LUTS – A plea for a holistic approach. - Beacon Hospital · LUTS-Classification LUTS can be...
Transcript of 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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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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Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Why do LUTS
occur?Aging
Cardiovascular disease
Obstructive sleep apnoea
Obesity
Metabolic Syndrome
Diabetes
Smoking
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Infections
Neurogenic cause
Reduction in functional abilities
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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!
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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.
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Flow Rates
Pre-op Flow Rate Post Op Flow Rate
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
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
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)
Hubert Gallagher, Mch; FRCSI, FRCSI(Urol)