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LUTSShawket Alkhayal
Consultant Urological Surgeon
Benenden Hospital
Tunbridge Wells Nuffield Hospital
LUTS are a major burden for the ageing male population.
Age is an important risk factor for LUTS and the prevalence of LUTS increases as men get older.
Bothersome LUTS can occur in up to 30% of men older than 65 years.
Male Lower Urinary Tract Symptoms (LUTS)
It can comprise voiding or storage urinary symptoms and can arise from any of the following organ problem:
Prostate: benign prostate enlargement (BPH), prostate cancer, prostatitis Urethra: strictures, inflammationBladder: Cystitis, Detrusor muscle weakness or overactivity, Bladder pain SyndromeNeurological disease
Voiding Symptoms
Weak or intermittent urinary stream
Hesitancy
Straining
Sense of incomplete emptying
Terminal dribbling
Storage Symptoms
Frequency
Urgency
Urge incontinence
Nocturia
Enuresis
Assessment
Medical history
Associated co-morbidities
Review current medication, to identify drugs that may be contributing to the problem
Specific questionnaire (IPSS)
Urinary frequency volume chart (Bladder Diary)
Examination
General examination
Examination of the abdomen
External genitalia
Digital Rectal Examination (DRE)
TestsUrine dipstick test
blood glucose protein leucocytes nitrites
Offer men PSA test after counselingSerum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation)
if you suspect renal impairment palpable bladder nocturnal enuresisrecurrent urinary tract infectionshistory of renal stones
Conservative ManagementStorage Symptoms
Bladder training for OAB symptoms
Advice on fluid intake
Lifestyle advice
Containment products if they are incontinent
Drug Therapyfor mild to moderate symptoms
For predominantly voiding symptoms-offer an alpha blocker
For predominantly storage symptoms offer an anticholinergic
For mixed symptoms offer an alpha blocker first then add anticholinergic after 4 weeks if no improvement
Referral for Specialist Assessment
If bothersome LUTS that have not responded to conservative management or drug treatment LUTS complicated by recurrent or persistent urinary tract infection orUrinary retention orRenal impairment you suspect is caused by lower urinary tract dysfunction orSuspected urological cancer
Specialist Assessment
History review
Examination including DRE
Bladder diary
IPSS
Flow test and check residual volumes
Alpha blockers if not been tried for voiding Symptoms with low flow rate and high residuals
Add 5 alpha reductase inhibitors for men with prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml
Anticholinegics for OAB symptoms with good flow test and minimal residuals
Late afternoon loop diuretic for nocturnal polyuria.
Oral desmopressin for nocturnal polyuria if other medical causes have been excluded and other treatments failed
Urodynamic Assessment
Predominantly storage symptoms
Men under 40 or over 85
Previous pelvic surgery
Neurological disease
Cystoscopy
Recurrent infection
Sterile pyuria
Haematuria
New storage symptoms
Bladder pain
Dysuria
Imaging of the Upper Urinary Tract
Chronic retention
Haematuria
Recurrent infection
Sterile pyuria
Profound symptoms or pain
Surgical Management of BPH
If voiding symptoms are severe, or If drug treatment and conservative management options have been unsuccessful or are not appropriate Discuss the alternatives to and outcomes from surgeryTURP, Bipolar TURP, HOLEPAll other surgical treatments should be in the context of audit or research
Management of OAB
if symptoms have not responded to conservative
management and drug treatments
Botox Bladder injections for men with detrusor over activity, and is willing and able to self-catheterise
Sacral nerve stimulation
Cystoplasty
Urinary Diversion
New treatments
PDE5-inhibitors (Tadalafil 5mg) for patients with LUTS and ED
Beta 3 agonist (Mirabegron) for OAB
PTNS- for OAB symptoms