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Lower urinary tract symptoms (LUTS) in elderly males

Lower urinary tract symptoms (LUTS) in elderly males. Victor Palit MS, FRCS, MPhil, FRCS (Urol), FEBU, PG Cert Med Ed, FHEA Consultant Urological surgeon University Hospital of North Tees and Hartlepool & honorary consultant JCUH. Structure of the talk.

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Lower urinary tract symptoms (LUTS) in elderly males

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  1. Lower urinary tract symptoms (LUTS) in elderly males Victor Palit MS, FRCS, MPhil, FRCS (Urol), FEBU, PG Cert Med Ed, FHEA Consultant Urological surgeon University Hospital of North Tees and Hartlepool & honorary consultant JCUH

  2. Structure of the talk • Red flag symptoms & signs & aetiology of LUTS • Presenting symptoms & signs- DRE & PSA • Management of symptoms • Summary

  3. Is the patient’s LUTS caused by cancer? • If not what is the cause and can it be treated?

  4. Red Flag symptoms & signs • Blood in Urine • Predominant symptom- urgency • Bothersome urinary symptoms not settling with medication • Constitutional symptoms- loss of wt, bone pain • Significant risk factors- smoker, worked with chemicals, PMH, FH • Abnormal DRE & PSA

  5. Underlying causes • Prostate enlargement • Infections • Overactive bladder • Bladder/urethral tumour • Bladder Stones/foreign body • Abdominal operations/spinal problems/rarely growth outside bladder/prostate

  6. Basic evaluation • History and symptom assessment • Abdominal and Rectal examination • Urinalysis • Serum creatinine and ? PSA • Post void residual volume (PVRV) bladder scan

  7. Total score: 0-7 Mildly symptomatic 8-19 moderately symptomatic; 20-35 severely symptomatic

  8. NICE recommendations for DRE • Assessment for GI/GU disease • Screening for colorectal/prostatic disease SYMPTOMS • Lower Urinary Tract Symptoms (LUTS) • Erectile dysfunction • Low back pain • Bone pain • Haematuria • Unexplained weight loss • Tenesmus • Rectal bleeding • Alteration of bowel habit

  9. DRE for prostate Normal consistency is • rubbery and firm, • with smooth surface and • median sulcus palpable between right & left lobes

  10. PSA testing (NICE guidance) General Overview • Offer men information, advice and time to decide if they wish to have a PSA test if their: • LUTS are suggestive of bladder outlet obstruction secondary to BPE or • Prostate feels abnormal on DRE or • Concern is about prostate cancer 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

  11. When to request PSA? • Bone pain with LUTS • LUTS with constitutional symptoms • Non visible /visible haematuria??? • No PSA within 4 weeks of UTI/ urological operation & pts with catheter

  12. NICE Recommendations on management of mild or moderate LUTS Bothersome to the patient, or complicated? Yes No Active surveillance? Give reassurance, offer advice on lifestyle interventions and information on their condition. Offer review if symptoms change. Active intervention Conservative management / drug treatment or surgery Offer baseline assessment (eg IPSS) 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

  13. NICE RecommendationsDrug Treatment - LUTS Offer an alpha blocker Moderate to severe LUTS Consider combination treatment with an alpha blocker and a 5ARI Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

  14. NICE RecommendationsConservative management – storage symptoms Storage symptoms • OAB Offer • supervised bladder training • advice on fluid intake • lifestyle advice • containment products (if needed) 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

  15. NICE RecommendationsDrug treatment – storage symptoms Offer an anticholinergic OAB Storage symptoms despite treatment with an alpha blocker alone Consider adding an anticholinergic 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

  16. Summary • LUTS has multifactorial aetiology- don’t forget cancer, stones & infections • Red flag symptoms & signs- haematuria, urgency, bothersome symptoms not settling with treatment, bone pain, wt loss, abnormal DRE & PSA • Life style changes/Containment device in mild symptoms if PVRV bladder scan is normal • Alpha blocker for mild to moderate symptoms- refer if no improvement • Anticholinergics for signs of overactive bladder- look for side effects

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