Diagnostic approach to LUTS in men Prof Dato Dr. Zulkifli Md - - PowerPoint PPT Presentation

Diagnostic approach to LUTS in men

Prof Dato Dr. Zulkifli Md Zainuddin Consultant Urologist / Head Of Urology Unit UKM Medical Center

Classification of LUTS

Storage symptoms Voiding symptoms Post micturition symptoms

• Altered bladder

sensation

• Increased daytime

frequency

• Nocturia
• Urgency
• Urinary incontinence
• Hesitancy
• Intermittency
• Slow stream
• Splitting/spraying
• Straining
• Terminal dribble
• Feeling of incomplete

bladder emptying

• Post micturition dribble

Abrams P et al. Neurourol Urodyn 2002;21:167-78

Evolution in view on male LUTS

Past: problems related to the prostate Currently: problems related to prostate, bladder and/or other

• rgans

Male LUTS

Conditions or diseases behind LUTS

Gravas S et al. EAU guidelines 2016, available at www.uroweb.org

LUTS

BPE/BOO prostatitis ureteral stone bladder tumour urethral stricture bladder stone foreign body UTI neurogenic bladder dysfunction detrusor underactivity nocturnal polyuria OAB/ detrusor

• veractivity

Speakman MJ. Eur Urol Suppl 2008;7:680-9; Chapple CR and Roehrborn CG. Eur Urol 2006;49:651-9

LUTS can be associated with body systems

• utside the lower urinary tract

Conditions associated with LUTS – prostate-related

Abrams P et al. Urology 2003;61:37-49; Chapple CR and Roehrborn CG. Eur Urol 2006;49:651-9

All aged men

BPO / BOO BPE BPH

Routine assessment of male LUTS

History (+ sexual function) Symptom score questionnaire Urinalysis Physical examination PSA* Measurement PVR

Gravas S et al. EAU guidelines 2016, available at www.uroweb.org

*if diagnosis of PCa will change the management or if PSA can assist in decision-making in patients at risk of progression of BPE

Symptom score questionnaires

• International Prostate Symptom Score (IPSS)
• Americal Urological Association Symptom Score (AUA-SS)
• International Consultation on Incontinence Questionnaire (ICI-MLUTS)
• Danish Prostate Symptom Score (DAN-PSS)

IPSS score

Symptom score questionnaires - IPSS

Gravas S et al. EAU guidelines 2016, available at www.uroweb.org

Score / Severity 0 to 7 Mild 8 to 19 Moderate 20 to 35 Severe

Index of symptom severity BUT weighted towards voiding

IPSS QoL: the most important question

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

The physical examination

• 1. Abdominal examination

→ rule out other possible urinary

• r rectal conditions
• 2. Digital Rectal Examination

(DRE) → fundamental method for assessing the shape and the volume of the prostate

Uroflow to assess the Effect of BPH

Flow rate (ml/sec)

• bstructed

normal

Time (seconds) 30 60

20 10

Measures peak urinary flow rate (Qmax), voided volume and micturition time. A micturition volume of at least 150ml is required for an adequate analysis Interpretation of maximum urinary flow rate values: > 15 ml/s normal 10-15 ml/s equivocal < 10 ml/s

• bstructed

Uroflowmetry

(a) Normal Flow rate tracing (b) Flow rate tracing showing in reduction in the maximum flow rate in a patient with bladder outflow

• bstruction due to BPH

BLADDER SCAN

Serum Prostate-Specific Antigen (PSA)

• Measurement recommended for patients with at

least 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management

• PSA is also a proxy of prostate size but its variability is
• high. Recent studies suggest that it may be used to

predict the risk of AUR and BPH-related surgery.

Serum Prostatic Specific Antigen

Transrectal ultrasound – guided biopsy of the Prostate

Association of baseline PSA and risk of clinical progression of BPH Placebo group

1 2 3 4 5 6 Progression > 4 point rise AUR Rate per 100 PYR < 1.4 1.4–3.9  4.0 PSA (ng/ml) p<0.0001 p=0.0003 p<0.0001

MTOPS (2002)

6.2 2.9 9.9 5.8 14.6 11.6

PSA as a predictor of surgery and AUR (placebo-treated BPH)

Roehrborn CG et al. Urology 1999;53:473–80

Incidence (%) Baseline PSA tertiles 0–1.2ng/mL 1.3–3.2ng/mL >3.2ng/mL Surgery AUR 21 18 15 12 9 6 3

PSA and its role in therapeutic decision making

• PSA and PV are powerful predictors of risk of

BPH progression

• PSA values of >1.6ng/mL predict a PV >40mL,

PSA values of >1.4ng/mL predict a greater risk

• f BPH progression
• PSA can be used to identify candidates for

intervention with appropriate therapy in order to reduce an increased risk of BPH progression and improve their QoL

EAU BPH guidelines Madersbacher S, et al. Eur Urol 2004;46:547–54 Roehrborn CG, et al. Urology 1999;53:581–89 Roehrborn CG, et al. Urology 1999;53:473–80 Jepsen JV, Bruskewitz RC. In: Lepor H, editor. Prostatic Diseases. Philadelphia: WB Saunders, 2000. p. 127–42

Urinalysis

• UTI
• Microhaematuria
• Diabetes Mellitus
• Recommended in most

guidelines.

Routine assessment of male LUTS: EAU guideline recommendations

LE GR A medical history must be taken from men with LUTS 4 A A validated symptom score questionnaire with QoL assessment should be used during the assessment of male LUTS and for re-evaluation of LUTS during treatment 3 B Physical examination including DRE should be a routine part of the assessment of male LUTS 3 B Urinalysis (dipstick/urinary sediment) must be used in the assessment of male LUTS 3 A PSA measurement should be performed only if a diagnosis of PCa will change the management or if PSA can assist in decision- making in patients at risk of progression of BPE 1b A Measurement of PVR in male LUTS should be a routine part of the assessment 3 B

Gravas S et al. EAU guidelines 2016, available at www.uroweb.org

Ultrasound

Frequency volume chart

• Recording of volume and time of each

void

• Additional information: fluids intake,

use of pads, activities , symptoms score : Bladder Diary

• Relevant in nocturia
• Duration: 3 days or longer

Urodynamics

• Invasive
• Offered only when conservative

treatment have failed

• Neurologic Disease

Cystoscopy

• Invasive
• Not responding to treatment
• Tumour
• Stricture

Assessment algorithm of LUTS in men ≥40 yr

Gravas S et al. EAU guidelines 2016, available at www.uroweb.org

Thank You