1. Functional disorders of the lower urinary tract
Chris Hillary
Honorary Urology Registrar and Research Fellow
Academic Urology Unit
Royal Hallamshire Hospital

2. Aims Describe normal function
Explain the development of benign prostatic enlargement
Describe male voiding symptoms
Cover the treatment of voiding symptoms
Discuss the management of urinary retention and obstructive uropathy

3. Objectives Elicit lower urinary tract symptoms during history taking
Understand how benign prostatic enlargement occurs and how to pharmacologically treat it
Know the complications of outflow tract surgery
Understand the difference between acute and chronic retention and why some patients develop renal failure

4. Normal function of the LUT
Convert a continuous process of excretion (urine production) to an intermittent process of elimination.
Store urine insensibly
Void urine when convenient

5. Lower Urinary Tract (LUT)
Detrusor muscle
Relaxes during storage (compliant)
Contracts during voiding
Distal sphincter mechanism
Contracts during storage
Relaxes during voiding

6. Neural control of the LUT
Parasympathetic (Cholinergic) S3-5
Drive detrusor contraction
Sympathetic (Noradrenergic) T10-L2
Sphincter/urethral contraction
Inhibits detrusor contraction

7. Its not just burning when you pee

8. …Or prostate exams

9. … Or even erections

10. What are lower urinary tract (LUTS) symptoms?
Storage symptoms
Voiding symptoms
Frequency
Nocturia
Urgency
Urgency Incontinence
Hesitancy
Straining
Poor/intermittent stream
Incomplete emptying
Post micturition dribbling
Haematuria
Dysuria

11. Definitions BPH – benign prostatic hyperplasia (histological)
BPE – benign prostatic enlargment (DRE findings)
BOO – bladder outflow obstruction (urodynamic proven obstruction)
LUTS - Lower urinary tract symptoms, a constellation of symptoms, neither gender nor disease specific

12. BPH is common
Histologically (post-mortem; Berry 1984) -23% of men aged 41 to 50 yrs -42% of men aged 51 to 60 yrs -71% of men aged 61 to 70 yrs -82% of men aged 71 to 80 yrs

13. Prostate

14. What is BPH?
Increase in epithelial and stromal cell numbers in the periurethral area of the prostate.
May be due to increase in cell number
Or due to decrease apoptosis
Or due to combination of the two

15. Benign prostatic obstruction
Dynamic component – alpha1 adrenoceptor mediated prostatic smooth muscle contraction
Smooth muscle accounts for 40% of the area density of the hyperplastic prostate
Static component – volume effect of BPE

16. Androgens and BPH
Androgens do not cause BPE, but are a requirement for BPH
Castration prior to puberty or genetic diseases that inhibit androgen action or production, men do not develop BPH
Androgen withdrawal leads to partial involution of established BPH

17. Patient evaluation
Establish symptoms that are most bothersome to the patient
Objective documentation of lower tract function
Exclusion of serious urological pathology

18. History What symptoms, storage, voiding or mixture
Duration of symptoms
Past medical history
Past surgical history
Drug history
Allergies
Symptom scoring e.g. IPSS
Bother (often incorporated as part of symptom score)

19. International Prostate Symptom Score (IPSS)h

20. Examination General examination i.e fitness for surgery
Abdominal examination
External genitalia
Digital rectal examination (DRE)
Focussed neurological examination
Urinalysis

22. Investigations Renal biochemistry Imaging PSA?
Flow rates and residual volume
Frequency volume chart
TRUSS – trans-rectal ultrasound scan (for size)
Flexible cystoscopy (if infection, stones, haematuria or recent onset storage symptoms)
Urodynamics

23. Frequency-volume chart

24. Normal flow rates Men < 40 >= 21 ml/s Men 40-60 >= 18 ml/s
Need to void at least 125mls of urine for representative flow
Flow rates can be reduced due to obstruction within the lower urinary tract
They can also be reduced due to detrusor underactivity (pump failure)

