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Approach to a man with Lower Urinary Tract Symptoms

Approach to a man with Lower Urinary Tract Symptoms. Dr. Yeung Fun Na, Fannie. Obstructive Hesitancy Weak stream Intermittency Terminal dribbling Incomplete emptying Straining Prolonged micturiction Overflow incontinence. Irritative Urgency Urge incontinence Frequency Nocturia

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Approach to a man with Lower Urinary Tract Symptoms

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  1. Approach to a man with Lower Urinary Tract Symptoms Dr. Yeung Fun Na, Fannie

  2. Obstructive Hesitancy Weak stream Intermittency Terminal dribbling Incomplete emptying Straining Prolonged micturiction Overflow incontinence Irritative Urgency Urge incontinence Frequency Nocturia Dysuria Suprapubic pain Lower Urinary Tract Symptoms

  3. 62 years old gentleman: “Doctor, I have to get up 2-3 times at night to urinate in the past year and the urinary stream is weak. I need to strain to begin urination most of the time. Is this related to my prostate? What Are the DDX in Your Mind? What Else Do You Want to Know?

  4. Possible DDX • Neurogenic bladder • Bladder neck contracture • CA prostate • Prostatitis • Urethral stricture • UTI

  5. History • LUTS (severity, duration) • Complications • Urinary stone • Retention of urine • Recurrent UTI • Uraemic symptoms • Past Hx: DM, CVA, Spine Trauma, neurological disease, previous endourological manipulation, perineal pain • Drug Hx: anticholinergic, B-adrenergic

  6. IPPS (prostate symptom score) • Assess frequency of the following symptoms (score from 0-5) • sense of incomplete emptying • Frequency • Intermittency • Urgency • Weak stream • Straining • nocturia

  7. QOL assessment index L • If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel bout that • 0 delighted • 1 pleased • 2 mostly satisfied • 3 mixed about equally satisfied and dissatisfied • 4 mostly dissatisfied • 5 unhappy • 6 terrible

  8. Physical Examinations • General: pallor, uaemic features • Abd: kidney, bladder, hernia • DRE: (prostate) surface, symmetry, sulcus, consistency, mobility, size; anal tone • Genitalia: phimosis, penile CA, meatal stenosis, urethral stricture

  9. Basic Investigations • Dipstick test • Blood x RFT, PSA, fasting glucose • MSU x C/ST, R/M • KUB

  10. Other Investigations • Uroflowmetry • TRUS + Bx • IVU, Cystoscopy, USG • Urodynamic studies • CT, MRI, Bone Scan

  11. When to refer • High symptom score • Abn DRE • Palpable bladder (RU > 300ml) • Hx of recurrent UTI / haematuria • PSA > 4 • Rapid onset of symptoms +/- low back pain • Complications develop (impaired renal function)

  12. Management of LUTS due to BPH • Conservative • Medical • Surgical • Mild symptoms conservative (simple advice) • Moderate symptoms  medical treatment • Severe symptoms / surgical indication  refer urologist

  13. Conservative management • Adequate dietary fibre • Avoid drugs that may precipitate urinary retention • Avoid excessive water intake, coffee / tea at night time • Adequate voiding, double voiding

  14. Medical Treatment • Alpha blockers (e.g. terazosin, doxazosin) • Relax muscle at bladder neck, prostatic urethra • Effective in 60% patients ( flow  PSS) • Possible SE: drowsiness, dizziness, headache 10-15% • Effective after 1-2 doses • Can be used as single agent in treating patients with HT esp useful in those with dyslipidaemia 2. 5 alpha-reductase inhibitor (e.g. finasteride) • Inhibit T DHT,  prostate volume • Possible SE:  libido, impotence 4% • Takes 3-6 months to have improvement in urine flow; less effective; more expensive

  15. Examples of commonly used Alpha-blocker • Hytrin (terazosin HCl) • Initial dose 1mg Nocte • Titrate stepwise to 2mg, then 5mg, 10mg daily • Cardura (doxazosin HCl) • Initial dose 1mg Nocte • Titrate stepwise to 2mg, 4mg, up to 8mg with recommended titration interval of 1-2 weeks • S/E: dizziness, headache

  16. Examples of commonly used Alpha-blocker • Cardura XL • Modified release formulation of Cardura, which releases doxazosin over 12-16 hours and provides a sustained plasma concentration throughout 24 hour dosing scheduled • Same efficacy with Cardura • Initial dose 4mg Nocte • No need for dose titration • Xatral SR (alfuzosin HCl) • 5mg daily, up to 5mg bd

  17. Surgical Treatment TURP (commonest prostate operation) • possible peri-operative complications and long term complications(like incontinence, urethral stricture, impotence, retrograde ejaculation, recurrent symptoms, prostatic re-growth) Others: - Open prostatectomy, TUIP, thermal therapy, laser therapy, stenting

  18. PSA (prostatic specific antigen) • Organ-specific, not cancer-specific • Normal cutoff value < 4.0 ng/ml •  with age, prostatic volume •  in 25% BPH, 80% CA • PSA > 10 and abn DRE: 65% cancer • Not for Routine Screening !!!

  19. Indications for PSA • Screening for High risk group - 1 x 1st degree: 2-5x - 2 x 1st degree: 5-10x - > 20% / year  biopsy • life expectancy > 10 years AND requesting for PSA test / highly suspicious of CA prostate e.g. abn DRE

  20. False Positives Recent episodes of • UTI • Retention of urine • Prostatitis Within 72 hours after ejaculation Shortly after prostatic surgery or biopsy

  21. Interpretation of PSA level • < 4 normal • 4-10 equivocal, 20% chance • > 10 > 50% •  > 20%/yr immediate bx • Age upper limit • 40-49 2.5 • 50-59 3.5 • 60-69 4.5 • 70-79 6.5

  22. THE END

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