LUTSShawket Alkhayal

Consultant Urological Surgeon

Benenden Hospital

Tunbridge Wells Nuffield Hospital

LUTS are a major burden for the ageing male population.

Age is an important risk factor for LUTS and the prevalence of LUTS increases as men get older.

Bothersome LUTS can occur in up to 30% of men older than 65 years.

Male Lower Urinary Tract Symptoms (LUTS)

It can comprise voiding or storage urinary symptoms and can arise from any of the following organ problem:

Prostate: benign prostate enlargement (BPH), prostate cancer, prostatitis Urethra: strictures, inflammationBladder: Cystitis, Detrusor muscle weakness or overactivity, Bladder pain SyndromeNeurological disease

Voiding Symptoms

Weak or intermittent urinary stream

Hesitancy

Straining

Sense of incomplete emptying

Terminal dribbling

Storage Symptoms

Frequency

Urgency

Urge incontinence

Nocturia

Enuresis

Assessment

Medical history

Associated co-morbidities

Review current medication, to identify drugs that may be contributing to the problem

Specific questionnaire (IPSS)

Urinary frequency volume chart (Bladder Diary)

Examination

General examination

Examination of the abdomen

External genitalia

Digital Rectal Examination (DRE)

TestsUrine dipstick test

blood glucose protein leucocytes nitrites

Offer men PSA test after counselingSerum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation)

if you suspect renal impairment palpable bladder nocturnal enuresisrecurrent urinary tract infectionshistory of renal stones

Conservative ManagementStorage Symptoms

Bladder training for OAB symptoms

Advice on fluid intake

Lifestyle advice

Containment products if they are incontinent

Drug Therapyfor mild to moderate symptoms

For predominantly voiding symptoms-offer an alpha blocker

For predominantly storage symptoms offer an anticholinergic

For mixed symptoms offer an alpha blocker first then add anticholinergic after 4 weeks if no improvement

Referral for Specialist Assessment

If bothersome LUTS that have not responded to conservative management or drug treatment LUTS complicated by recurrent or persistent urinary tract infection orUrinary retention orRenal impairment you suspect is caused by lower urinary tract dysfunction orSuspected urological cancer

Specialist Assessment

History review

Examination including DRE

Bladder diary

IPSS

Flow test and check residual volumes

Alpha blockers if not been tried for voiding Symptoms with low flow rate and high residuals

Add 5 alpha reductase inhibitors for men with prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml

Anticholinegics for OAB symptoms with good flow test and minimal residuals

Late afternoon loop diuretic for nocturnal polyuria.

Oral desmopressin for nocturnal polyuria if other medical causes have been excluded and other treatments failed

Urodynamic Assessment

Predominantly storage symptoms

Men under 40 or over 85

Previous pelvic surgery

Neurological disease

Cystoscopy

Recurrent infection

Sterile pyuria

Haematuria

New storage symptoms

Bladder pain

Dysuria

Imaging of the Upper Urinary Tract

Chronic retention

Haematuria

Recurrent infection

Sterile pyuria

Profound symptoms or pain

Surgical Management of BPH

If voiding symptoms are severe, or If drug treatment and conservative management options have been unsuccessful or are not appropriate Discuss the alternatives to and outcomes from surgeryTURP, Bipolar TURP, HOLEPAll other surgical treatments should be in the context of audit or research

Management of OAB

if symptoms have not responded to conservative

management and drug treatments

Botox Bladder injections for men with detrusor over activity, and is willing and able to self-catheterise

Sacral nerve stimulation

Cystoplasty

Urinary Diversion

New treatments

PDE5-inhibitors (Tadalafil 5mg) for patients with LUTS and ED

Beta 3 agonist (Mirabegron) for OAB

PTNS- for OAB symptoms