2008

Causes of symptoms

Hyperplasia of epithelial and stromal components of prostate

Progressive obstruction of urinary outflow

Increased activity of detrusor muscle Causes

Frequency, nocturia Poor flow , intermittent stream Hesitation, terminal dribbling

Prevalence

Men > 50 = 41% have symptoms of LUTS

Only 18% have a diagnosis Only 10% aware of drugs or

surgery that will help it

Risk factors

Age ? obesity

Differential diagnosis

• Poorly controlled diabetes• Neurological disorders• Urinary tract infections• Abacterial prostatitis• Overactive bladder• Drugs – diuretics, anticholinergics,

antidepressants• Lifestyle factors – caffeine, alcohol,

xs fluids

Abnormal symptoms

The presence of the following symptoms indicates referral to urologist for futher assessment Urinary incontinence Retention Dysuria Haematuria Acute change in symptoms

Examination

Palpation of abdomen for enlarged bladder enlarged kidneys constipation

Rectal examination for Size and consistency of prostate

gland

Investigations

• Blood tests– Fbc esr– U&e’s– Fasting blood sugar– ? PSA – level rises with increasing

volume of prostate gland

• Urinalysis– Infection– haematuria

Investigations

Additional tests as appropriate by GP Ultrasound for residual urine volume

Urinary diaries

Specialist investigations Reasons for doing them

Patient reassurance Patient explanation Objective assessment of symptoms Diagnostic precision Ranking of treatment options Prediction of treatment outcome

Specialist investigations Uroflowmetry

max flow rate and volume of residual urine after voiding – low flow rate indicates need for TURP

Bladder pressure studies pressure measurement during filling and

emptying (cystometry) gives information on over/under activity of detrusor muscle and obstruction of bladder outlet. Predicts response to treatment. Use antimuscarinics for over activity and turp for bladder outlet obstruction

Specialist investigations Urinary tract imaging

Ultrasound to estimate residual urine Urethroscopy

Visual inspection of bladder and uerethra is used in dysuria or haematuria

Assesment

• A validated questionnaire using international prostate symptom scale.

• Completion gives total score of 35– 1 – 7 mild– 8 – 19 moderate– 20 – 35 severe

• Response to the quality of life questionnaire strong predictor or whether intervention is necessary

Scoring system

– Ask 7 questions. Answers on scale 0 – 5 depending on severity of symptoms

– For first 6 questions scores are • Not at all = 0• < 1 in 5 = 1• < half the time = 2• About half the time = 3• > half the time = 4• Almost always = 5

– Q7 • Never = 0, once = 1, 2x = 2, 3x = 3, 4x =

4, 5x = 5

Questions

In last month how often have you1. Had sensation of not emptying bladder

completely2. Had urge to urinated < 2 hours after

previously finished3. Found you stopped and started again several

times4. Found it difficult to postpone urination5. Had a weak stream (compared to when aged

30)6. Had to push or strain to begin urination7. How many times did you get out of bed per

night to urinate

Quality of life

• If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?– Delighted 0– Pleased 1– Mostly satisfied 2– Mixed feelings 3– Mostly dissatisfied 4– Terrible 5

Management

Lifestyle modification Reduce fluid intake Stop diuretics if poss Avoid xs night time fluid

intake/caffeine /alcohol Empty bladder before long

trips/meetings

Management

Treat co morbid contributing conditions Diabetes uti

Management

Drug therapy Alpha blockers

Improve bladder and prostate smooth muscle tone

More effective than 5 alpha reductase inhibitors

All work equally well Tamsulosin and alfuzosin require no

dose titration

Management

Drug therapy 5 alpha reductase inhibitors

Reduce prostate volume Reduces risk of prostate cancer, increases

risk of high grade disease Combined therapy

Men with large prostate > 40g or PSA >4 or moderate to severe symptoms combined therapy will prevent 2 episodes of clinical progression per 100men over 4yrs. Much less effective for men with smaller prostates

Management

Drug therapy Storage problems

Men with symptoms of urinary urgency, frequency, small, urine volumes and nocturia in the absence of serious obstructive symptoms are categorised as over active bladder

Bladder training Biofeedback Antimuscarinic drugs ( oxybutinin,

tolteridine) alone or in combination with treatment for obstructive symptoms

Management

Surgery TURP

Greatest improvement in symptoms 5% severe haemorrhage risk Requires GA

Alternative energy sources for TURP Ultrasound Laser microwave

Management

Surgery Adverse effects of surgery

Loss of ejaculation Erectile dysfunction Retrograde ejaculation Incontinence Stricture formation Urinary retention