Lower Urinary Tract Symptoms (LUTS) and Management of Benign Prostatic Obstruction
Lower Urinary Tract Symptoms (LUTS) and Nurse …...Lower Urinary Tract Symptoms (LUTS) and...
Transcript of Lower Urinary Tract Symptoms (LUTS) and Nurse …...Lower Urinary Tract Symptoms (LUTS) and...
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Lower Urinary Tract Symptoms (LUTS) and Nurse-Led Clinics
Sean Diver
Urology Advanced Nurse Practitioner candidate
Letterkenny University Hospital 01/02/2018
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Lower Urinary Tract Symptoms
• LUTS - one of most common clinical complaints in adult men
• Often described by terms such as:
BPH BPO BPE BOO
• However LUTS do not necessarily relate to prostate pathology
(EAU, 2015)
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Causes of male lower urinary tract symptoms
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Benign Prostatic Obstruction (BPO)
• Most prevalent condition affecting the prostate – Accounting for 80% of clinical presentations for prostate disease.
• Estimated to afflict > 2 million men in UK
• Age related autopsy studies – 41-50 y = 20%, 51-60y = 50%, > 80y = 90%
(Kirby ,2012)
• Census Ireland: Males 45-64y = 520,243:
Males 65y and over = 243,314 (CSO, 2011)
• Prevalence increases with age – Ageing population = rise in the number of men with BPO
(McAninch & Lue, 2013)
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LUTS in early BPO Voiding symptoms – Hesitancy
– A reduced stream
– Incomplete emptying
– Double voiding
– Straining
– Post void dribbling
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LUTS in early BPO Voiding symptoms – Hesitancy
– A reduced stream
– Incomplete emptying
– Double voiding
– Straining
– Post void dribbling
Storage symptoms – Nocturia
– Frequency
– Urgency
– Urge incontinence
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LUTS in advanced BPO
• Acute / Chronic urinary retention
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LUTS in advanced BPO
• Acute / Chronic urinary retention
• Overflow incontinence
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LUTS in advanced BPO
• Acute / Chronic urinary retention
• Overflow incontinence
• Bladder stone formation
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LUTS in advanced BPO
• Acute / Chronic urinary retention
• Overflow incontinence
• Bladder stone formation
• Deterioration in renal function
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LUTS in advanced BPO
• Acute / Chronic urinary retention
• Overflow incontinence
• Bladder stone formation
• Deterioration in renal function
• Formation of bladder diverticulum
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LUTS in advanced BPO
• Acute / Chronic urinary retention
• Overflow incontinence
• Bladder stone formation
• Deterioration in renal function
• Formation of bladder diverticulum
• Recurrent UTI
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Impact on Quality of Life
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Assessment of male LUTS at Nurse Led Clinic
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Causes of male lower urinary tract symptoms
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Clinical Guidelines
• NICE clinical guideline 97: Lower urinary tract symptoms in men: assessment and management (June 2015) www.nice.or.uk/guidance/cg97
• EAU Guideline: Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (2015) www.uroweb.org/guideline
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Assessment of male LUTS
• Health history
• Symptom assessment
• Physical examination
Additional tests
• Urinalysis
• Blood tests
• Uroflowmetry
• Residual urine measurement
• Pressure/flow studies
• Ultrasound
• Cystoscopy
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Assessment of male LUTS
• Health history
• Symptom assessment
• Physical examination
Additional tests
• Urinalysis
• Blood tests
• Uroflowmetry
• Residual urine measurement
• Pressure/flow studies
• Ultrasound
• Cystoscopy
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
• Medication history
• Additional information
EAU recommend a health history must always be taken from men with LUTS (EAU, 2015)
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Neurological conditions – Parkinson's disease
– Cerebrovascular accident
– Cerebral atrophy
– Multiple sclerosis
• Cardiovascular – Heart failure
• Diabetes
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Major abdominal / pelvic surgery – AP resection
• Spinal surgery – Discectomy
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
– Urological surgery
– Urinary tract infections
– Interstitial cystitis
– Prostate cancer
– Bladder cancer
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
– Most bothersome symptoms
– Duration / timing
– Quality or severity
– Setting
– Associated factors
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
• Medication history
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
• Medication history
• Current medications for LUTS?
