BPH / LUTS - prostatecanceruk.org · LUTS 57 LUTS Management Uncomplicated LUTS Complicated LUTS...
Transcript of BPH / LUTS - prostatecanceruk.org · LUTS 57 LUTS Management Uncomplicated LUTS Complicated LUTS...
LUTS 1
BPH / LUTS
Dr Jonny Coxon
GP
Beaconsfield Medical Practice
Brighton
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“As man draws near the common goal
Can anything be sadder
Than he who, master of his soul
Is servant to his bladder‟
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Plan of attack
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Plan of attack
• Prevalence including ‘under-reporting’
• Presentation
• What are lower urinary tract symptoms (LUTS)?
• Distinction between storage / voiding etc
• Initial assessment in primary care
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Plan of attack
• Overactive bladder
• Medical management
• Who to refer
• What happens in secondary care
• Case scenarios
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Prevalence
• Depends who you ask
• Not all male LUTS = BPH
• Not all BPH causes LUTS
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Prevalence
0
10
20
30
40
50
60
70
80
90
100
20-29 30-39 40-49 50-59 60-69 70-79 80-89
Pre
vale
nce (
%) Pradhan (1975)
Swyer (1944)
Franks (1954)
Moore (1943)
Harbitz (1972)
Holund (1980)
Baron (1941)
Fang-Liu (1991)
Karube (1961)
Age (y)
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Prevalence
It is abnormal NOT to have benign growth of the prostate with
increasing age
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Prevalence
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Prevalence
• Approximately 1/3 of men over 50 have moderate to severe lower urinary tract symptoms
• = 3.2 million men in UK
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• Huge issue = getting men to report symptoms in first place
• Some can be rather stoical: “just part of growing old”
Presentation: what do patients say?
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Presentation: what do patients say?
• “I don’t understand it doc, I keep feeling like I need a pee, but hardly any comes out.”
• “My sleeping’s getting awful.”
• “Do you know the public toilets round here are awful…”
• “I have to plan my day around toilet breaks”
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• “I might be fine for ages then suddenly, whoosh, I’ve got to go.”
• “I keep having to make excuses in meetings.”
• “I can’t make it round the golf course these days.”
Presentation: what do patients say?
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• “I’m worried about me prostrate”
• “While I’m here doc…”
• “I’m here because the wife sent me in.”
Presentation: what do patients say?
Lack of
physical
intimacy
Anger or
conflict
Avoidance
or withdrawal
A feeling of
distance or
isolation
Lack of
communication
Pro
po
rti
on
of
me
n w
ith
en
larg
ed
pro
sta
te a
nd
th
eir
sp
ou
se
s r
ep
orti
ng
sp
ec
ific
re
lati
on
sh
ip c
on
ce
rn
s Men with mild symptoms (n=216)
Men with moderate-to-severe symptoms (n=203)
Spouses of men with enlarged prostate (n=77)
Roehrborn CG et al. Prostate Cancer Prostatic Dis 2006;9:30–34.
Presentation
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Worry that patient may have cancer 71%
Worry about patient’s need for surgery 66%
Deterioration in sex life due to symptoms 66%
Social life affected by patient’s symptoms 47%
Become tired because of waking at night 42%
Sells, Donovan, Ewings & MacDonagh. BJU Int 2000, 85, 440-445
Presentation: what do partners say?
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• GPs worry about missing prostate cancer – only 11% confident in distinguishing between BPH
& Prostate Cancer
• 54% refer men before maximising medical
therapy
• GPs seek specialist advice in 1/3 of men with LUTS
Presentation: what do we say?
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• Urologists feel that approx 40% of BPH referrals could be managed in primary care
• 68% of urologists agree that interpreting PSA results is difficult for GPs
Presentation: what do we say?
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What are LUTS?
• What happened to “prostatism”?
• Or at least “BPH”?
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LUTS =
Lower Urinary Tract Symptoms
BPH =
Benign Prostatic Hyperplasia
BPE =
Benign Prostatic Enlargement
BOO =
Bladder Outlet Obstruction
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What are LUTS?
