luts – a plea for a holistic approach. - beacon hospital · luts-classification luts can be...

LUTS – A plea for a holistic approach.HUBERT GALLAGHER, MCh; FRCSI, FRCSI(Urol)

Head of Urology

Beacon Hospital

LUTS-

Classification 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 – The

Problem

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


LUTS and Gender

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

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Why do LUTS

occur?Aging

Cardiovascular disease

Obstructive sleep apnoea

Obesity

Metabolic Syndrome

Diabetes

Smoking

___________________________________________

Infections

Neurogenic cause

Reduction in functional abilities


MetS/CVD and LUTS/BPH

Metabolic Syndrome

Insulin resistance Hormonal changes Pelvic atherosclerosis Inflammation

High insulin level

High IGF-1 levelLower 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


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

Preventing LUTS/BPH by preventing/treating CVD


Preventing LUTS/BPH by preventing/treating CVD

Treating LUTS like CVD as a lifestyle issue may improve or prevent deterioration.

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!


OSA and Co-morbidities

Obstructive breathing and its associated co-morbidities may lead to bothersome nocturia

Nocturia has a detrimental effect on quality of sleep and quality of life

By treating obstructive breathing, LUTS can improve.

CPAP reduces nocturia episodes

Lifestyle advice may also improve obstructive breathing and nocturia

If you don’t ask…you won’t find!!

Hypertension

ObesityDiabetes

Cardiovascular events

OSA

NP


Association between obstructive

breathing and LUTS – Mechanism 1

Increased airways pressure Hypoxia Pulmonary vasoconstriction

Increased right atrial transmural pressureIncreased ANP production

Increased sodium and water excretion Nocturnal polyuria

NOCTURIAHubert Gallagher, Mch; FRCSI, FRCSI(Urol)

Association between obstructive

breathing and LUTS – Mechanism 2

Increased airways pressure Hypoxia Increased Catecholamines

Increased Insulin ResistanceGlycosuria

Increased water excretion Nocturnal polyuria

NOCTURIAHubert Gallagher, Mch; FRCSI, FRCSI(Urol)

When to refer to urology?

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


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


Medical Management of LUTS/BPH

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

or mirabegron


Patient 1

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 obstructive prostate; Intravesical middle lobe; bladder calculus; trabeculated bladder with diverticulae.

UTI while waiting for TURP

Histology 31.5g resection; BPH with acute and chronic prostatitis.


Flow Rates

Pre-op Flow Rate Post Op Flow Rate


Patient 2

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 of diaphragm and poor pelvic floor excursion and good vaginal tone and power.

Soft tissue work on abdomen and re-education of breathing technique


luts – a plea for a holistic approach. - beacon hospital · luts-classification luts can be...

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