• Other meds may affect LUTS
– Acting directly on lower urinary tract
– Increased urine production
– Impaired cognition and mobility
– Causing constipation
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Medications • Alcohol – Impairs mobility, reduces sensation, sedates, increases frequency/urgency by
diuresis • Alpha blockers- Relax smooth urethral smooth muscle • Antihistamines – antimuscarinic side effects • Antimuscarunics/antispasmodics – relax detrusor muscle • Antipsychotics – voiding difficulties due to antimuscarinic side effects • Anxiolytics – decreased awareness, drowsiness, impaired mobility • Caffeine – diuretic, bladder irritant • Calcium channel blockers – increased frequency, nocturia • Cytoxics – Hemorrhagic cystitis • Diuretics – rapid diuresis, polyuria, frequency, urgency, exacerbate OB • Hypnotics – decreased awareness, drowsiness • Opiates – bladder sphincter spasm, • Tricyclic antidepressants – antimuscarinic side effects • Clonazepam – Urinary incontinence • Baclofen/Dantrolene – increased frequency, urinary incontinence • Ketamine- long term bladder damage, interstitial cystitis, frequency, urgency, fibrotic
bladder, pain, haematuria • Nefopam – Antimuscarinic side effects, • Pseudoephedrine – increased sphincter tone, urinary retention • Risperidone – sedation, relaxes proximal urethral smooth muscle
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Medications • Alcohol – Impairs mobility, reduces sensation, sedates, increases frequency/urgency by
diuresis • Alpha blockers- Relax smooth urethral smooth muscle • Antihistamines – antimuscarinic side effects • Antimuscarunics/antispasmodics – relax detrusor muscle • Antipsychotics – voiding difficulties due to antimuscarinic side effects • Anxiolytics – decreased awareness, drowsiness, impaired mobility • Caffeine – diuretic, bladder irritant • Calcium channel blockers – increased frequency, nocturia • Cytoxics – Hemorrhagic cystitis • Diuretics – rapid diuresis, polyuria, frequency, urgency, exacerbate OB • Hypnotics – decreased awareness, drowsiness • Opiates – bladder spincter spasm, • Tricyclic antidepressants – antimuscarinic side effects • Clonazepam – Urinary incontinence • Baclofen/Dantrolene – increased frequency, urinary incontinence • Ketamine- long term bladder damage, interstitial cystitis, frequency, urgency, fibrotic
bladder, pain, haematuria • Nefopam – Antimuscarinic side effects, • Pseudoephedrine – increased sphincter tone, urinary retention • Risperidone – sedation, relaxes proximal urethral smooth muscle
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
• Medication history
• Additional information
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Health History (Focused on urinary tract/general health issues/ overall fitness)
• Medical history
• Surgical history
• Urological history
• LUTS
• Medication history
• Additional information
– Visible Haematuria
– Dysuria
– Incontinence
– Fluid intake
– Nicotine habit
– Alcohol intake
– Bowel habit
– Family Hx (Pca)
– Social Hx
– Age
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Assessment of male LUTS
• Health history
• Symptom assessment
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Symptom Assessment
• International prostate symptom score (validated questionnaire) – Voiding and storage symptoms
– 7 questions • Asymptomatic 0 points
• Mildly symptomatic 1-7 points
• Moderately symptomatic 8-19 points
• Severely symptomatic 20-35 points
• Quality of life question
EAU recommend a validated questionnaire in all men with LUTS and for re-evaluation during treatment (EAU, 2015)
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International prostate symptom score [IPSS]
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Frequency Volume charts / bladder diaries
Should be used to assess LUTS with a prominent storage component and should be
performed for a duration of at least 3 days (EAU 2015)
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
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Physical Examination
• Digital rectal examination – Size
– Texture
– Consistency
• Suprapubic Area – Palpable bladder
• Genital examination – Phimosis
– Meatal stenosis
• Focused neurological examination
• ? Lower limb Oedema
EAU recommendation (2015) –
routine examination for all men with LUTS
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
– Must be used in the
assessment of male LUTS
(EAU, 2015)
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
• Blood tests
– PSA if diagnosis of Pca
will change management • NCCP 2017
