14/07/2015 · MA MD MRCS MRCGP DRCOG ... Plan of attack ... 14/07/2015 4 LUTS 28 LUTS Assessment: History • Other elements of PMH, e.g. –Diabetes

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LUTS 1

BPH / LUTS

Dr Jonny Coxon

MA MD MRCS MRCGP DRCOG

Beaconsfield Medical Practice, Brighton

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“As man draws near the common goal

Can anything be sadder

Than he who, master of his soul

Is servant to his bladder‟

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Plan of attack

• Prevalence including ‘under-reporting’

• Presentation

• What are lower urinary tract symptoms (LUTS)?

• Distinction between storage / voiding etc

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• Initial assessment in primary care

• Medical management

• Who to refer

• What happens in secondary care

Plan of attack

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Prevalence of BPH

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Prevalence

It is abnormal NOT to have benign growth of the prostate with

increasing age

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Prevalence

TZ

PZ

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Prevalence

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Prevalence • 2007 US study: enlarged prostate = 4th most

common diagnosis in men over 50.

• Approximately 1/3 of men over 50 have moderate to severe LUTS

• i.e. ~ 3 million men in UK

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• Huge issue = men reporting symptoms at all

• Some can be rather stoical: “just part of growing old”

Presentation: what do patients say?

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• “I don’t understand it doc, I keep feeling like I need a pee, but hardly any comes out.”

• “My sleeping’s getting terrible.”

• “You know, the public toilets round here are awful”

• “I have to plan my day around toilet breaks”

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• “I might be fine for ages then suddenly, whoosh, I’ve got to go.”

• “I keep having to make excuses in meetings.”

• “I can’t make it round the golf course these days.”


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• “I’m worried about me prostrate”

• “While I’m here doc…”


Lack of

physical

intimacy

Anger or

conflict

Avoidance

or withdrawal

A feeling of

distance or

isolation

Lack of

communication

Re

po

rti

ng

sp

ec

ific

re

lati

on

sh

ip

co

nc

ern

s

Men with mild symptoms (n=216)

Men with moderate-to-severe symptoms (n=203)

Spouses of men with enlarged prostate (n=77)

Roehrborn CG et al. Prostate Cancer Prostatic Dis 2006;9:30–34.

Presentation

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• “I’m worried about me prostrate”

• “While I’m here doc…”

• “I’m here because the wife sent me in.”


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• GPs worry about missing prostate cancer – only 11% confident distinguishing between BPH & PCa

• ~ ½ refer before maximising medical therapy

• GPs seek specialist advice in 1/3 men with LUTS

Presentation: what do we say?

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• Urologists feel ~40% of BPH referrals could be managed in primary care

• ~ 2/3 of urologists agree that interpreting PSA is difficult for GPs

Presentation: what do we say?

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What are LUTS?

• What happened to “prostatism”?

• Or at least “BPH”?

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LUTS =

Lower Urinary Tract Symptoms

BPH =

Benign Prostatic Hyperplasia

BPE =

Benign Prostatic Enlargement

BOO =

Bladder Outlet Obstruction

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What are LUTS?

BPH

BOO

CNS Renal

Cardiac Pituitary

BPE

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LUTS: Storage symptoms

• Urgency +/- Urge Incontinence

• Frequency

• Nocturia

• (Nocturnal enuresis)

(OAB)

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LUTS: Voiding symptoms

• Poor flow

• Intermittency

• Hesitancy

• Straining

• Terminal dribble

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LUTS: Post-micturition

1) Post micturition dribble

2) Incomplete emptying

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LUTS: Assessment

June 2015

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LUTS: Assessment

4 pages of interest:

• Initial assessment

• Referral

• Conservative management

• Drug treatment

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LUTS: Assessment

Consider as minimum 2-part consultation:

• Part 1

– Initial Hx & Ex

– Provide info

– Tests & forms to fill in

• Part 2

– Review & discuss management

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LUTS Assessment: History

• Storage symptoms

• Voiding symptoms

• How much bother from symptoms?

