out the possibility of diabetes as the serum blood
sugar must be over 180mg/dLbefore glucose is spilled
into the urine.
12
Therefore fasting or random blood
sugar is needed to identify hyperglycemia as the onset
of polyuria/polydipsia in the diabetic could certainly
mimic the symptoms of OAB. If the PCP suspects
obstruction in the male patient renal function studies
may identify upper tract involvement.
There has been tremendous controversy regarding
checking the prostate-specific antigen (PSA) level.
13
It
must be remembered that the PSA is prostate specific
and not cancer specific. In fact, it was shown that a
PSA value of 1.5 ng/mL, in any age male, correlates to
a minimal volume of 30 cc.
14
Knowing the size of the
prostate can help guide therapeutic options. As was
shown in the placebo arm of the Medical Therapy of
Prostatic Symptoms (MTOPS) a prostate volume of 31 cc
is directly related to increased risk of progression or
worsening of LUTS caused by the obstructing prostate.
15
A bladder or voiding diary can be very helpful
in evaluating the extent of the problem and offering
clues on how best to proceed with evaluation and
treatment. It is a simple and practical method of
obtaining detailed information about a patient’s
voiding habits.
7
The basic structure of the diary or log
is to keep track of timing of the voided volume as well
as preceding urgency. With the use of a diary patients
may become aware of various habits that contribute
to their symptoms that they can subsequently be
changed in order to eliminate or minimize symptoms.
For instance, they may find the problems are only at
work when they may be rushing through the voiding
process, when drinking a large amount of fluid at the
movie or unable to readily access a restroom.
The post void residual (PVR) is not necessary in
the initial evaluation of the uncomplicated patient
(i.e., patients without a history of or risk factors for
urinary retention).
1
Risk factors for retention include
obstructive symptoms, history of incontinence,
prostate surgery or neurologic diagnoses. Although
there are many opinions regarding the absolute
values, a PVR of less than 50 mL represents reasonably
efficient voiding and therefore places the patient at
low risk of retention. APVR over 200 mL is consistent
with clinically significant inadequate emptying and
therefore the patient is at higher risk of retention.
12
An increased PVR may be a problem as it causes a
significant decrease in functional bladder capacity
which can lead to symptoms of urgency, frequency
or nocturia.
16
A high PVR can also result in recurrent
urinary tract infections.
17
In regards to the patient with
BPH, a large residual urine volume is consistent with
a significant risk of disease progression. One reason
to check the PVR is when the patient’s symptoms are
refractory to initial therapy and the PCP is trying to
check for retention as a result of severe obstruction
as the source for the poor response. If this value is
needed, it can be measured by direct catheterization
or ultrasound scanning. Regardless of the technique
used it is important for the patient to have the test
performed when they have a full bladder.
Urodynamic studies are not necessary in the
majority of patients, especially thosewithout neurologic
compromise, and are not recommended in the
uncomplicated patient.
1
If the patient is refractory to
therapy or symptoms worsen, then the test may be
considered as one looks for other causes such as detrusor
sphincter dysenergia. Cystoscopy has a role only in the
