LUTS – A plea for a holistic approach. HUBERT GALLAGHER, MCh; FRCSI, FRCSI(Urol) Head of Urology Beacon Hospital
LUTS- Classification Men LUTS can be divided into: Storage Frequency Nocturia Urgency +/- incontinence Enuresis Leaking/SUI Voiding Weak flow Women intermittency Hesitancy Straining Postmicturition Incomplete emptying Post micturition dribbling Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Storage Symptoms LUTS – The Problem LUTS has traditionally concentrated on men with prostate trouble and women with bladder trouble. Both men and women report storage and postmicturition symptoms suggesting that Storage LUTS are not sex specific and are not related to the prostate. LUTS are a common problem and cause considerable impact on QoL. Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
LUTS and Gender ♀ ♀ Both men and women suffer nearly equally from voiding symptoms traditionally regarded as ‘prostate’ symptoms. In women this may represent detrusor underactivity whereas in men it may be DUA and/or BOO. Women suffer significantly more storage type symptoms and incontinence as might be ♂ ♀ expected. Stress incontinence is mainly a female symptom in the absence of prior prostatic surgery. Storage symptoms are often much more bothersome than voiding symptoms Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Why do LUTS occur? Aging Cardiovascular disease Obstructive sleep apnoea Obesity Metabolic Syndrome Diabetes Smoking ___________________________________________ Infections Neurogenic cause Reduction in functional abilities Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
MetS/CVD and LUTS/BPH Metabolic Syndrome Insulin resistance Hormonal changes Pelvic atherosclerosis Inflammation High cytosolic free Increased oestradiol Cytokine release Ischaemia High insulin level Ca++ in smooth Lower testosterone High IGF-1 level muscle and neural Lower IGF-1 binding cells Sympathetic nervous system activation LUTS/ BPH Increased smooth muscle tone Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Preventing LUTS/BPH by preventing/treating CVD CVD and LUTS occur in the same population and increase with age and an aging population. Risk factors for CVD are also risk factors for LUTS and BPH Smoking Obesity Diabetes Metabolic syndrome Hyperlipidaemia Diet – high salt and fat intake Hypertension Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Preventing LUTS/BPH by preventing/treating CVD Treating LUTS like CVD as a lifestyle issue may improve or prevent deterioration. Exercise has been shown to reduce mediators of inflammation Regular exercise has been shown to reduce the risks of LUTS/BPH by 24-40% A diet including vegetables, chicken and bread were associated with less OAB symptoms whereas carbonated drinks, smoking and obesity were associated with OAB in women. Dietary Lycopenes, B-carotene, carotenoids and Vitamin A reduced LUTS by 40-50% perhaps by an anti-inflammatory effect. Multiple studies show that statins delay or reduce LUTS 1-2 standard measures of alcohol daily is a associated with a 20-40% risk reduction and LUTS! Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
OSA and Co-morbidities Obstructive breathing and its Hypertension associated co-morbidities may lead to bothersome nocturia Nocturia has a detrimental effect on quality of sleep and quality of life OSA By treating obstructive breathing, Diabetes Obesity NP LUTS can improve. CPAP reduces nocturia episodes Lifestyle advice may also improve obstructive breathing and nocturia Cardiovascular events If you don’t ask…you won’t find!! Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Association between obstructive breathing and LUTS – Mechanism 1 Increased airways pressure Hypoxia Pulmonary vasoconstriction Increased right atrial transmural pressure Increased ANP production Nocturnal polyuria Increased sodium and water excretion NOCTURIA Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Association between obstructive breathing and LUTS – Mechanism 2 Increased airways pressure Hypoxia Increased Catecholamines Increased Insulin Resistance Glycosuria Nocturnal polyuria Increased water excretion NOCTURIA Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
When to refer to urology? Many patients can be managed in primary care provided a careful history and physical examination (including DRE) are performed. Allows the GP to assess the severity and bothersomness of LUTS IPSS score is helpful for initial assessment and for assessing response to treatment Referral is mandatory for the following patients: 1: Haematuria 2: Urinary infection in men and recurrent infections in women 3: Nocturnal enuresis of recent onset (likely chronic retention) 4: Straining to void, intermittency or deteriorating flow 5: Failure to respond to initial treatment and persisting symptoms 6: Pneumaturia (implies colo- or entero-vesical fistula 7: Raised PSA or abnormal DRE 8: Concomitant neurological conditions Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
LUTS - Severity IPSS Scores allow easy assessment of symptom severity and bothersomness Easy to apply, reproducible Can be used to determine alterations in symptoms and responses to treatment Many men minimize symptoms and underestimate their symptoms IPSS Score 0-7 Mildly symptomatic IPSS Score 8-19 Moderately symptomatic IPSS score 20 – 35 Severely symptomatic Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Medical Management of LUTS/BPH Storage symptoms Voiding symptoms Predominantly voiding symptoms Predominantly storage symptoms Small prostate (<40cc) Exclude urinary infection/haematuria Frequency volume chart Alpha-blocker (male) Large prostate (>40cc) Lifestyle advice Alpha-blocker Fluids 5-ARI Caffeine Combination therapy Pre-emptive voiding Mixed storage and voiding Travel-john symptoms Bladder retraining Add in anti muscarinic Pelvic floor physiotherapy Beta-3 alpha adrenergic Refractory or persisting symptoms receptor agonist (mirabegron) Trial of an either an anti muscarinic or mirabegron Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Patient 1 Assessment/History Investigations 72 year old man 3T mpMRI prostate – 65cc gland; no suspicious lesion Increasing PSA over 10 years (9.5ng/mL) Repeat PSA 11.9ng/mL MRI and negative biopsy 2014 Calcified lesion in bladder N x 2; Frequency+ Small volumes Flexible Cystoscopy – very obstructive prostate; Intravesical Urgency+ Occasionally middle lobe; bladder calculus; trabeculated bladder with Flow slow but steady diverticulae. Father TURP; CaP age 94 UTI while waiting for TURP Smoker Histology 31.5g resection; BPH with Moderate Claudication/PVD acute and chronic prostatitis. Moderate to large BPH on DRE Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Flow Rates Post Op Flow Rate Pre-op Flow Rate Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Patient 2 Assessment/history Investigations 63 yo Female – P2 G2; infrequent attender; FVC: functional capacity 450mls, output post menopausal ~2L/day; N x 2; D x 6-7 Constant desire to void, followed by urgency US Kidneys and pelvis normal and incontinence x 6/12 MSU Normal Tolterodine no help, mirabegron significantly Flexible cystoscopy normal; no prolapse; improved things normal introitus, no GSI N x 2; D 4-5; flooded on occasion; no GSI; Post void residual: Nil currently with Meds N x 1 and D 3. No cystitis. Advices: Reduce caffeine intake Water: a reasonable amount; Tea 8/day Continue mirabegron for moment – aim to Ongoing low back pain aggravated by stop after pelvic floor physiotherapy. movement and when bad aggravates urinary symptoms Refer for pelvic floor physiotherapy Impression: Sensory urgency due to low back Over active abdominal muscles with bracing discomfort and increased tone in pelvic of diaphragm and poor pelvic floor excursion musculature; failure to relax pelvic muscles. and good vaginal tone and power. Soft tissue work on abdomen and re- education of breathing technique Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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