BPH
BOO
CNS Renal
Cardiac Pituitary
BPE
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LUTS: Storage symptoms
• Urgency +/- Urge Incontinence
• Frequency
• Nocturia
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LUTS: Storage symptoms
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LUTS: Voiding symptoms
• Poor flow
• Intermittency
• Hesitancy
• Straining
• Terminal dribble
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LUTS: Post-micturition
• Post micturition dribble
• Incomplete emptying
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LUTS: Assessment
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LUTS: Assessment
4 pages of interest:
• Initial assessment
• Referral
• Conservative management
• Drug treatment
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LUTS: Assessment
Consider as 2-part consultation:
• Initial Hx & Ex
• Provide info
• Tests & forms to fill in
• Review and choose management
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LUTS Assessment: History
• Storage symptoms
• Voiding symptoms
• How much bother from symptoms?
• What is the patient’s worry?
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LUTS Assessment: History
• Other elements of PMH, e.g.
– Diabetes
– Heart failure
– Kidney failure
– Liver failure
– OSA
– Oedema
– Chronic venous stasis
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LUTS Assessment: History
• Medications, eg:
– α-blockers
– Diuretics
– Ca channel blockers
– SSRIs
– Bronchodilators (anti-cholinergics)
– Antihistamines
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LUTS Assessment: History
• Medications, eg:
– Lithium
– Benzodiazepines
– NSAIDs
– Pioglitazone
– Gabapentin
– Pregabalin
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LUTS Assessment: Examination
• Abdomen
• External genitalia
• PR / DRE
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LUTS Assessment: Examination
PR / DRE:
• Is it smooth?
• Is it big?
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LUTS Assessment: Examination
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LUTS Assessment: Examination
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LUTS Assessment: Investigations
• Urine dipstick test
• Bloods:
– “Offer a serum creatinine test (+ eGFR) only if you suspect renal impairment”
– PSA?
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• Offer men information, advice and time to decide if they wish to have PSA testing if:
– LUTS are suggestive of bladder outlet obstruction secondary to BPE or
– their prostate feels abnormal on DRE or
– they are concerned about prostate cancer
LUTS Assessment: PSA?
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LUTS Assessment: Investigations
• “Ask men with bothersome LUTS to complete a urinary frequency volume chart.”
• “Offer men considering treatment an assessment of baseline symptoms with a validated symptom score (e.g. IPSS).”
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LUTS Assessment: Investigations
• What’s normal?
• Void: 250ml
• Fluid in: approx 1.5L / 24 hrs
• Urine out: approx 1.5L / 24 hrs
• Frequency defined as > than 8 voids/day
• Nocturia defined as > 1 void at night
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LUTS Assessment: Investigations
• Reduced volume voids with marked variation in voided volume – characteristic of OAB
• Reduced volume voids without significant variation in voided volume – ‘red flag’
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• Ask re ED
• Measure BP
• Might add to bloods:
– Lipids
– Glucose
LUTS Assessment: Not NICE
• MSAM: Multinational Survey of the Ageing Male
• N =12,815 men aged 50-80 years
0
20
40
60
80
100
Mild Moderate Severe
LUTS severity
Inc
ide
nc
e e
rec
tio
n p
rob
lem
s (
%)
Rosen R et al. Eur Urol 2003;44:637-49
LUTS & ED
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LUTS & ED
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• Interest in sex declines with worsening LUTS
• Several studies shown association of LUTS with ED & premature ejaculation
• Treatment itself can worsen or even improve sexual function
• Unclear how much association is physiological or related to sleep disturbance/anxiety
LUTS & ED
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• PDE-5 inhibitors improve both ED & LUTS in men with both conditions
• Significant improvement in IPSS scores
• (No change seen in urodynamic variables)
• May see more effective combined with α-blocker (but caution giving together)
LUTS & ED
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LUTS & Metabolic Syndrome
Gacci et al, Eur Urol 2011; 60: 809-825
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LUTS & Metabolic Syndrome
N=409, men
presenting with LUTS
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LUTS & Metabolic Syndrome
N=409, men
presenting with LUTS
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LUTS & Metabolic Syndrome
Kellogg Parsons J et al Eur Urol 2011
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LUTS & Metabolic Syndrome
St Sauver JL et al BJU Int 2010
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LUTS & Metabolic Syndrome
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LUTS & Metabolic Syndrome
• Primary Care = ideal setting for holistic management of male LUTS
• The prostate as the “gateway to men’s health”
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LUTS Management
Uncomplicated LUTS Complicated LUTS
• Gradual onset
• Impalpable bladder
• Normal external genitalia
• Benign feeling prostate
• Normal PSA
• No infection / haematuria
• Raised PSA / Abnormal DRE
• Pelvic / Urogenital pain
• UTI / Dysuria
• Palpable bladder
• Incontinence
• Haematuria
• Severe symptoms
• Bladder stones!