• What is the patient’s worry?

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• Other elements of PMH, e.g.

– Diabetes

– Heart failure

– Kidney failure

– Liver failure

– OSA

– Oedema, chronic venous stasis

– Neurological conditions

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• Medications, e.g.:

– α-blockers

– Diuretics

– Ca channel blockers

– SSRIs

– Bronchodilators (anti-cholinergics)

– Antihistamines

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• Medications, e.g.:

– Lithium

– Benzodiazepines

– NSAIDs

– Pioglitazone

– Gabapentin

– Pregabalin

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LUTS Assessment: Examination

• Abdomen

• External genitalia

• PR / DRE

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PR / DRE:

• Is it smooth?

• Is it big?

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LUTS 34


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LUTS Assessment: Investigations

• Urine dipstick test

• Bloods:

– “Offer a serum creatinine test only if you suspect renal impairment”

– PSA?

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• Offer men information, advice and time to decide if they wish to have PSA testing if:

– LUTS are suggestive of bladder outlet obstruction secondary to BPE or

– their prostate feels abnormal on DRE or

– they are concerned about prostate cancer

LUTS Assessment: PSA?

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• “Ask men with bothersome LUTS to complete a urinary frequency volume chart.”

• “Offer men considering treatment an assessment of baseline symptoms with a validated symptom score (e.g. IPSS).”

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• What’s normal?

• Void: ~250ml

• Fluid in: ~1.5-2L / 24 hrs

• Urine out: ~1.5-2L / 24 hrs

– 30ml/kg / 24hrs

• Frequency: > 8 voids/ 24hrs

• Nocturia: as > 1 void at night

• (Nocturnal polyuria: >⅓ volume at night)

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• Small volume voids with variation in voided volume – characteristic of OAB

• Small volume voids without significant variation in voided volume:

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• Ask re ED

• Measure BP

• Might add to bloods:

– Lipids

– Glucose

LUTS Assessment: Not NICE LUTS & Erectile Dysfunction

Inc

ide

nc

e , %

2

12

2

25

5

45

17

53

7

33

6

43

12

53

19

64

16

41

20

50

31

52

44 45

0

10

20

30

40

50

60

70 No, I cannot get an erection

Net reduction in stiffness

Rosen et al. Eur Urol 2003;44(6):637-49.

LUTS Severity

Age 50 – 59 years

LUTS Severity

Age 60 – 69 years

LUTS Severity

Age 70 – 79 years

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• Interest in sex declines with worsening LUTS

• Many studies shown association of LUTS with ED

• Prostate disease 2nd only to DM as ED risk factor:

– more than PVD, hyperlipidaemia, HT, depression, IHD.

LUTS & ED

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• Treatment itself can worsen or even improve sexual function

• Unclear how much association is physiological, or related to sleep disturbance/anxiety

LUTS & ED

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LUTS & Metabolic Syndrome

Gacci et al, Eur Urol 2011; 60: 809-825

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Link with Metabolic Syndrome

N=409, men presenting with moderate/severe LUTS Lee et al BJUI 2012; 110:540-5

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Link with Metabolic Syndrome

N=409, men presenting with moderate/severe LUTS Lee et al BJUI 2012; 110:540-5

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Kellogg Parsons J et al Eur Urol 2011

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St Sauver JL et al BJU Int 2010

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• Primary Care = ideal setting for holistic management of male LUTS

• The prostate as the “gateway to men’s health”

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LUTS Management

Uncomplicated LUTS Complicated LUTS

• Gradual onset

• Impalpable bladder

• Normal external genitalia

• Benign feeling prostate

• Normal PSA

• No infection / haematuria

• Raised PSA / Abnormal DRE

• Pelvic / Urogenital pain

• UTI / Dysuria

• Palpable bladder

• Incontinence

• Haematuria

• Severe symptoms

• Bladder stones!

