1. Lower Urinary Tract Symptoms (LUTS)
Supervised by:
Dr- Al Traifi
Saad hamdan
Faisal aldahash
Meshal alsadhan

2. Objectives: Why LUTS? Common causes? What are the symptoms?
Patient work up
Details of the Common etiology BPH

3. INTRODUCTION LUTS is the commonest presentation in urology .
It’s a group of symptoms not a diseases
It is due to many diseases

4. Lower Urinary Tract Symptoms (LUTS)
Causes
Benign prostatic hyperplasia (BPH) with obstruction
Detrusor muscle weakness and/or instability
Urinary Tract Infection (UTI)
Chronic prostatitis
Urinary stone
Malignancy: prostate or bladder
Neurological disease, e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome

5. In males: Outflow obstruction BPH Meatal stenosis
Impaired detrusor function
NM dysfunction
Detrusor instability
Impaired detrusor contractility
Psychogenic voiding dysfunction
Infection
Cystitis, prostatitis, prostatic abcess and urethral diverticulum.
neoplastic
Prostatic cancer, bladder cancer
Others:
Bladder diverticulum, stone and interstitial cystitis.

6. Mostly storage symptoms
In females :
Mostly storage symptoms
UTI
Pregnancy
Anxiety
Overactive bladder
Interstitial cystitis
Postmenopausal urogenital atrophy
Bladder tumor or stone
Genital prolapses or pelvic mass
Mostly voiding symptoms
Age related detrusor muscle weakness
Obstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis)
Urethritis
Drugs ( diuretics, alcohol, lithium, anticholinergics)

7. Lower Urinary Tract Symptoms (LUTS)
Voiding (Obstructive)
Hesitancy: delay in starting micturation
Poor stream.
Straining for voiding
Interruption of the urinary stream
Terminal dribbling.

8. Storage (Irritaive) Frequency. Nocturia.
Urgency: sudden desire for urination that is difficult to postponed.
Urge incontinence.
dysuria

9. Post void Symptoms Post void Dribbling
Sense of incomplete emptying the bladder

10. History of DM Urological intervention CNS problems and symptoms
Hematuria
Previous urinary retention
Burning Micturation and Febrile UTI
Drugs intake
Constipation
Dm: diabetic autonomic neuropathy
Prostatectomy (damage to external sphincter) : dribble, stress and urge incontinance
Saddle sensation S3-S5 …..at or below T10-L2 flaccid urinary retention ubove: overactive blader (loss of cortical control)
side effects: urenary retention with morphine and atropine
BPH constioation: CA --> bone  Ca  const. or less appetite or less exerscse
constioation  prostitis by pressure and migrating bac.

11. International Prostate Symptoms Score (IPSS) & Q of L
Not
at All
Less Than
1 Time in 5
Less Than Half
the Time
About Half
More Than Half
Almost
Always
1. Over the past month, how often have you had
a sensation of not emptying your bladder
completely after you finished urinating? 1 2 3 4 5
2. Over the past month, how often have you had
to urinate again less than 2 hours after you
finished urinating?
3. Over the past month, how often have you
found you stopped and started again several
times when you urinated?
4. Over the past month, how often have you
found it difficult to postpone urination?
5-Over the past month, how often have you had
a weak urinary stream?
6. Over the past month, how often have you had to push or strain to begin urination?
7. Over the past month, how many times did you
most typically get up to urinate from the time
you went to bed at night until the time you
got up in the morning?
None
1 time
2 times
3 times
4 times
5 times
If you were to spend the rest of your life with
your urinary condition just the way it is now,
how would you think/believe about that?
Delighted
Pleased
Mostly satisfied
Mixed equally
Unhappy
Terrible

12. Clinical Examination Abdominal examination Bladder palpation
Kidney palpation
PR examination.
Notice: size, surface, consistancy, sulcus, tenderness,

13. Per- rectal Examination
Notice: size, surface, consistancy, sulcus, tenderness,

14. Investigations MSU (Mid-stream urine )& Urine culture
Urine Cytology (for presence of cancerous cells under microscope)
U&E
LFT
PSA (Prostate-specific antigen)

