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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 organs
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
stoneforeign
body
UTI
neurogenic
bladder
dysfunction
detrusor
underactivity
nocturnal
polyuria
OAB/ detrusor
overactivity
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 outside 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(+ sexualfunction)
Symptomscore
questionnaireUrinalysis
Physicalexamination
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 questionIf 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 urinaryor rectal conditions
2. Digital Rectal Examination(DRE)
→ fundamental method forassessing the shape and thevolume of the prostate
Uroflow to assess the Effect of BPH
Flow rate (ml/sec)
obstructed
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 requiredfor an adequate analysis
Interpretation of maximum urinary flow rate values:
> 15 ml/s normal
10-15 ml/s equivocal
< 10 ml/s obstructed
Uroflowmetry
(a) Normal Flow rate tracing(b) Flow rate tracing showing in reduction in the maximum flow rate in a patient with bladder outflow obstruction 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
0
1
2
3
4
5
6
Progression > 4 point rise AUR
Rate per100 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
Inci
de
nce
(%
)Baseline PSA tertiles
0–1.2ng/mL
1.3–3.2ng/mL
>3.2ng/mL
Surgery AUR
21
18
15
12
9
6
3
0
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 of 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
