LUTS & Cancer pathway

Mr Francis Thomas

Urology Consultant

DRI &BDGH

Topics

• Male and female LUTS

• Urinary retention

• Post void Residual urine

• Referral pathway • LUTS

• Raised PSA

• Hematuria

• Services in community

Causes of LUTS in men

• BPE • Life style habits • Detrusor muscle weakness or

overactivity, • Prostate inflammation, • UTI • Prostate cancer • Neurological diseases • Medical causes • Medications

Cardiac

LUTS

BPE

BOO

CNS Renal

Pituitary

Initial assessment • History

• Predominant symptoms

• Life style

• General medical history

• Drug history

• Physical examination

• Abdomen

• DRE

• Genitalia

• IPSS score

• Urine dipstick

Initial assessment • PSA-

• Abnormal prostate • Patient concerns

• Serum creatinine- • Suspect renal impairment • Palpable bladder • Nocturnal eneuresis • Recurrent UTI • H/o Renal stones

• USS KUB • Suspecting renal failure

Conservative Management

• Reassurance and further information

• Life style interventions- mainly for storage symptoms • Fluid balance

• Decrease tea/coffee/ alcohol/fizzy drinks

• Decrease night time drinks

• Bladder training

• Treat bowel constipation

• Reduce weight

Drug treatment

• Alpha blocker for moderate to severe LUTS ( eg: Tamsulosin, Alfuzosin)

• Anticholinergics for OAB (Solifenacin, Tolteridine etc)

• 5 alpha reductase (Finasteride, Dutasteride) –Prostate >30gm –PSA >1.4ng/ml –High risk for progression

Combination therapy (alpha blocker+5 alpha reductase)

–Bothersome moderate to severe LUTS

–Prostate >30gm –PSA >1.4ng/ml –High risk for progression

Alpha blocker+ Anticholinergic

–Persistent storage symptoms after treatment with alpha blocker alone

Improvement in Flow Qmax Prazosin, Alfuzosin, Tamsulosin, Terazosin

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Buzelin 93 Buzelin 97 Lee 97 Na 98

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Effect of finasteride on prostate volume Effect&of&finasteride&on&prostate&volume

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Mainly Voiding symptoms

Mainly storage symptoms

Voiding +storage symptoms

Large prostate PSA>1.4 Symptoms not improved

Alpha blocker Life style advise

Anticholinergics

Alpha blocker + anticholinergic+/-life style advise

Alpha blocker + 5 alpha reductase

Alpha blocker + PDE5 inhibitor

Voiding symptoms +Erectile dysfunction

SCENARIOS

• 60 YEAR OLD MAN presenting with • Slow stream , hesistancy , frequency

• Urinalysis negative

• PSA- 0.4

• PR- moderate size BPE

• 55 year old man with urgency, frequency , hesitancy • Urine positive for Nonvisible hematuria

• PR- moderate size bpe

Review after 4-6 weeks

• Continue active monitoring (reassurance and lifestyle modifications)

• Active intervention

• Drug therapy

• Referral to specialist

Referral

• Bothersome LUTS

• Not responded to drug treatment

• Complicated LUTS • UTI

• Retention

• Renal impairment

• Lower urinary tract dysfunction

• Suspected malignancy • Hematuria

• Abnormal prostate

• Raised PSA

Nocturia

Waking to pass urine during the main sleep period

Causes

• Nocturnal polyuria (It is defined as passing more than one third of your 24-hour urine output at night )

• BPE

• UTI

• Medications

• Medical causes- cardiac failure

• Sleep apnoea-sleep disturbances

Nocturia-assessment

• History-

• Identify causative factors

• Lifestyle habits

• Fluid intake

Assess with

• Frequency volume chart

• Urinalysis

Nocturia

• Lifestyle modifications

• Less fluid intake after 6 pm

• Reduce salt and sugar in diet

• Simple evening leg elevation or compression stockings can redistribute third space fluid

• Continuous positive airway pressure (CPAP)

• Alpha blockers- for BPE

• Anticholinergics-minimal effect

• Afternoon diuretics

• Desmopressin- oral or nasal spray ( monitor Sodium)

Retention of urine

Acute retention < 1000 ml urine • Painful

Acute on chronic retention >1litre urine • Painful

Chronic retention • RV>1 L, Palpable bladder • painless

High pressure chronic retention • Painful or painless • Renal failure, • Hydroureteronephrosis (on USS KUB)

Investigations +assessment • Prostate examination • Check U&E • USS KUB if renal failure

Management

Acute retention

• Catheterise- GP practice/RDASH/Hospital

• Alpha blocker before TWOC (after 48hrs)

