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 Red flag symptoms & signs & aetiology of LUTS Presenting symptoms & signs- DRE & PSA Management of symptoms Summary

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

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

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

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

8-19 moderately symptomatic; Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost all the time Your score Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 1 2 3 4 5 Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination? None 1 time 2 times 3 times 4 times 5 times or more Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Total score Quality of life due to urinary symptoms Delighted Pleased Mostly satisfied Mixed Mostly dissatisfied Unhappy Terible If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Total score: 0-7 Mildly symptomatic 8-19 moderately symptomatic; 20-35 severely symptomatic 9

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

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

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 12

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

NICE Recommendations on management of mild or moderate LUTS Bothersome to the patient, or complicated? No Yes 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 16

NICE Recommendations Drug Treatment - LUTS Moderate to severe LUTS Offer an alpha blocker Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml Consider combination treatment with an alpha blocker and a 5ARI Offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate. Take into account comorbidities and current treatment when offering drug treatment for LUTS. Do not offer homeopathy, phytotherapy or acupuncture. Consider offering a late afternoon loop diuretic for nocturnal polyuria. Consider offering oral desmopressin for nocturnal polyuria if other medical causes have been excluded and the man has not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment. If LUTS do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery). 1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010 17

NICE Recommendations Conservative management – 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 18

NICE Recommendations Drug treatment – storage symptoms OAB Offer an anticholinergic 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 19

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