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
HUBERT GALLAGHER, MCh; FRCSI, FRCSI(Urol) Head of Urology Beacon Hospital
LUTS can be divided into:
Storage
Frequency Nocturia Urgency +/- incontinence Enuresis Leaking/SUI
Voiding
Weak flow intermittency Hesitancy Straining
Postmicturition
Incomplete emptying Post micturition dribbling
Men Women
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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.
Storage Symptoms
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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)
Aging Cardiovascular disease Obstructive sleep apnoea Obesity Metabolic Syndrome Diabetes Smoking
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Infections Neurogenic cause Reduction in functional abilities
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Metabolic Syndrome Insulin resistance Hormonal changes Pelvic atherosclerosis Inflammation
High insulin level High IGF-1 level Lower IGF-1 binding High cytosolic free Ca++ in smooth muscle and neural cells Increased oestradiol Lower testosterone Ischaemia Cytokine release Sympathetic nervous system activation Increased smooth muscle tone
LUTS/ BPH
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
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)
Obstructive breathing and its
associated co-morbidities may lead to bothersome nocturia
Nocturia has a detrimental effect
life
By treating obstructive breathing,
LUTS can improve.
CPAP reduces nocturia episodes Lifestyle advice may also improve
nocturia
If you don’t ask…you won’t find!!
Hypertension Obesity Diabetes Cardiovascular events
OSA NP
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Increased airways pressure Hypoxia Pulmonary vasoconstriction Increased right atrial transmural pressure Increased ANP production Increased sodium and water excretion Nocturnal polyuria NOCTURIA
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Increased airways pressure Hypoxia Increased Catecholamines Increased Insulin Resistance Glycosuria Increased water excretion Nocturnal polyuria NOCTURIA
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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)
Voiding symptoms
Predominantly voiding symptoms
Small prostate (<40cc)
Alpha-blocker (male)
Large prostate (>40cc)
Alpha-blocker 5-ARI Combination therapy
Mixed storage and voiding symptoms
Add in anti muscarinic Beta-3 alpha adrenergic
receptor agonist (mirabegron)
Storage symptoms
Predominantly storage symptoms
Exclude urinary infection/haematuria
Frequency volume chart
Lifestyle advice
Fluids Caffeine Pre-emptive voiding Travel-john Bladder retraining
Pelvic floor physiotherapy
Refractory or persisting symptoms
Trial of an either an anti muscarinic
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Assessment/History
72 year old man
Increasing PSA over 10 years (9.5ng/mL)
MRI and negative biopsy 2014
N x 2; Frequency+ Small volumes
Urgency+ Occasionally
Flow slow but steady
Father TURP; CaP age 94
Smoker
Moderate Claudication/PVD
Moderate to large BPH on DRE
Investigations
3T mpMRI prostate – 65cc gland; no suspicious lesion
Repeat PSA 11.9ng/mL
Calcified lesion in bladder
Flexible Cystoscopy – very
middle lobe; bladder calculus; trabeculated bladder with diverticulae.
UTI while waiting for TURP
Histology 31.5g resection; BPH with acute and chronic prostatitis.
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Pre-op Flow Rate Post Op Flow Rate
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Assessment/history
63 yo Female – P2 G2; infrequent attender; post menopausal
Constant desire to void, followed by urgency and incontinence x 6/12
Tolterodine no help, mirabegron significantly improved things
N x 2; D 4-5; flooded on occasion; no GSI; currently with Meds N x 1 and D 3. No cystitis.
Water: a reasonable amount; Tea 8/day
Ongoing low back pain aggravated by movement and when bad aggravates urinary symptoms
Impression: Sensory urgency due to low back discomfort and increased tone in pelvic musculature; failure to relax pelvic muscles.
Investigations
FVC: functional capacity 450mls, output ~2L/day; N x 2; D x 6-7
US Kidneys and pelvis normal
MSU Normal
Flexible cystoscopy normal; no prolapse; normal introitus, no GSI
Post void residual: Nil
Advices: Reduce caffeine intake
Continue mirabegron for moment – aim to stop after pelvic floor physiotherapy.
Refer for pelvic floor physiotherapy
Over active abdominal muscles with bracing
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)