C/C retention with symptoms

– ISC

– catheter

– Surgery

C/C retention without symptoms (not catheterised)

• Active surveillance- monitor

– PV RV

– USS kidneys

– Serum creatinine

Retention of urine

High pressure chronic retention • Renal failure,

• Hydroureteronephrosis

RX

• Catheterise

• Admit in hospital for monitoring

• LTC/Surgery

Effect of medical therapy on the development of AUR Effect&of&medical&therapy&on&the&

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• 75 year old man presents with difficulty passing urine through out night. • Fit and well

• O/E – palpable bladder

AUR/TWOC

• Community pathway -RDASH

• Patient presenting with AUR in community-

refer to unplanned care services for catheterisation and then seen in RDASH clinic for assessment /TWOC and further referral to Urology

• Patients discharged from hospitals with catheter referred to RDASH clinic for TWOC or for further catheter care

• Patients given clear advise and support – with catheter passport and contact details of RDASH clinic

RDASH/

UNPLANNED CARE

AUR in community

TWOC from hospital

ISC/CATHETER PROBLEMS

TWOC from community

DRI Urology Department

Post void scans /USS KUB

• Post void residuals

• No minimal or maximum values

• Take into consideration • Symptoms

• UTI

• Renal function

• Treatment depends on • whether symptomatic or not

• Renal function

Surgery- mainly storage symptoms • Failed conservative and drug treatment

• Urodynamic studies to assess bladder

• Botulinum toxin injection

• Sacral nerve neuromodulation

• Cystoplasty • Willing and able to self catheterize

• Detrusor overactivity

• Small capacity bladder

• Artificial sphincter- stress UI

• Urinary diversion

– Failed cystoplasty

– Failed sacral nerve stimulation

Surgery- voiding symptoms

-Severe voiding symptoms

-Failed drug and conservative treatment

• TURP • Monopolar/bipolar

• Green light

• Prostate embolisation

• HoLEP

• Uro-lift

• Aqua ablation

• Open prostatectomy->80-100 gm prostate

Female LUTS

Mr Francis Thomas

Consultant Urologist

DRI &BDGH

Definitions

• Urgency -a sudden compelling desire to urinate that is difficult to delay

• Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency

• Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing.

• Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or

coughing.

• Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with

frequency and nocturia.

• OAB that occurs with incontinence is known as ‘OAB wet’

• OAB that occurs without incontinence is known as 'OAB dry’

History

• Duration

• Type of incontinence

• Triggering factors- uti, stress

• Obstructive symptoms

• Pads usage –numbers, size, wetness

• Lifestyle factors-caffeine, smoking, alcohol

• Menstural/obstetric

• Bowel habits

• Previous pelvic surgery/radiotherapy

• Drugs

• Medical problems –diabetes etc

Assessment

• Frequency volume chart

• Minimum of 3 days to include rest days and working days

• Fluid dairy

• Urinalysis

• Post void residuals

• Pelvic and speculum examination

• Cough test

• USS pelvis

Specialist opinion

• Haematuria

• Recurrent UTI

• Persisting bladder or urethral pain

• Pelvic mass/palpable bladder

• Urogenital fistula

• Previous continence surgery

• Fecal incontinence

• Neurological disease

• Previous Pelvic cancer

• Previous pelvic radiotherapy

Treatment

• Categorise the symptoms and diagnose the type of incontinence • SUI,UI,MIXED OR OAB • Treat the predisposing and precipitating factors

• UTI, Constipation, Loose weight (BMI>30)

• Lifestyle advice • Reduce caffeine/fizzydrinks/smoking • Fluid intake 1.5-2litres

• Bladder training exercises • Pelvic floor exercises

• If mixed incontinence start treating the predominant symptom • SUI with OAB – Treat OAB symptoms prior to treatment of SUI

• Prolapse that is symptomatic and is visible and or below the introitus should be treated

Treatment-Conservative measures

BLADDER TRAINING -6 weeks-3 months

• There are many different regimes, but they all involve suppressing the feelings of urinary urgency.

• Require a few months’ training to reach its full potential.