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LUTS Management

• If LUTS not bothersome or complicated, reassure

Cancer worry:

• Actually for majority of cases, NO strong link between LUTS & onset of prostate cancer

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LUTS Management

• Think possible causes (PMH/Meds)

• Offer:

– advice on lifestyle interventions (e.g. fluid intake, caffeine, time of diuretics)

– information on the condition

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LUTS Management

• For men with mild-moderate bothersome LUTS, discuss:

• Active surveillance:

– reassurance & lifestyle advice without immediate treatment, or

• Active intervention:

– conservative management

– drug treatment

– surgery

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LUTS Management - Conservative

• If you suspect OAB, offer:

– supervised bladder training

– lifestyle advice, fluid intake

– if needed, containment products.

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• If you suspect OAB, offer:

– supervised bladder training

– lifestyle advice, fluid intake

– if needed, containment products.

• Do not offer penile clamps

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• For men with storage LUTS (particularly urge incontinence):

– Offer temporary containment products (e.g. pads or collecting devices)

– Achieve social continence until diagnosis & management plan discussed

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• Explain to men with post-micturition dribble how to perform urethral milking:

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LUTS Management – Drug Rx

• Often only if bothersome LUTS, & conservative management unsuccessful or not appropriate.

• Do not offer homeopathy, phytotherapy or acupuncture.

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• Overactive bladder:

–Offer an anticholinergic

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• Overactive bladder:

–mirabegron (Betmiga), 50mg od

–β3-adrenoceptor agonist

–Newly licensed 2013 for OAB

• NICE: only if anticholinergic is ineffective, contraindicated or not tolerated

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LUTS Management – Drug Rx 1. Moderate to severe LUTS (not OAB predominant):

–Offer an α-blocker

2. LUTS with PSA >1.4, prostate >30g:

- high risk of progression:

–Offer a 5-α reductase inhibitor (5-ARI)

1 and 2:

–Offer combination treatment

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• Progression =

– Worsening symptoms

– Acute retention

– BPH-related surgery

Risk factors:

– Age over 70

– Moderate to severe symptoms that are bothersome

– PSA > 1.4 ng/ml, Prostate volume >30ml


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Adapted from Marberger MJ et al Eur Urol 2000;38:563-568.

Risk of AUR by Baseline Serum PSA in Untreated Men (Placebo Group)

% o

f m

en

wit

h A

UR

(2

ye

ars

)

Serum PSA level <1.4 ng/ml

(n=705)

Serum PSA level ≥1.4 ng/ml

(n=1394)

9-fold increase in risk (p<0.001)

0.4

3.9

5

4

3

2

1

0

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LUTS Management: α-blockers

• Reduce tone of bladder neck / prostate

• Ideal first line in primary care for ‘mixed LUTS’

• Rapid onset 4-6 weeks

• No effect on PSA level or prostate size

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LUTS Management: α-blockers

• BUT do not prevent progression

• S/E include: dizzy, faint, weak, bowel effects, headache, ejaculatory dysfunction …

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LUTS Management: 5-ARIs

• Inhibit conversion of T to DHT

• ↓prostate volume

• Most effective in larger prostates

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LUTS Management: 5-ARIs

• Beneficial effects start at 6-9 months, fully develop over years

• ↓symptoms & ↓rate of AUR / surgery

• S/E include: fatigue, ED, ↓ libido, gynaecomastia

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–60

–50

–40

–30

–20

–10

0

10

20

0 6 12 18 24 30 36 42 48

Treatment month

Me

an

ch

an

ge

in

PS

A (

%)

Double-blind1 Open phase2

placebo

dutasteride

1. Adapted from Roehrborn CG et al. Urology 2002; 60: 434-441.

2. Adapted from Debruyne F et al. Eur Urol 2004; 46: 488-495.

5.5 2.2

10.7 6.8

15.0

2.8

–50.5

–35.7

–48.6 –43.5

–9.2

-52.9

–48.4

–57.2

5-ARIs reduce PSA level

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LUTS Management: 5-ARIs & PSA

• Any confirmed increase from lowest PSA level may signal non-compliance to therapy, or prostate cancer (particularly high-grade)