– Renal profile if renal impairment is suspected, in presence of hydronephrosis or if surgery is considered
(EAU, 2015)
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
• Blood tests
• Uroflowmetry
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Uroflowmetry
EAU recommendation (2015)- Should be performed prior to any
treatment
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Uroflow normal
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Uroflow Obstruction
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Uroflow / Stricture
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
• Blood tests
• Uroflowmetry
• Residual urine measurement
EAU recommendation (2015) – PVR measurement should be routine for assessment of male LUTS
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Assessment of male LUTS
• Health History
• Symptom assessment
• Physical examination
• Urinalysis
• Blood tests
• Uroflowmetry
• Residual urine measurement
• Urodynamic studies
• Ultrasound
• Cystoscopy
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Treatment
• Conservative management (Watchful waiting)
• Drug treatment
• Surgery
– Patient evaluation
– Ability of treatment to change findings
– Treatment preference of patient
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Conservative management
Suitable for patients with mild symptoms and little associated bother
• Life style changes – Limit fluid intake before travelling or bedtime
• Provide assistance
– Access to toilet / mobility / dexterity
• Fluid intake – Caffeine / Alcohol
• Double void technique / bladder retraining
• Management of constipation
• Review medication
• Education/Reassurance/ periodic monitoring
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Drug treatment
• Drug treatment
– α1 Adrenoceptor antagonist
– 5α Reductase inhibitors
– Muscarinic receptor antagonists
– Beta-3 agonists
– Phosphodiesterase 5 inhibitors
– Plant extracts: Phytotherapy
– Combination therapies
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Development of Pathway for nurse led male LUTS assessment at
Letterkenny University Hospital
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Male LUTS pathway
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Male LUTS pathway
GP Uroflow OPD OPD
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Male LUTS pathway
GP Uroflow OPD OPD
18m 2m 3m
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Male LUTS pathway
GP Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
18m 2m 3m
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Male LUTS pathway
GP Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
18m 2m 3m
2m 3m
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Male LUTS pathway
Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
Advanced Nurse led assessment
18m 2m 3m
2m 3m
GP
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Master in Advanced Nursing Practice
Registered Nurse
Prescriber
Registered Advanced
Nurse Practitioner
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Advanced Nurse led
Assessment
Master in Advanced Nursing Practice
Registered Nurse
Prescribing
Registered Advanced
Nurse Practitioner
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Advanced Nurse led
Assessment
Discharge to GP
Prescribe/ Monitor at Nurse led
Clinic
Consultant review at
OPD
Master in Advanced Nursing Practice
Registered Nurse
Prescribing
Registered Advanced
Nurse Practitioner
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Male LUTS pathway
GP Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
18m 2m 3m
2m 3m
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Male LUTS pathway
Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
GP Advanced Nurse led assessment
18m 2m 3m
2m 3m
GP
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Male LUTS pathway
Uroflow OPD OPD
GP Nurse led
assessment +Uroflow
OPD
GP Advanced Nurse led assessment
18m 2m 3m
2m 3m
3m
GP
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OPD Urology schedule @ LUH
• Average clinic = 50 patients
– 20 new GP referrals
– 10 recall appointments
– 10 LUTS patients
– 10 Prostate cancer reviews
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OPD Urology schedule @ LUH
• Average clinic = 50 patients
– 20 new GP referrals
– 10 recall appointments
– 10 LUTS patients
– 10 Prostate cancer reviews
• LUTS patients removed to nurse led clinic
= 20% increase in OPD capacity
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Urology Assessment Clinic 2017
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UAC Referral pathway
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LUTS Assessment