LUTS A plea for a holistic approach. HUBERT GALLAGHER, MCh; - PowerPoint PPT Presentation

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)