25. Post Void Residual (PVR)
100% normal men have PVR < 12 ml
Bates 2003 (2/93 patients with PVR > 250ml developed hydronephrosis and elevated creatinine – average PVR was 425 with an associated FR of <5ml/s)
Consider detrusor underactivity as cause of high PVR

26. Flow rates
Normal
Obstructed

27. More flow rates

28. Flow rates Qmax >15ml/s - 24% obstructed

29. Complications of BPE Symptom progression (17-40%) Infections (0.1-12%)
Stones ( %)
Haematuria
Acute retention (1-2% per year)
Chronic retention
Interactive obstructive uropathy (<2.5%)

30. Acute retention of urine (AUR)
Painful
Typically 600-1L residual urine
Normal U&E’s
Pain relieved by catheterisation
Precipitated retention – often does not recur
Spontaneous retention – 50% recur very early, 70% within a year
Alpha-blockers have a role in TWOC
ISC
Bladder outflow surgery

31. Chronic retention of urine
More difficult to define
Incomplete bladder emptying
Increased risk of infections and stones
Can be low pressure with detrusor failure
Can be high pressure, with risk of interactive obstructive uropathy

32. Interactive obstructive uropathy
Nocturnal enuresis should alert to the risk of interactive obstructive uropathy
Residual volume can be up to 4L
Check U&E’s and monitor daily if creatinine raised
Observe for a diuresis
Lying/standing blood pressures
5% require iv fluids
Long term options – TURP or indwelling catheter

33. USS - hydronephrosis

34. IVU – bilateral hydronephrosis

35. CT – bilateral hydronephrosis

36. Bladder stones

37. Bladder stones

38. Treatment aims Improve urinary symptoms Improve quality of life
Reduce complications of bladder outflow obstruction

39. Observation or watchful waiting
Suitable for men with mild symptoms
Over 5 years 25% progress, just under half remain static and 30% improve, 2% experience acute retention (Ball et al 1981).
Lifestyle changes may be useful

40. Medical treatment
Aimed at either reducing the prostatic smooth muscle tone or reducing size of the prostate
Alpha – adrenergic antagonists, (e.g. Alfuzasin XL, Tamsulosin), improves flow average 3ml/s
5-alpha-reductase inhibitors, (e.g. Finasteride, dutasteride) inhibit the conversion of testosterone to the more active, dihydrotestosterone, reduces size 20-30%
Combination therapy better than either singly
Anti-cholinergics for overactivity

41. Two drug classes with different effects
Alpha blockers
5a-reductase inhibitors 
Improve symptoms/flow
Onset of symptom relief in 1–2 weeks 
Delay symptomatic progression
Prevent symptomatic progression
Reduce PV
Maintain reductions in PV
Reduce longer-term risk of AUR and surgery

42. Indications for surgery
RUSHES
Retention
UTI’s
Stones
Haematuria (refractory to 5-ARI)
Elevated creatinine due to BOO
Symptom deterioration

43. Surgical treatment Bladder neck incision
Trans-urethral resection of prostate (TURP)
Bipolar
Greenlight laser
Thullium laser
Holmium enucleation
Millins retro-pubic prostatectomy
(TUNA, TUMT, HIFU, stents)

44. TURP

45. Complications of TURP Immediate – Sepsis, haemorrhage, TUR syndrome
Early – Sepsis, haemorrhage and clot retention
Late - Retrograde ejaculation, erectile dysfunction, urethral stricture, bladder neck stenosis, urinary incontinence

46. Conclusions LUTS can be divided into storage or voiding symptoms
Evaluation of LUTS includes hx, exam, symptom score, FR and RU, renal function
Treatment of symptomatic BPE can be medical with alpha-adrenergic antagonists or 5-alpha-reductase inhibitors or combination of both
Surgical treatment of BPE - often TURP
Acute retention is painful and pain is relived by a catheter
Interactive obstructive uropathy is rare
Usually large residual, renal dysfunction which improves with a catheter. Long term treatment managment is TURP or long term catheter

48. Further reading
Oxford handbook of urology - Reynard, Brewster and Biers 2009
Urology Lecture Notes – Blandy and Kaisary 2009
NICE guidelines LUTS