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LUTS Management
• If LUTS not bothersome or complicated, reassure
• Offer:
– advice on lifestyle interventions (for example, fluid intake)
– information on the condition.
• Offer review if symptoms change.
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LUTS Management
• For men with mild-moderate bothersome LUTS, discuss:
• Active surveillance:
– reassurance & lifestyle advice without immediate treatment and with regular follow-up, or
• Active intervention:
– conservative management
– drug treatment
– surgery
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LUTS Management - Conservative
• If you suspect OAB, offer:
– supervised bladder training
– advice on fluid intake
– lifestyle advice and,
– if needed, containment products.
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LUTS Management - Conservative
• If you suspect OAB, offer:
– supervised bladder training
– advice on fluid intake
– lifestyle advice and,
– if needed, containment products.
• Do not offer penile clamps
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LUTS Management - Conservative
• For men with storage LUTS (particularly urinary incontinence):
– Offer temporary containment products (e.g. pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
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LUTS Management - Conservative
• Voiding symptoms:
–Offer ISC before indwelling catheter if LUTS cannot be corrected by less invasive measures.
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LUTS Management - Conservative
• Explain to men with post micturition dribble how to perform urethral milking
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LUTS Management – Drug Rx
• Only if bothersome LUTS, & conservative management unsuccessful or not appropriate.
• Do not offer homeopathy, phytotherapy or acupuncture.
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LUTS Management – Drug Rx
• Overactive bladder:
–Offer an anticholinergic
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LUTS Management – Drug Rx 1. Moderate to severe LUTS:
–Offer an α-blocker • Alfuzosin, doxazosin, tamsulosin or terazosin
2. LUTS with prostate >30g , PSA >1.4, high risk of progression:
–Offer a 5-α reductase inhibitor (5-ARI) • Dutasteride, finasteride
1 and 2:
–Offer combination treatment
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• Progression =
– Deterioration in symptoms
– Acute retention
– BPH-related surgery
• Risk factors:
– Age over 70 with LUTS
– Moderate to severe symptoms that are bothersome i.e. IPSS ≥8 (QoL question over 3)
– PSA > 1.4 ng/ml, Prostate volume >30ml
LUTS Management – Drug Rx
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Adapted from Marberger MJ et al Eur Urol 2000;38:563-568.
Risk of AUR by Baseline Serum PSA in Untreated Men (Placebo Group)
% o
f m
en
wit
h A
UR
(2
ye
ars
)
Serum PSA level <1.4 ng/ml
(n=705)
Serum PSA level ≥1.4 ng/ml
(n=1394)
9-fold increase in risk (p<0.001)
0.4
3.9
5
4
3
2
1
0
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LUTS Management: α-blockers
• Reduce tone of bladder neck / prostate
• Ideal first line in primary care for ‘mixed LUTS’
• Rapid onset 4-6 weeks
• No effect on PSA level or prostate size
• BUT do not prevent progression
• S/E include: dizzy, faint, weak, bowel effects, headache (see SmPC for full list)
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LUTS Management: 5-ARIs
• Finasteride or Dutasteride (Avodart/Combodart )
• Inhibit conversion of testosterone to DHT
• ↓prostate volume
• Most effective in larger prostates
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LUTS Management: 5-ARIs
• Beneficial effects start at 9 months, fully develop over years
• ↓symptoms & ↓rate of AUR / surgery
• S/E include: fatigue, ED, loss of libido, gynaecomastia (see SmPC for full list)
–60
–50
–40
–30
–20
–10
0
10
20
0 6 12 18 24 30 36 42 48
Treatment month
Me
an
ch
an
ge
in
PS
A (
%)
