Approach to a man with Lower Urinary Tract Symptoms

Dr. Yeung Fun Na, Fannie

Lower Urinary Tract Symptoms

Obstructive- Hesitancy- Weak stream- Intermittency- Terminal dribbling- Incomplete emptying- Straining- Prolonged micturiction- Overflow incontinence

Irritative - Urgency- Urge incontinence- Frequency- Nocturia- Dysuria- Suprapubic pain

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?

Possible DDX

1. Neurogenic bladder2. Bladder neck contracture3. CA prostate4. Prostatitis5. Urethral stricture6. UTI

History

1. LUTS (severity, duration)2. Complications - Urinary stone- Retention of urine - Recurrent UTI- Uraemic symptoms3. Past Hx: DM, CVA, Spine Trauma, neurological disea

se, previous endourological manipulation, perineal pain

4. Drug Hx: anticholinergic, B-adrenergic

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

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 that0 delighted1 pleased2 mostly satisfied3 mixed about equally satisfied and dissatisfied4 mostly dissatisfied5 unhappy 6 terrible

Physical Examinations

General: pallor, uaemic features

Abd: kidney, bladder, hernia

DRE: (prostate) surface, symmetry, sulcus, consistency, mobility, size; anal toneGenitalia: phimosis, penile CA, meatal stenosis, urethral stricture

Basic Investigations

Dipstick testBlood x RFT, PSA, fasting glucoseMSU x C/ST, R/MKUB

Other Investigations

UroflowmetryTRUS + BxIVU, Cystoscopy, USGUrodynamic studiesCT, MRI, Bone Scan

When to refer

1. High symptom score2. Abn DRE3. Palpable bladder (RU > 300ml)4. Hx of recurrent UTI / haematuria5. PSA > 46. Rapid onset of symptoms +/- low back pain7. Complications develop (impaired renal function)

Management of LUTS due to BPH

ConservativeMedical Surgical

Mild symptoms conservative (simple advice)Moderate symptoms medical treatmentSevere symptoms / surgical indication refer urologist

Conservative management

1. Adequate dietary fibre2. Avoid drugs that may precipitate urinar

y retention3. Avoid excessive water intake, coffee / te

a at night time4. Adequate voiding, double voiding

Medical Treatment

1. 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 usef

ul in those with dyslipidaemia2. 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 effecti

ve; more expensive

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 recomme

nded titration interval of 1-2 weeks- S/E: dizziness, headache

Examples of commonly used Alpha-blocker

- Cardura XL- Modified release formulation of Cardura, which release

s 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

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, las

er therapy, stenting

PSA (prostatic specific antigen)

1. Organ-specific, not cancer-specific2. Normal cutoff value < 4.0 ng/ml3. with age, prostatic volume4. in 25% BPH, 80% CA5. PSA > 10 and abn DRE: 65% cancer6. Not for Routine Screening !!!

Indications for PSA

1. Screening for High risk group - 1 x 1st degree: 2-5x- 2 x 1st degree: 5-10x- > 20% / year biopsy

2. life expectancy > 10 years AND requesting for PSA test / highly suspicious of CA prostate e.g. abn DRE

False Positives

Recent episodes of - UTI- Retention of urine- ProstatitisWithin 72 hours after ejaculationShortly after prostatic surgery or biopsy

Interpretation of PSA level

< 4 normal4-10 equivocal, 20% chance> 10 > 50% > 20%/yr immediate bx

Age upper limit 40-49 2.550-59 3.560-69 4.570-79 6.5

THE END