Transcript Approach to a man with Lower Urinary Tract Symptoms

Approach to a man with Lower
Urinary Tract Symptoms
Dr. Yeung Fun Na, Fannie
Lower Urinary Tract Symptoms
Obstructive
-
Hesitancy
Weak stream
Intermittency
Terminal dribbling
Incomplete emptying
Straining
Prolonged micturiction
Overflow incontinence
Irritative
-
Urgency
Urge incontinence
Frequency
Nocturia
Dysuria
Suprapubic pain
62 years old gentleman: “Doctor, I have to get up
2-3 times at night to urinate in the past year and
the urinary stream is weak. I need to strain to
begin urination most of the time. Is this related to
my prostate?
What Are the DDX in Your Mind?
What Else Do You Want to Know?
Possible DDX
1.
2.
3.
4.
5.
6.
Neurogenic bladder
Bladder neck contracture
CA prostate
Prostatitis
Urethral stricture
UTI
History
1. LUTS (severity, duration)
2. Complications
-
3.
4.
Urinary stone
Retention of urine
Recurrent UTI
Uraemic symptoms
Past Hx: DM, CVA, Spine Trauma, neurological disease,
previous endourological manipulation, perineal pain
Drug Hx: anticholinergic, B-adrenergic
IPPS
(prostate symptom score)
Assess frequency of the following symptoms
(score from 0-5)
-
sense of incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
nocturia
QOL assessment index L
If you were to spend the rest of your life with
your urinary condition just the way it is now, how
would you feel bout that
0
1
2
3
4
5
6
delighted
pleased
mostly satisfied
mixed about equally satisfied and dissatisfied
mostly dissatisfied
unhappy
terrible
Physical Examinations
General: pallor, uaemic features
Abd: kidney, bladder, hernia
DRE: (prostate) surface, symmetry, sulcus, consistency,
mobility, size; anal tone
Genitalia:
phimosis, penile CA, meatal stenosis,
urethral stricture
Basic Investigations
Dipstick test
Blood x RFT, PSA, fasting glucose
MSU x C/ST, R/M
KUB
Other Investigations
Uroflowmetry
TRUS + Bx
IVU, Cystoscopy, USG
Urodynamic studies
CT, MRI, Bone Scan
When to refer
1.
2.
3.
4.
5.
6.
7.
High symptom score
Abn DRE
Palpable bladder (RU > 300ml)
Hx of recurrent UTI / haematuria
PSA > 4
Rapid onset of symptoms +/- low back pain
Complications develop (impaired renal function)
Management of LUTS due to
BPH
Conservative
Medical
Surgical
Mild symptoms conservative (simple advice)
Moderate symptoms  medical treatment
Severe symptoms / surgical indication  refer
urologist
Conservative management
1. Adequate dietary fibre
2. Avoid drugs that may precipitate urinary
retention
3. Avoid excessive water intake, coffee / tea
at night time
4. Adequate voiding, double voiding
Medical Treatment
1. Alpha blockers (e.g. terazosin, doxazosin)
-
Relax muscle at bladder neck, prostatic urethra
Effective in 60% patients ( flow  PSS)
Possible SE: drowsiness, dizziness, headache 10-15%
Effective after 1-2 doses
Can be used as single agent in treating patients with HT esp useful
in those with dyslipidaemia
2. 5 alpha-reductase inhibitor (e.g. finasteride)
-
Inhibit T DHT,  prostate volume
Possible SE:  libido, impotence 4%
Takes 3-6 months to have improvement in urine flow; less effective;
more expensive
Examples of commonly used Alphablocker
Hytrin (terazosin HCl)
- Initial dose 1mg Nocte
- Titrate stepwise to 2mg, then 5mg, 10mg daily
Cardura (doxazosin HCl)
- Initial dose 1mg Nocte
- Titrate stepwise to 2mg, 4mg, up to 8mg with
recommended titration interval of 1-2 weeks
- S/E: dizziness, headache
Examples of commonly used Alphablocker
- Cardura XL
- Modified release formulation of Cardura, which releases
doxazosin over 12-16 hours and provides a sustained
plasma concentration throughout 24 hour dosing
scheduled
- Same efficacy with Cardura
- Initial dose 4mg Nocte
- No need for dose titration
Xatral SR (alfuzosin HCl)
- 5mg daily, up to 5mg bd
Surgical Treatment
TURP (commonest prostate operation)
- possible peri-operative complications and long
term complications (like incontinence, urethral stricture,
impotence, retrograde ejaculation, recurrent symptoms,
prostatic re-growth)
Others:
- Open prostatectomy, TUIP, thermal therapy, laser
therapy, stenting
PSA (prostatic specific antigen)
1.
2.
3.
4.
5.
6.
Organ-specific, not cancer-specific
Normal cutoff value < 4.0 ng/ml
 with age, prostatic volume
 in 25% BPH, 80% CA
PSA > 10 and abn DRE: 65% cancer
Not for Routine Screening !!!
Indications for PSA
1. Screening for High risk group
- 1 x 1st degree: 2-5x
- 2 x 1st degree: 5-10x
- > 20% / year  biopsy
2. life expectancy > 10 years AND
requesting for PSA test / highly suspicious
of CA prostate e.g. abn DRE
False Positives
Recent episodes of
- UTI
- Retention of urine
- Prostatitis
Within 72 hours after ejaculation
Shortly after prostatic surgery or biopsy
Interpretation of PSA level
<4
4-10
> 10
 > 20%/yr
Age
40-49
50-59
60-69
70-79
normal
equivocal, 20% chance
> 50%
immediate bx
upper limit
2.5
3.5
4.5
6.5
THE END