Lower urinary tract symptoms
(LUTS) in elderly males
Victor Palit
MS, FRCS, MPhil, FRCS (Urol), FEBU, PG
Cert Med Ed, FHEA
Consultant Urological surgeon
University Hospital of North Tees and
Hartlepool & honorary consultant JCUH
Structure of the talk
• Red flag symptoms & signs & aetiology of
LUTS
• Presenting symptoms & signs- DRE &
PSA
• Management of symptoms
• Summary
• Is the patient’s LUTS caused by cancer?
• If not what is the cause and can it be
treated?
Red Flag symptoms & signs
• Blood in Urine
• Predominant symptom- urgency
• Bothersome urinary symptoms not settling
with medication
• Constitutional symptoms- loss of wt, bone
pain
• Significant risk factors- smoker, worked
with chemicals, PMH, FH
• Abnormal DRE & PSA
Underlying causes
•
•
•
•
•
•
Prostate enlargement
Infections
Overactive bladder
Bladder/urethral tumour
Bladder Stones/foreign body
Abdominal operations/spinal
problems/rarely growth outside
bladder/prostate
Basic evaluation
•
•
•
•
•
History and symptom assessment
Abdominal and Rectal examination
Urinalysis
Serum creatinine and ? PSA
Post void residual volume (PVRV) bladder
scan
Incomplete emptying
Total score:
0-7
Mildly
symptom
atic
8-19
moderat
ely
symptom
atic;
20-35
severely
symptom
atic
Over the past month, how often have
you had a sensation of not emptying
your bladder completely after you finish
urinating?
Frequency
Over the past month, how often have
you had to urinate again less than two
hours after you finished urinating?
Intermittency
Over the past month, how often have
you found you stopped and started
again several times when you urinated?
Urgency
Over the last month, how difficult have
you found it to postpone urination?
Weak stream
Over the past month, how often have
you had a weak urinary stream?
Straining
Over the past month, how often have
you had to push or strain to begin
urination?
Not at all
Less
than 1
time in 5
Less
than half
the time
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
None
1 time
2 times
About
half the
time
3 times
More
than half
the time
4 times
Almost
all the
time
5 times
or more
Your
score
Your
score
Nocturia
Over the past month, many times did
you most typically get up to urinate from
the time you went to bed until the time
you got up in the morning?
Total score
Quality of life due to urinary
symptoms
Delighted
Pleased
Mostly
satisfied
Mixed
Mostly
dissatisfie
d
Unhappy
Terible
NICE recommendations for DRE
• Assessment for GI/GU disease
• Screening for colorectal/prostatic disease
SYMPTOMS
• Lower Urinary Tract Symptoms (LUTS)
• Erectile dysfunction
• Low back pain
• Bone pain
• Haematuria
• Unexplained weight loss
• Tenesmus
• Rectal bleeding
• Alteration of bowel habit
DRE for prostate
Normal consistency is
• rubbery and firm,
• with smooth surface and
• median sulcus palpable between right &
left lobes
PSA testing (NICE guidance)
General Overview
• Offer men information, advice and
time to decide if they wish to have a
PSA test if their:
– LUTS are suggestive of bladder
outlet obstruction secondary to
BPE or
– Prostate feels abnormal on DRE or
– Concern is about prostate cancer
1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010
When to request PSA?
•
•
•
•
Bone pain with LUTS
LUTS with constitutional symptoms
Non visible /visible haematuria???
No PSA within 4 weeks of UTI/ urological
operation & pts with catheter
NICE Recommendations on management of mild
or moderate LUTS
Bothersome to the patient, or complicated?
No
Active surveillance?
Give reassurance, offer advice on
lifestyle interventions and information on
their condition.
Offer review if symptoms change.
Yes
Active intervention
Conservative management /
drug treatment or surgery
Offer baseline assessment (eg IPSS)
1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010
NICE Recommendations
Drug Treatment - LUTS
Moderate to severe LUTS
Bothersome moderate to
severe LUTS, and a
prostate estimated to be
larger than 30g or PSA
greater than 1.4 ng/ml
Offer an alpha blocker
Consider combination treatment with an
alpha blocker and a 5ARI
1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010
NICE Recommendations
Conservative management – storage
symptoms
Storage symptoms
OAB
Offer
• supervised bladder training
• advice on fluid intake
• lifestyle advice
• containment products (if needed)
1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010
NICE Recommendations
Drug treatment – storage symptoms
OAB
Offer an anticholinergic
Storage symptoms despite
treatment with an alpha
blocker alone
Consider adding an anticholinergic
1. http://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/English. Accessed 20th May 2010
Summary
• LUTS has multifactorial aetiology- don’t forget
cancer, stones & infections
• Red flag symptoms & signs- haematuria,
urgency, bothersome symptoms not settling with
treatment, bone pain, wt loss, abnormal DRE &
PSA
• Life style changes/Containment device in mild
symptoms if PVRV bladder scan is normal
• Alpha blocker for mild to moderate symptomsrefer if no improvement
• Anticholinergics for signs of overactive bladderlook for side effects