1. More mens bits… LUTS
Hugh Alberti
January 2017

2. Case studies in 2 groups Case 1:
Mr G. Land is a 72 year old farmer. He rarely attends. But today he comes to discuss his waterworks. He is asking if anything can help him as getting up at night for a pee is making getting up at dawn to sort the cows out more difficult. Also, he’s fed up having to wipe the toilet clean (or his wife is) every time he has a wee. Where do you go from here?
Case 2:
Mr I.P.Allott is a 55 year old gentleman, a new patient to the practice. On his first consultation with you he tells you he has had urinary problems getting worse over 2 years since he stopped work. His last doctors couldn’t help him. He has to go all the time, and occasionally doesn’t make it. He gets up frequently at night. Life is intolerable.
Groups of 4-5, one person roleplay the patient (with the answers) the others alternate roleplaying the doctor.
You’ll all need a sheet and a piece of paper.

3. Overview How common are the problems?
Increases with age; maybe 30-40% over the age of 50.
You will not see all of these people
Lower urinary tract symptoms in older men are common and bothersome, leading to considerable use of healthcare services. Exactly how common depends upon what you read, where you read it – and likely who you talk to (urology clinic, general practice)
In the BMJ article on BPH regarding menof 50 years or older in England, Scotland, and Wales, 41% described symptoms classed as moderate to severe, but only 18% reported that they had received a clinical diagnosis of BPH. Quality of life and general health status decreased as severity of symptoms increased; however, only about 1 in 10 respondents was aware of the availability of prescription drugs or surgical options for BPH. Storage and voiding symptoms were self reported by 51% and 26% respectively of men aged 39 and older from five European countries, with the prevalence of reporting increasing with age.
NICE reports that bothersome LUTS can occur in up to 30% of men over 65 years of age.The prevalence again increases as men get older.
Increasing age and possibly obesity are the aetiological factors

4. What are L.U.T.S.?
Lower urinary tract symptoms is a term of convenience that encompasses storage, voiding and post-micturition problems.
It’s a term and not a diagnosis.
Lower urinary tract symptoms is a term of convenience that encompasses storage, voiding and post-micturition problems.
What do I mean a term – not a diagnosis, it is not always due to enlargement of the prostate gland, as symptoms are seen in men without enlarged prostates, and indeed women.
There are different causes, and different treatments are appropriate for them.
Management can be conservative, with drug treatment, and with surgical intervention.

5. L.U.T.S. consists of - Storage problems Voiding problems
Detrusor problems
Retention
Incontinence
Bladder storage problems. Our ability to hold on to our urine (frequency, urgency, urge incontinence, and nocturia)
Voiding problems, our ability to get rid of the urine we have stored (hesitancy, straining, weak urine flow, dribbling and incomplete emptying)
The topic does lend itself to BPH/BPE (hyperplasia of the epithelial and stromal components of the prostate gland, which leads to progressive obstruction of urine flow, and increased activity of the detrusor muscle)
However – voiding problems might be due to a primary detrusor muscle instability, and LUTS can be caused by things such as strictures, neuropathic conditions, medications, or lifestyle factors.
There isn’t really time to do justice to retention and incontinence – but it is covered in the referenced texts.

6. Clinical Presentation
History of problem
Examination
Exclude other causes
Judicious use investigations
When do we refer?
History, physical examination, and laboratory and urodynamic tests are used to identify the presence, severity, and aetiology of lower urinary tract symptoms and to guide treatment, including the need for referral to urologists.
History can determine if the symptoms are caused by other medical conditions (poorly controlled diabetes, neurological disorders, urinary tract infections, chronic abacterial prostatitis), medications, (diuretics, anticholinergics, antidepressants),or lifestyle factors (caffeine, alcohol, excess intake of liquids).
.Abdominal examination to detect palpable bladder is indicated if obstruction of the bladder outlet is suspected.

