Lower urinary tract symptoms (LUTS) in elderly males

Victor Palit MS, FRCS, MPhil, FRCS (Urol), FEBU, PG

Cert Med Ed, FHEAConsultant Urological surgeon

University Hospital of North Tees and Hartlepool & honorary consultant JCUH

Structure of the talk

• Red flag symptoms & signs & aetiology of LUTS

• Presenting symptoms & signs- DRE & PSA

• Management of symptoms

• Summary

• Is the patient’s LUTS caused by cancer?

• If not what is the cause and can it be treated?

Red Flag symptoms & signs

• Blood in Urine• Predominant symptom- urgency• Bothersome urinary symptoms not settling

with medication• Constitutional symptoms- loss of wt, bone

pain• Significant risk factors- smoker, worked

with chemicals, PMH, FH• Abnormal DRE & PSA

Underlying causes

• Prostate enlargement

• Infections

• Overactive bladder

• Bladder/urethral tumour

• Bladder Stones/foreign body

• Abdominal operations/spinal problems/rarely growth outside bladder/prostate

Basic evaluation

• History and symptom assessment

• Abdominal and Rectal examination

• Urinalysis

• Serum creatinine and ? PSA

• Post void residual volume (PVRV) bladder scan

Not at all Less than 1 time in 5

Less than half the time

About half the time

More than half the time

Almost all the time

Your score

Incomplete emptyingOver the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?

0 1 2 3 4 5

FrequencyOver the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5

IntermittencyOver the past month, how often have you found you stopped and started again several times when you urinated?

0 1 2 3 4 5

UrgencyOver the last month, how difficult have you found it to postpone urination?

0 1 2 3 4 5

Weak streamOver the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5

StrainingOver the past month, how often have you had to push or strain to begin urination?

0 1 2 3 4 5

None 1 time 2 times 3 times 4 times 5 times or more

Your score

NocturiaOver the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

Total score

Quality of life due to urinary symptoms

Delighted Pleased Mostly satisfied

Mixed Mostly dissatisfied

Unhappy Terible

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

0 1 2 3 4 5

Total score:

0-7 Mildly symptomatic

8-19 moderately symptomatic;

20-35 severely symptomatic

NICE recommendations for DRE

• Assessment for GI/GU disease• Screening for colorectal/prostatic disease SYMPTOMS• Lower Urinary Tract Symptoms (LUTS)• Erectile dysfunction• Low back pain• Bone pain• Haematuria• Unexplained weight loss• Tenesmus• Rectal bleeding• Alteration of bowel habit

DRE for prostate

Normal consistency is

• rubbery and firm,

• with smooth surface and

• median sulcus palpable between right & left lobes

PSA testing (NICE guidance)

General Overview• Offer men information, advice and time to

decide if they wish to have a PSA test if their:

– LUTS are suggestive of bladder outlet obstruction secondary to BPE or

– Prostate feels abnormal on DRE or

– Concern is about prostate cancer

1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

When to request PSA?

• Bone pain with LUTS

• LUTS with constitutional symptoms

• Non visible /visible haematuria???

• No PSA within 4 weeks of UTI/ urological operation & pts with catheter

NICE Recommendations on management of mild or moderate LUTS

1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

Bothersome to the patient, or complicated?

Active surveillance?Give reassurance, offer advice on

lifestyle interventions and information on their condition.

Offer review if symptoms change.

Active interventionConservative management /

drug treatment or surgery

YesNo

Offer baseline assessment (eg IPSS)

NICE RecommendationsDrug Treatment - LUTS

1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

Moderate to severe LUTS Offer an alpha blocker

Bothersome moderate to severe LUTS, and a

prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml

Consider combination treatment with an alpha blocker and a 5ARI

NICE RecommendationsConservative management – storage

symptoms

1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

Storage symptoms

OAB

Offer• supervised bladder training• advice on fluid intake• lifestyle advice • containment products (if needed)

NICE RecommendationsDrug treatment – storage symptoms

1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010

OAB

Storage symptoms despite treatment with an alpha

blocker alone

Offer an anticholinergic

Consider adding an anticholinergic

Summary• LUTS has multifactorial aetiology- don’t forget

cancer, stones & infections• Red flag symptoms & signs- haematuria,

urgency, bothersome symptoms not settling with treatment, bone pain, wt loss, abnormal DRE & PSA

• Life style changes/Containment device in mild symptoms if PVRV bladder scan is normal

• Alpha blocker for mild to moderate symptoms- refer if no improvement

• Anticholinergics for signs of overactive bladder- look for side effects