Transcript Reynolds LUTS-BPH Educationx - 352.06 KB

Lower Urinary Tract Symptoms
in the Aging Male
Ross Moskowitz, MD
Resident Physician
Atreya Dash, MD
Assistant Clinical Professor
Objectives
•
•
•
•
•
Definitions
Epidemiology
Symptomatology
Evaluation
Treatment
Definitions
• Benign Prostatic Hyperplasia (BPH)
– Refers to a histological finding
– No inherent clinical meaning
• Many men will have BPH but no symptoms
– Presence of BPH increases with age
Definitions
• Modern term (more appropriate than BPH or
prostatism) is Lower Urinary Tract
Symptoms (LUTS)
– Removes implication that symptoms have organ
specific cause
• LUTS divided into two categories:
– Voiding or obstructive symptoms
– Storage or irritative symptoms
Definitions
• International prostate symptom score (IPSS): Validated
subjective questionnaire for LUTS
• Seven symptoms evaluated:
-Weak flow of stream
-Intermittency
-Difficulty initiating
stream
-Nocturia
-Straining to void
-Frequency
-Urgency
•
Each scored 0-5
– Total score 0-7 Mild; 8-19 Moderate; 20-35 Severe LUTS
•
Bother score: Single concluding question evaluating quality of life with
LUTS, heavily weighed when determine whether or not to intervene,
scored 1-6
Definitions
• Bladder Outlet Obstruction (BOO) may develop
from progressive BPH and worsen LUTS, especially
voiding symptoms
• Non-invasive uroflowmetry may provide some
objective diagnostic data
– Patient voids into weighed receptacle to measure volume
and rate of flow
Definitions
• Urine flowmetry values:
– Max flow rate ≥15 mL/s normal
– Between 10-15 mL/s equivocal
– Max flow rate < 10 mL/s obstructive
– Important: Obstruction may be anatomical (i.e. from enlarged
prostate) or functional (i.e. diminished detrusor contractility)
Uroflowmetry Examples
Normal voiding curve
Total Vol: 317ml
Max flow: 21ml/sec
Obstructed voiding curve
Total Vol: 122ml
Max flow: 4ml/sec
The Post Void Residual
• Measured in mls, elevated in BOO
– Should be near zero in normal voiding, but no specific
cut-off for an elevated PVR
• Can either be measured by ultrasound or
in/out catheterization
• Bladder Scanner: ultrasonic machine
dedicated to measurement of bladder volume
Epidemiology
• In men > 40 years-old half will develop BPH
and increase with age
– Prostatic enlargement may progress and lead to
BOO
– 30-50% will have bothersome LUTS
– Therefore nearly ¼ male population will develop
BPH-related bothersome LUTS
Symptomatology
• Voiding Symptoms
– Weak force of stream
– Hesitancy
– Intermittency
– Straining
– Terminal dribbling
Symptomatology
• Storage symptoms
– Urgency
– Frequency
– Nocturia
– Urge incontinence
The Evaluation
• History & Physical
– Include digital rectal exam
• Assessment of severity of LUTS
– At minimum qualitative
– Consider International Prostate Symptom Score
(IPSS)
• Labs: Urinalysis and PSA
• Consider voiding diary with frequency and
volume
The Evaluation
• Complicated LUTS  Specialty evaluation referral
• Indications:
–
–
–
–
–
–
–
–
–
–
History prostate cancer or elevated PSA
Hematuria
Bladder stones
Bladder cancer
Urethral stricture
Neurologic disease
Prostatitis
Urinary retention
Recurrent UTI
Failed medical therapy or interest in surgery
The Evaluation
• Uncomplicated LUTS
• Low Bother score
– IPSS at office visit(s)
– Lifestyle modification
– Consider medical management
– Reassurance and follow
Treatment
• Uncomplicated LUTS with bothersome
symptoms
– Review specific symptoms and/or voiding diary
– Modify medications, especially diuretics or procholinergics
– Modify fluid intake or diet
• Caffeine, alcohol, spicy/acidic foods can worsen LUTS
– Address underlying medical conditions
• Treat constipation