7. Like the gruffalo’s head
How the prostate feels
Walnut sized
Like the gruffalo’s head
Satsuma sized
DO NOT pass on the digital rectal examination.
Use the IPSS form. Fear that lower urinary tract symptoms may be caused by prostate cancer is a major reason that men consult their doctor. However, men can be reassured that those with lower urinary tract symptoms are not at higher risk of having prostate cancer than men without these symptoms.Therefore, although measurement of prostate specific antigen is widely used to try to detect cancer, these approaches are not routinely indicated.
Levels of prostate specific antigen are associated with prostate volume; not just cancer. Widespread measurement of prostate specific antigen is likely to lead to increased falsely abnormal findings and subsequent diagnostic tests (see screening.nhs.uk/prostate/).
The presence of urinary incontinence, retention, haematuria, dysuria, or acute change in symptoms can indicate other conditions or complications of BPH. These patients often need to be referred to a urologist for further evaluation even if they have not reported their symptoms as bothersome

8. N.I.C.E. says
• At initial assessment, offer men with LUTS an assessment of their general medical history to identify possible causes of LUTS, and associated co-morbidities. Review current medication, including herbal and over-the- counter medicines, to identify drugs that may be contributing to the problem.
• At initial assessment, offer men with LUTS a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE).
• At initial assessment, ask men with bothersome LUTS to complete a urinary frequency volume chart.
• Refer men for specialist assessment if they have LUTS complicated by recurrent or persistent urinary tract infection, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.
So what I am basically saying is,
YES to digital rectal examination
Yes to urinary frequency volume chart
Not necessarily yes to PSA.
At initial assessment, offer men with LUTS information, advice and time to decide if they wish to have prostate specific antigen (PSA) testing if:
• their LUTS are suggestive of bladder outlet obstruction secondary to BPE or
• their prostate feels abnormal on DRE or
• they are concerned about prostate cancer.
At initial assessment, offer men with LUTS a serum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation) only if you suspect renal impairment (for example, the man has a palpable bladder, nocturnal enuresis, recurrent urinary tract infections or a history of renal stones).
Do not routinely offer cystoscopy to men with uncomplicated LUTS (that is, without evidence of bladder abnormality) at initial assessment.
Do not routinely offer imaging of the upper urinary tract to men with uncomplicated LUTS at initial assessment.
Do not routinely offer flow-rate measurement to men with LUTS at initial assessment.
Do not routinely offer a post void residual volume measurement to men with LUTS at initial assessment.

9. The IPSS is validated, simple to use, and helps assess the presence, type and severity of symptoms, and response to treatment.
Patient response on the quality of life question is a strong predictor for determining if interventions are Indicated. There can be quite some discrepancy between patients and score and tolerance of symptoms.

10. There are a few on google – all much of a muchness
There are a few on google – all much of a muchness. It’s basically an input/output chart. Trying to determine how much drunk, what drunk, how often going for a wee, what volumes, any leakage. Over a few days is useful.
Good baseline, though I imagine not that nice to do.

11. Management Why treat? How to treat watchful waiting
life style management
drug therapy
surgery
Why do anything, as slow progression of symptoms and bothersome effects of these symptoms is the norm with BPH. About 15% of men with moderate to severe symptoms had clinically noticeable worsening of their condition during 5 years follow up. More serious complications – such as AUR (1-3% over 5 years) renal insufficiency or the need for surgical intervention – are uncommon.
Aim of treatment is to improve bothersome symptoms, prevent progression, reduce longer term complications (AUR, incontinence, recurrent uti, renal insufficiency, and the need for surgery.)
Treatment options will be influenced by severity of symptoms and patient preference. For BPH – surgery will provide the largest improvement in symptom score on the IPSS.
A conservative approach with reassurance regarding low risk of serious complication, symptoms not meaning cancer, and review of other medication may be all some men need – as they accept the LUTS as a part of normal aging. Currently, about a third of symptomatic patients (known about) are managed this way.

12. Intake advice, retraining and urethral milking…
More specific conservative treatment includes advice regarding fluid management (not too much, or too little), toileting (go before journeys, meetings, bed) and bladder retraining. Explain to men with post micturition dribble how to perform urethral milking.
You may want to consider utilising the services of the continence nurse here, as there is a good chance they will be better able to educate and implement and reinforce changes than your average g.p. (me.)

13. Drug Therapies Voiding… Alpha – 1 selective adrenergic antagonists
5 alpha – reductase inhibitors
Combination therapy
Storage…
Antimuscarinics
NICE says to offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate
For symptoms associated with BPH/BPE, (voiding +/- storage),
Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) to men with moderate to severe LUTS. ( NICE guidance, ‘mild’ refers to an International Prostate Symptom Score (IPSS) of 0–7, ‘moderate’ refers to an IPSS of 8–19 and ‘severe’ refers to an IPSS of 20–35. )
With drug treatment – generally expect a reduction in IPSS score of between 3-6points. A four point reduction is meant to be of significance, and maybe 60% of men will achieve this.
In the first year of treatment, alpha blockers will be more noticeably beneficial than 5 alpha reductase inhibitors. Indeed maximum benefit might be achieved within the first month. They work by relaxation of smooth muscle in the prostate and bladder neck. All alpha blockers seem to be roughly equivalent.
James Cook formulary advises start with a once daily agent. Some you need to build up the dose. Doxazosin will probably be the cheapest, tamsulosin (caps – not tabs) relatively cheap and no titration. Side effects include postural hypotension (start at night time) dizziness and fatigue, and a few men might be surprised by abnormal ejaculation.
Review men taking alpha blockers at 4–6 weeks and then every 6–12 months.