– should be carefully evaluated

• Can still use PSA to help risk assessment of PCa, after a new baseline established

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LUTS Management: Combination

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LUTS Management: Combination

• Studies show combination Rx:

–Most effective for controlling symptoms

–Most effective for reducing progression

• e.g. At 4 years, combination vs tamsulosin alone reduced risk of AUR / surgery by 70%

• 7.7% actual risk reduction (NNT=13)

Roehrborn CG et al. J Urol 2008;179:616–21;

Siami P et al. Contemp Clin Trials 2007;28:770–9

McConnell JD et al. NEJM 2003;349:2387–98

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LUTS 79 LUTS 80


2012:

Cialis (tadalafil) 5 mg od: Licensed for treating the “signs & symptoms of BPH”

SLS restrictions amended, so can prescribe for condition other than ED

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Tadalafil for LUTS:

• IPSS scores do improve

• May be more effective combined with α-blocker (caution)

• NICE 2015: Do not offer solely for LUTS, unless part of a trial

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Oelke et al. Eur Urol 2012;61: 917 - 925

* Please note that tamsulosin is an active control. This study was powered for direct comparisons between tadalafil and placebo and between tamsulosin and placebo.

IPSS: Tadalafil vs placebo & Tamsulosin vs placebo

Add muscarinic receptor antagonist

+ continue with Edu/Lifestyle

Edu/Lifestyle with or without

5-ARI ± α1-blocker/

PDE5-I

Male LUTS EAU Guidelines 2015

(without indications for surgery)

Watchful waiting

with or without Edu/Lifestyle

Edu/Lifestyle with or without Anti cholinergic

Edu/Lifestyle with or without Vasopressin

Analogue

Bothersome symptoms?

Storage symptoms predominant?

Edu/Lifestyle with or without

α1-blocker/PDE5-I

- + Nocturnal polyuria

predominant?

Prostate volume >40 ml?

Long-term treatment?

Residual storage symptoms

-

-

-

-

+

+

+

+

Gratzke C et al. Eur Urol 2015;67:1099-1109


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Back to NICE:

• Consider adding an anticholinergic if storage symptoms after α–blocker alone for LUTS

• LOW risk of retention

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LUTS Management – Drug Rx Back to NICE:

• Nocturnal polyuria (>1/3 urine at night)

– Consider late-afternoon loop diuretic

– Consider oral desmopressin, if other medical causes have been excluded

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LUTS: Referral

• Bothersome LUTS not responded to conservative & drug management

• LUTS complicated by:

– recurrent or persistent UTI

– retention (acute / chronic)

– renal impairment thought due to LUT dysfunction

– stress urinary incontinence

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LUTS: Secondary Care

• Flow-rate

• Post-void residual

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• Flow-rate


• Possibly:

– Cystoscopy

– Upper tract imaging

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LUTS 91


• Flow-rate


• Possibly:

– Cystoscopy

– Upper tract imaging

– Urodynamics (if considering surgery)

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LUTS: Surgery Voiding:

• TURP

• TUVP

• HoLEP (laser)

• TUIP (often smaller prostates, younger men)

• ‘Urolift’ for some

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LUTS: Surgery

Storage:

• Botox injections

• Sacral / tibial nerve stimulation

• Cystoplasty

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LUTS: Surgery

Stress incontinence:

• Implantation of an artificial sphincter

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LUTS: SUMMARY

• Common, under-reported

• Ask: what is bothering the patient?

• Strong link with ED / Metabolic Syndrome

• Holistic assessment

• Think: balls

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LUTS: SUMMARY

• Lifestyle intervention especially fluid intake

• Medical therapy according to symptoms

• Find & treat nocturnal polyuria

• Remember: a progressive condition

• Refer if not responding / atypical / complicated

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14/07/2015 · MA MD MRCS MRCGP DRCOG ... Plan of attack ... 14/07/2015 4 LUTS 28 LUTS Assessment: History • Other elements of PMH, e.g. –Diabetes