• Leg edema: elevation prior to bedtime to treat nocturia
– Bladder training
– Medical therapy
• Pursue specialty consultation if above fails
Treatment
Medical Therapy
• Alpha adrenergic receptor blockers
– Treat bladder outlet obstruction
– Dynamic effect on bladder neck and prostate
• Target alpha adrenergic smooth muscle receptors
– Side effects: hypotension, fatigue, dizziness, nasal
congestion, ED, abnormal ejaculation
– Selective versus non-selective to minimize side effects
• Selective α1a: tamsulosin and silodosin
• Non-selective α1: terazosin, doxazosin, alfuzosin
Treatment
Medical Therapy
• 5α-reductase inhibitors (5-ARIs)
– Treat bladder outlet obstruction by treating
enlarged prostate
• Decreases prostate volume, takes up to six months
for maximal effect
– Inhibits intraprostatic conversion of testosterone to
dihydrotestosterone
– Type 1 and 2 isoenzymes
– More useful in large prostates > 30 cc size (surrogate of
size is ≥ PSA 1.5 ng/mL)
Treatment
Medical Therapy
• 5 ARI side-effects
– Decreased libido, ejaculatory dysfunction, ED,
gynecomastia
– Hair growth: finasteride is the same medication,
different dose, as Propecia®
• Combination therapy
– Use of both alpha blockers and 5-ARIs
– Better than single drug but more side effects
Treatment
Medical Therapy
• Anti-muscarinics
– Treats storage symptoms
– Better effect in combination with alpha blocker
– Bladder has M2 and M3 muscarinic receptors
• M2 receptors also in salivary glands, CNS, cardiovascular, GI:
explains side effects: dry mouth, dry eyes, constipation
– M3 selective medications may have fewer side effects
than non-selective targeting M2 and M3
• M3: darifenacin, solifenacin
• M2: oxybutynin, tropsium, tolterodine, fesoterodine
• Other considerations
– Phytotherapy
Treatment
• Saw Palmetto (Seranoa repens) ineffective in a randomized trial
– Phosphodiesterase 5 inhibitors
• Some effect in relieving LUTS, besides use in erectile
dysfunction
• Only tadalafil approved
– Surgery: Resection, vaporization or removal of prostatic
tissue
• Performed in patients who are appropriate candidates, failed or
did not tolerate medical management, and whose quality of life
significantly impacted by LUTS
Problem based learning (PBL)
Cases
• Here we will present three cases of LUTS
with different plans of management based on
etiology and severity of symptoms
PBL Cases
• 72 year old male, retired professor, with history of
hypertension and diabetes, with complaints of slow
urinary stream, frequency, nocturia twice per night, and
occasional double voiding
• No dysuria, no gross hematuria, no incontinence, no
history of UTI
PBL Cases
• IPSS: 12 (moderate symptoms), Bother score
3/6
• Patient non-smoker, drinks 5 cups coffee per
day
• DRE: 30-40gms, smooth
• Hgb A1c=8.5, UA negative, PSA 1.33
PBL Cases
• Interventions:
– Decrease caffeine intake
– Limit fluids after dinner
– Improved diabetes control
– Patient had already started taking saw palmetto
and would like to see how that works
PBL Cases
• 6 month follow up:
– IPSS 9, Bother 2/6
– Self discontinued saw palmetto (no
improvement)
– Decreased frequency and nocturia
– Last Hgb A1c 6.4
– Still not satisfied with symptoms
– Trial on tamsulosin 0.4mg/daily
PBL Cases
• Next follow up:
– IPSS 5, Bother 1/6
– Satisfied with symptom control
– No complaints of dizziness or orthostatic
hypotension with tamsulosin, but thinks he may
be having some retrograde ejaculation
– Plan: Continue current management
PBL Cases
• 63 year old male, business executive, with
history of low back pain with spinal surgery
three years ago, with worsening LUTS,
mainly bothered by frequency, slow stream,
and double voiding
• No dysuria, no hematuria, no incontinence,