14. Bothersome LUTS + >30g
LUTS: Drug treatment
Cause
Treatment
Review
LUTS
Alpha blocker
4-6w then 6mly
OAB
Anticholinergic
LUTS + prostate >30g
5ARI (Finasteride)
3-6m then 12mly
Bothersome LUTS + >30g
AB + 5ARI
Unresponsive LUTS
Add anticholinergic

15. Plus? Remember all drugs only partially effective
BPH not a risk factor for Ca, but Ca may present with LUTS
Nocturnal polyuria – (>35% output)
?Late afternoon diuretic ??desmopressin
?Tadalafil for LUTS (“not recommended”)

16. Don’t expect miracles though
5-alpha reductase inhibitors
They work by reducing androgenic drive to the prostate, and thus reducing size.
NICE. Offer a 5-alpha reductase inhibitor to men with LUTS who have prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml, and who are considered to be at high risk of progression (for example, older men).
Clinical evidence states finasteride has a significant benefit over placebo at symptom reduction – and also reduces the risk of acute urinary retention and surgery. This was seen in those with prostates assessed as over 40g. Then benefit is more as time passes.
Side effects include reduced libido, impotence and decreased ejaculation (not to mention breasts)
Review men taking 5-alpha reductase inhibitors at 3–6 months and then every 6–12 months.
NICE states consider offering a combination of an alpha blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml. OR PSA ABOVE WHAT? This is the same as 5-alpha reductase inhibitor alone advice.
The BMJ article states the decision to use combination therapy is complex.
Storage alone (or with voiding symptoms), can offer an antimuscarinics to men to manage the symptoms of OAB – urgency (with or without incontinence)/frequency/small volumes/nocturia.Appropriate drugs are solifenacin, trospium tolterodine, oxybutynin. The immediate release oxybutynin is less well tolerated. All can cause dry mouth, constipation and visual disturbance.
Use with caution in significant obstructive symptoms as theoretical risk of precipitating retention. Also think glaucoma.
Review men taking anticholinergics every 4–6 weeks until symptoms are stable, and then every 6–12 months.
This would be unlikely

17. Surgical Intervention
Surgery is effective
N.I.C.E. has advised which are the best surgical options.
Be cautious though regarding surgery for storage symptoms
A urologist is likely best placed to discuss some of the options
TURP remains the standard surgical treatment for BPH, although it does not account for the 90% of procedures it used to.
It is highly effective, and a reduction of points still after one year is expected. There are risks – (5% severe haemorrhage) To reduce this risks – other techniques are being looked at.
NICE - If offering surgery for managing voiding LUTS presumed secondary to BPE, offer monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place.
Other concerns patientsmight have are sexual side effects, incontinence, and the need for further surgery for stricture formation, urinary retention and relapse. This risk of further surgery seems to be about 1% per year. Whilst clinical evidence suggests immediate problems of retrograde ejaculation levels of 75%, erectile dysfunction of 14%, and incontinence of 5%, another trial did not find prostatectomy led to more erectile dysfunction or incontinence than watchful waiting.

18. Any questions from the cases… http://www. bmj. com/content/357/bmj
Any questions from the cases… (10m in consultation LUTS in an older man)

19. References
NICE clinical guideline 9 ‘The management of lower urinary tract symptoms in men’
Issue date: May 2010
Benign prostatic hyperplasia.Part 1—Diagnosis, Timothy J Wilt, James N’Dow BMJ 2008;336: Part 2—Management BMJ 2008;336:206-10
Lower urinary tract symptoms in men. BMJ 2007;334:2
Extracts from “Clinical Evidence” Benign prostatic hyperplasia BMJ 2001;323:1042–6
10­minute consultation Prostatic symptoms Andrew Farmer. BMJ 2001;322:1468
Managing urinary incontinence in older people Subashini Thirugnanasothy BMJ 2010;341:c3835