Double-blind1 Open phase2
placebo
dutasteride
1. Adapted from Roehrborn CG et al. Urology 2002; 60: 434-441.
2. Adapted from Debruyne F et al. Eur Urol 2004; 46: 488-495.
5.5 2.2
10.7 6.8
15.0
2.8
–50.5
–35.7
–48.6 –43.5
–9.2
-52.9
–48.4
–57.2
5-ARIs reduce PSA level
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LUTS Management: Combination
• MTOPS & CombAT studies
• Most effective for controlling symptoms
• Most effective for reducing progression
• At 4 years in CombAT, combination reduced risk of AUR / surgery by 70% vs tamsulosin alone
• 7.7% actual risk reduction (NNT=13)
Roehrborn CG et al. J Urol 2008;179:616–21;
Siami P et al. Contemp Clin Trials 2007;28:770–9
McConnell JD et al. NEJM 2003;349:2387–98
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LUTS Management: Combination
• In CombAT, More men in the combination group (0.9%) had cardiac failure versus dutasteride (0.2%) & tamsulosin (0.6%)
• Also seen in REDUCE study
• No difference in overall cardiovascular events
• Rates of cardiac failure in all treatment groups were low compared with the placebo group of pooled Phase III BPH studies (1.3%)
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LUTS Management: 5-ARIs & PSA
REDUCE study:
• Extent of PSA decrease in the first 6 months does not predict the diagnosis of prostate cancer
• Patients should have a new PSA baseline established after 6 months
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LUTS Management: 5-ARIs & PSA
REDUCE study:
• Any confirmed increase from lowest PSA level may signal non-compliance to therapy or the presence of prostate cancer (particularly high-grade)
– should be carefully evaluated
• Treatment does not interfere with the use of PSA to assist diagnosis of prostate cancer, after a new baseline has been established
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LUTS Management – Drug Rx
Back to NICE:
• Consider adding an anticholinergic if storage symptoms after α–blocker alone for LUTS
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LUTS Management – Drug Rx Back to NICE:
• Nocturnal polyuria (>1/3 urine at night)
– Consider late-afternoon loop diuretic
– Consider oral desmopressin, if other medical causes have been excluded
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LUTS: Referral
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LUTS: Referral
• Bothersome LUTS not responded to conservative & drug management
• LUTS complicated by:
– recurrent or persistent UTI
– retention (acute / chronic)
– renal impairment thought due to LUT dysfunction
– suspected urological cancer
– stress urinary incontinence.
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LUTS: Secondary Care
• Flow-rate
• Post-void residual
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LUTS: Secondary Care
• Flow-rate
• Post-void residual
• Possibly:
– Cystoscopy
– Upper tract imaging
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LUTS: Secondary Care
• Flow-rate
• Post-void residual
• Possibly:
– Cystoscopy
– Upper tract imaging
– Urodynamics (if considering surgery)
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LUTS: Surgery
Voiding:
• TURP
• TUVP
• HoLEP (laser)
• TUIP (often smaller prostates, younger men)
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LUTS: Surgery
Storage:
• Botox injections
• Cystoplasty
• Sacral nerve stimulation
Stress incontinence:
• Implantation of an artificial sphincter
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LUTS: SUMMARY
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LUTS: SUMMARY
• Common, under-reported
• Ask: what is bothering the patient?
• Strong link with ED / Metabolic Syndrome
• Holistic assessment
• Think: balls
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LUTS: SUMMARY
• Lifestyle intervention especially fluid intake
• Medical therapy according to symptoms
• Find and treat nocturnal polyuria
• Remember: a progressive condition
• Refer if not responding / atypical / complicated