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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 鍾旭東 | 男性下泌尿道症狀是膀胱出口阻塞嗎? 合理的臨床檢查:系統性回顧 | 2014/9/29 下午 05:23:40 | 0 |
| 原 文 | 題 目 | Does this man with lower urinary tract symptoms have bladder outlet obstruction?: The Rational Clinical Examination: a systematic review. |
| 作 者 | DSilva KA, Dahm P, Wong CL | |
| 出 處 | JAMA;312(5):535-42. | |
| 出版日期 | 6 August, 2014 | |
| 評 論 |
男性下泌尿道症狀絕對是泌尿科醫師最常碰到的臨床問題，當然直覺的大家都會認為是前列腺的增生或是肥大導致膀胱出口阻塞所產生的症狀，然而，事實上大家也都了解，精確的診斷膀胱出口阻塞往往需要侵入性的檢查，例如置放尿管及尿路動力學檢查，而精確的診斷才能夠使得給予的治療有實質的幫助。這篇相當深入的文獻回顧收集了過去六十多年研究內容品質符合標準的論文，來評估臨床上對於男性下泌尿道症狀甚麼樣的檢查才是適當合理的呢? 結果發現 國際前列腺症狀評分大於二十分傾向有膀胱出口阻塞;小於二十分的病人則大多不是膀胱出口阻塞。其他的理學檢查無法精準的判斷病人是否有膀胱出口阻塞，同時這個研究也發現膀胱掃描與利用導尿管測量的餘尿量是相當高度相關的。作者認為症狀評估並無法精準預測膀胱出口阻塞，同時建議臨床用膀胱掃描來評估膀胱餘尿量是必要的。 這篇研究能夠刊登在美國醫學會的文章，我相信是非常重要的報告，這個完整的回顧確立了泌尿科醫師的專業重要性，因為理學檢查或是症狀並無法斷定膀胱出口阻塞，必須要由泌尿科醫師詳細的評估，包括膀胱掃描或是尿路動力學才能夠提供病人最適切的治療，尤其對於泌尿科醫師在製作診療指引時，這篇研究也有很重要的參考價值。 |
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| abstract |
Early, accurate diagnosis of bladder outlet obstruction in men with lower urinary tract symptoms may reduce the need for invasive testing (ie, catheter placement, urodynamics), and prompt early treatment to provide symptomatic relief and avoid complications. OBJECTIVES: To systematically review the evidence on (1) the diagnostic accuracy of office-based tests for bladder outlet obstruction in men with lower urinary tract symptoms; and (2) the accuracy of the bladder scan as a measure of urine volume because management decisions rely on measuring postvoid bladder residual volumes. DATA SOURCES AND STUDY SELECTION: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (1950-March 2014), along with reference lists from retrieved articles were searched to identify studies of diagnostic test accuracy among males with lower urinary tract symptoms due to bladder outlet obstruction. MEDLINE, EMBASE, CINAHL, and the Cochrane Library (1950-March 2014) were searched to identify studies of urine volumes measured with a bladder scanner vs those measured with bladder catheterization. Prospective studies were ed if they compared 1 or more office-based, noninvasive diagnostic test with the reference test or were invasive urodynamic studies, and if urine volumes were measured with a bladder scanner and bladder catheterization. DATA EXTRACTION AND SYNTHESIS: For the bladder outlet obstruction objective, 8628 unique citations were identified. Ten studies (1262 patients among 9 unique cohorts) met inclusion criteria. For the bladder scan objective, 2254 unique citations were identified. Twenty studies (n = 1397 patients) met inclusion criteria. MAIN OUTCOMES AND MEASURES: The first main outcome and measure was the diagnostic accuracy of individual symptoms and questionnaires compared with the reference standard (urodynamic studies) for the diagnosis of bladder outlet obstruction in males with lower urinary tract symptoms. The second was the correlation between urine volumes measured with a bladder scanner and those measured with bladder catheterization. RESULTS: Among males with lower urinary tract symptoms, the likelihood ratios (LRs) of individual symptoms and questionnaires for diagnosing bladder outlet obstruction from the highest quality studies had 95% CIs that included 1.0, suggesting they are not significantly associated with one another. An International Prostate Symptom Score cutoff of 20 or greater increased the likelihood of bladder outlet obstruction (positive LR, 1.5; 95% CI, 1.1-2.0), as scores of less than 20 had an LR that included 1.0 in the 95% CI (negative LR, 0.82; 95% CI, 0.67-1.00). We found no data on the accuracy of physical examination findings to predict bladder outlet obstruction. Urine volumes measured by a bladder scanner correlated highly with urine volumes measured by bladder catheterization (summary correlation coefficient, 0.93; 95% CI, 0.91-0.95). CONCLUSIONS AND RELEVANCE: In patients with lower urinary tract symptoms, the symptoms alone are not enough to adequately diagnose bladder outlet obstruction. A bladder scan for urine volume should be performed to assess patients with suspected large postvoid residual volumes. |
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