15. US

17. Size and CA
transrectal

18. Ascending Urethrogram
urethral injury, or urethral stricture
before attempting to place a Foley catheter

19. Urodynamics
Voiding Diary
Uroflometry
Cystometry
Pressure/Flow Study

20. Voiding Diary

21. Uroflometry

22. Uroflometry

23. Cystometry
Over active Bladder
Pdetmax
detrusor pressure

24. Pressure/Flow Study
gold standard for diagnosing BOO bladder outlet obstruction
Underactive detrusor muscle.
obstructed urethra bph

25. Pressure/Flow Study gold standard for diagnosing BOO
Underactive detrusor muscle.
obstructed urethra bph

26. Management Watchful Waiting Alpha Blockers: e.g. Prazosin
Alpha Reductase Inhibitors :e.g. Finasteride

27. Benign Prostatic Hyperplasia BPH
It is the comments etiology of LUTS
Disease of elderly men.
It is a histological diagnosis and represents as an increase in the number of epithelial and stromal elements of prostate

28. Con.
The increase of the elements of prostate ,will result in the formation of large nodules in the periurethral region of the prostate.
the nodules compress the urethral canal to cause partial, or sometimes complete obstruction of the urethra,
which interferes with the normal flow of urine.

29. Clinical manifestation:
Storage symptoms :
Frequency
Urgency
nocturia

30. Voiding symptoms :
Hesitancy
Poor stream
Double voiding
Post void dribbling
Incomplete emptying
Pain and dysuria are usually not present

31. PR examination
Normally, prostate is firm, smooth and with a palpable sulcus.
Signs of BPH: enlarged firm with palpable sulcus.
Sign of malignancy: hard nodular surface with impalpable sulcus.

33. Investigation Urinalysis PSA (prostate specific antigen )
Blood Urea Nitrogen and creatinine US
Cystoscopy

34. Treatment Medical: Tamsulosin:
It blocks adrenergic alpha-1 receptor of smooth muscle of prostate.
It decrease bladder neck and urethral resistance.
It is usually indicated in BPH.

35. Tamsulosin ADVERSE EFFECT: 1- Headache . 2- Arthralgia . 3-Rhinitis .
4- Decrease libido .
5- back pain .
Contraindications:
1- Liver disease .
2- Orthostatic hypotension .
3- Hypersensetivity .

36. Finasteride
It is a 5-alpha reductase inhibitor.
It is an antiandrogenic drug .
It is used in case of BPH .
It is also indicated in case of alopecia in women .

37. Finasteride ADVERSE EFFECT: 1- Breast enlargement 2- Impotence 3- Rash
Contraindications:
1- Hypersensitivity
2- Pregnancy
3- Children

38. BPH Indications for surgery
Renal impairment.
Hydronephrosis.
Recurrent UTI
secondary vesical stones
Recurrent Hematuria
Retention of urine
Significant symptoms not responding to medication.

39. Surgery Transurethral Open Prostatectomy Minimal Invasive
Invasive, Transurethral Resection Prostatectomy ( TURP)
Open Prostatectomy

40. THE END

41. Notes BPH is the most common cause of urine obstruction in male .
Terminal voiding dripping: means dripping when the patient still in the bathroom (immediately after voiding).
Post voiding dripping: means dripping ,but when the patient outside the bathroom (after a period of time) .
negative PR test doesn't exclude BPH.
Big BPH may lead to increase PSA.

42. Cont. > 100 ml is a significant residual volume after void.
The urodynamic is a very accurate diagnostic tool.
CHF patient came with nocturia.
In urine retention:
acute : the patient’s complain is pain 
chronic: the patient complaining of overflow incontinence.
Tamsulosin can cause retrograde ejaculation in males. 

43. Cont. Pus >>> culture RBCs >>> cytology
When there is hypertrophy of the wall of bladder (>4cm ) >>urethral constriction.
Middle lobe enlargement doesn't respond to radiotherapy.
Urine flowmetry:
Voiding volume must be more than ml.
in young male adult normal peak flow is 25ml /sec.
elderly is more than 15 ml /sec.
Female flow is stronger.

44. Cystometry:- Pressure flow study
Dertrouser pressure (normal is < 15 ml of water ??)
Pressure flow study
Increased pressure and decreased flow >>prostate
Decreased pressure and decreased flow >>Dertrouser