lower urinary tract symptoms (luts) in elderly males victor palit ms, frcs, mphil, frcs (urol),...
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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
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