has had one UTI in the past two years
PBL Cases
• IPSS: 25 (severe symptoms),
score 5/6
Bother
• Patient non-smoker, drinks 2 cups coffee per
day
• DRE: 70-80gms, smooth
• UA negative, PSA 2.8
PBL Cases
• Interventions:
• Initially started on tamsulosin, with slight
improvement of symptoms
• Few weeks later started on finasteride
• Patient considering surgical management, but would
like to allow medications, specifically finasteride, more
time to work
• Uroflowmetry obtained:
– Obstructive voiding pattern, max flow 6ml/s, voided 210cc,
135cc post void residual by ultrasonic bladder scan
PBL Cases
• 6 month follow up:
– IPSS 19, Bother 4/6
– Patient tolerating tamsulosin and finasteride,
some complaints of decreased libido but still able
to get erections
– Patient now interested in surgical management
• Urodynamic study obtained in scenario of spine
surgery to differentiate between functional and
anatomical obstruction
PBL Cases
• Urodynamics (Cystometrography):
– Measure intra-abdominal pressure and intravesical
pressure while bladder is filled in a retrograde fashion
with a catheter, and having patient then void
– Detrusor pressure (bladder squeezing) is calculated by
subtracting abdominal pressure from vesicular pressure
– Anatomical obstruction will have high detrusor pressure with low
voiding rate
– Functional obstruction will have low detrusor pressure with low
voiding rate
PBL Cases
• This patient confirmed by urodynamics to have high
detrusor pressure during slow voiding rate, and so
believed to benefit from relieving the anatomical
obstruction
• Patient proceeded with transurethral resection of the
prostate (TURP):
– Endoscopic operative procedure to widen the prostatic urethral
channel
PBL Cases
• Postoperative follow up:
– IPSS 8; Bother 2
– Uroflowmetry: Voided 312 cc, max flow rate 17ml/sec,
post void residual by bladder scan 36cc
– Overall patient very satisfied with LUTS management
and has discontinued tamsulosin and finasteride
– Postoperative hematuria has resolved, and some urinary
urgency has continued to improve
– Does have anticipated retrograde ejaculation
PBL Cases
• 69 year old, retired trucker, history of hypertension
and hyperlipidemia, with gradually worsening LUTS
over past few years, mainly bothered by frequency
and strong urgency
• No dysuria, no hematuria, treated for two UTI in the
past few years, rare urinary dribbling with urgency
PBL Cases
• IPSS: 17 (moderate symptoms),
Bother score 4/6
•
•
•
•
Patient smokes 1ppd x 35 years, no caffeine
DRE: 50-60gms, smooth
PSA 1.7
UA: 15rbc, 3wbc, negative nitrite, positive leukocyte
esterase
• UCx: no growth
PBL Cases
• Interventions:
• Initially started on tamsulosin with no improvement of
symptoms
• Repeat urinalyses obtained with continued
microscopic hematuria
• Urine cytology obtained, found urothelial cells
concerning for malignancy
PBL Cases
• Interventions:
• Hematuria work-up completed
–CT Urogram (includes iv contrast with
delayed renal excretory phase)
–Urine cytology
–Cystoscopy
• In-office cystoscopy revealed area within
bladder velvety red/erythematous
PBL Cases
• Operative intervention: Cystoscopy with biopsy
and electrocautery fulguration
–Pathology: Carcinoma in-situ (CIS) of the
bladder
• Can present with irritative voiding symptoms
• Usually initially managed with intravesical
agents; refractory or multifocal CIS managed
with radical cystectomy
References
McVary KT, Roehrborn CG, Avins AL et al: American
Urological Association Guideline: Management of Benign
Prostatic Hyperplasia (BPH). 2010.
Abrams P, Chapple C, Khoury S et al: Evaluation and
Treatment of Lower Urinary Tract Symptoms in Older
Men. J Urol 2009; 181: 1779.
Thank You