Download Consultant Urological Surgeon Benenden Hospital Tunbridge Wells

LUTS
Shawket Alkhayal
Consultant Urological Surgeon
Benenden Hospital
Tunbridge Wells Nuffield Hospital
LUTS are a major burden for the ageing
male population.
Age is an important risk factor for LUTS
and the prevalence of LUTS increases as
men get older.
Bothersome LUTS can occur in up to 30%
of men older than 65 years.
Male Lower Urinary Tract Symptoms
(LUTS)
It can comprise voiding or storage urinary
symptoms and can arise from any of the
following organ problem:
Prostate: benign prostate enlargement
(BPH), prostate cancer, prostatitis
Urethra: strictures, inflammation
Bladder: Cystitis, Detrusor muscle weakness
or overactivity, Bladder pain Syndrome
Neurological disease
Voiding Symptoms
Weak or intermittent urinary stream
Hesitancy
Straining
Sense of incomplete emptying
Terminal dribbling
Storage Symptoms
Frequency
Urgency
Urge incontinence
Nocturia
Enuresis
Assessment
Medical history
Associated co-morbidities
Review current medication, to identify drugs that may
be contributing to the problem
Specific questionnaire (IPSS)
Urinary frequency volume chart (Bladder Diary)
Examination
General examination
Examination of the abdomen
External genitalia
Digital Rectal Examination (DRE)
Tests
Urine dipstick test
blood
glucose
protein
leucocytes
nitrites
Offer men PSA test after counseling
Serum creatinine test (plus estimated
glomerular filtration rate [eGFR] calculation)
if you suspect renal impairment
palpable bladder
nocturnal enuresis
recurrent urinary tract infections
history of renal stones
Conservative Management
Storage Symptoms
Bladder training for OAB symptoms
Advice on fluid intake
Lifestyle advice
Containment products if they are
incontinent
Drug Therapy
for mild to moderate symptoms
For predominantly voiding symptoms-offer an
alpha blocker
For predominantly storage symptoms offer an
anticholinergic
For mixed symptoms offer an alpha blocker first
then add anticholinergic after 4 weeks if no
improvement
Referral for Specialist Assessment
If bothersome LUTS that have not responded to
conservative management or drug treatment
LUTS complicated by recurrent or persistent
urinary tract infection or
Urinary retention or
Renal impairment you suspect is caused by lower
urinary tract dysfunction or
Suspected urological cancer
Specialist Assessment
History review
Examination including DRE
Bladder diary
IPSS
Flow test and check residual volumes
Alpha blockers if not been tried for voiding Symptoms
with low flow rate and high residuals
Add 5 alpha reductase inhibitors for men with prostates
estimated to be larger than 30 g or a PSA level greater
than 1.4 ng/ml
Anticholinegics for OAB symptoms with good flow test
and minimal residuals
Late afternoon loop diuretic for nocturnal polyuria.
Oral desmopressin for nocturnal polyuria if other medical
causes have been excluded and other treatments failed
Urodynamic Assessment
Predominantly storage symptoms
Men under 40 or over 85
Previous pelvic surgery
Neurological disease
Cystoscopy
Recurrent infection
Sterile pyuria
Haematuria
New storage symptoms
Bladder pain
Dysuria
Imaging of the Upper Urinary
Tract
Chronic retention
Haematuria
Recurrent infection
Sterile pyuria
Profound symptoms or pain
Surgical Management of BPH
If voiding symptoms are severe, or
If drug treatment and conservative
management options have been
unsuccessful or are not appropriate
Discuss the alternatives to and outcomes
from surgery
TURP, Bipolar TURP, HOLEP
All other surgical treatments should be in the
context of audit or research
Management of OAB
if symptoms have not responded to conservative
management and drug treatments
Botox Bladder injections for men with
detrusor over activity, and is willing and able to
self-catheterise
Sacral nerve stimulation
Cystoplasty
Urinary Diversion
New treatments
PDE5-inhibitors (Tadalafil 5mg) for patients with
LUTS and ED
Beta 3 agonist (Mirabegron) for OAB
PTNS- for OAB symptoms