• Timed voiding

Pelvic floor muscle training(PFMT)

Assess pelvic muscle tone

• Supervised PFMT- 3months

• 8 contractions each held for 8 seconds three times a day

• RDASH clinic and physiotherapy department- offers bladder training and PFMT advice

Treatment

PADS/CATHETERS/URINALS

-Use them only as • Coping strategy –pending assessment and treatment

• An adjunct to ongoing treatment

• When all treatment options have been explored and failed

Medications • Start with one with low acquisition cost

• Most of anticholinergics have same side effect profile

• Oxybutynin-(not in elderly)

• Tolteridine -

• Darifenacin-

• Solifenacin-

• Trospium chloride

• Fesoteridine

• Mirabegron- beta 3 agonist • Mirabegron +anticholinergic

• Topical oestrogens for vaginal atrophy-6 weeks to 3months

OAB DRUGS

• Counsel about success and associated common side effects

• Some side effects indicate that the treatment is starting to have an effect

• May take up to 4 weeks for medicines to start working

• Need to continue with bladder training /PFMT along with OAB drugs

• 4 week review and then 6month review

• Try atleast two drugs before referral to specialist centres

Referral- &secondary care If OAB symptoms, SUI/mixed incontinence not responding to bladder training, PFMT and OAB drugs

OAB

MDT

• Urodynamics

• Intravesical Botulinum toxin

• Posterior tibial nerve stimulation

• Sacral neuro modulation

• Augmentation cystoplasty

• Urinary diversion-ileal conduit

SUI

MDT

• Urodynamics

• Rectus fascial slings

• Colposuspension

• Urethral bulking agents

• Artificial sphincters

• Urinary diversion

Women with bladder symptoms

Referred for Pelvic floor exercises

Clinic – revisit – 6-8 weeks

RDASH

clinic

Urinalysis

Flow rate & bladder

scan

Fluid and dietary advise

Clinical examination

& medications

Pelvic floor

exercise

Referred to Gynaecologist if prolapse etc--

Urology

clinic

Urinalysis

Flow rate & bladder

scan

Fluid and dietary advise

Clinical examination

& medications

Discharged if symptoms resolved

Referred to Urology/Gynaecology MDT as appropriate

Hospital pathway Community pathway- RDASH

GP

Clinical scenarios

• 40 year old lady presenting with frequency ,urgency, incontinence for 3 months . Otherwise fit and well.

• 40 year old lady presenting with frequency ,urgency, incontinence for 3 months . Otherwise fit and well. Already on medications (anticholinergic) for 2 months but symptoms not better.

• 65 year old lady with frequency , urgency and hesitancy , otherwise fit and well. O/E – microscopic hematuria, vaginal atrophy.

Cancer 2 WW Pathways

Hematuria referral

2 ww referral

• >45 yrs of age hematuria without UTI

• Non visible hematuria (NVH) >60 yrs and have either dysuria or raised WBC count

Non urgent referral

• Visible hematuria <45 yrs of age

• Non visible hematuria <60 yrs

• Recurrent UTI

• NVH with proteinuria / renal failure • Refer renal physician

• Current pathway • One stop PSA clinic

One stop PSA clinic – 2WW

Abnormal PSA

MRI done and reported same day

PROSTATE BIOPSY- same day

CLINIC

MDT ONCOLOGY

Seen in clinic-2WW

Abnormal PSA

MRI PROSTATE

MRI MDT

PROSTATE BIOPSY

CLINIC

ONCOLOGY MDT

3 C

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ISIT

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South Yorkshire, Bassetlaw and North Derbyshire Cancer Alliance

Urology

Fast Track Referral – 2 Week Wait

Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE)

1. Asymptomatic patient requesting PSA test Require two blood tests, at least 4 weeks apart Informed consent: e.g. Prostate Cancer Risk Management Programme (PCRMP) leaflet Refer as 2ww if: Both PSA >3.0 (for all ages)

(For raised PSA in men with significant co-morbidities, performance status >3 or life

expectancy <10 years, consider discussion with patient/family/carers and/or a specialist before urgent referral.)

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/509191/Patient_info_sheet.pdf

Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE)

2. Symptomatic patient: Prostatic symptoms/LUTS Please Wait atleast 6 weeks following treated UTI before undertaking PSA test.

Refer if:

Abnormal DRE

Or

Both PSA >3.0 (Obtain two PSA tests, at least 4 weeks apart)

(For raised PSA in men with significant co-morbidities, performance status >3 or life expectancy <10

years, consider discussion with patient/family/carers and/or a specialist before urgent referral.)

Informed consent: e.g. (PCRMP) leaflet provided

Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE)

3. Symptomatic patient: Suspected distant metastases

Refer:

• If abnormal DRE

• Or a single PSA >20

• In this group of patients if PSA result is between 10-20 suggest repeat and review in 4 weeks with second PSA test.

• If repeat PSA level <10 – Constitutional symptoms are unlikely to be directly due to prostate cancer but consider criteria above.

Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE)

4. Prostate feels malignant (Firm, hard, nodular or craggy) on (DRE)

• One PSA is sufficient, Any PSA value