Dr Imran Cheema
ST3
19/10/2010
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Lower Urinary Tract Symptoms.
History taking & use of IPSS.
Differential diagnosis of LUTS.
Examination and Investigation.
Management of BPH.
PSA request and counselling.
Prostate cancer.
Prostatitis and its Management.
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Obstructive
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Poor stream, Hesitancy,
Terminal Dribbling,
Incomplete Bladder Emptying,
Overflow Incontinence
Irritative
Frequency, Nocturia,
 Urgency, Dysuria
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Describes difficulty starting and stopping when
urinating with a poor stream.
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Compelled to void again soon after going.
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Getting up during night average 3x.
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PMH – Hypertension.
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What else would you like to know?
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Assess symptoms & severity.
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Assess impact on quality of life.
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Identify other causes of LUTS.
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Identify complications.
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Identify co-morbidities that may complicate
treatment.
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6/12 Hx gradual worsening symptoms.
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Worries when out & about – always looking for
toilet.
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No dysuria or haematuria.
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No Hx of incontinence.
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Thinks is part of ageing!
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DH – Amlodipine 5mg.
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Objective measurement to grade symptoms.
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Useful to quantify severity, help to choose
appropriate treatment & monitoring response.
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Mild = 0-7, Moderate = 8-19, Severe 20-35.
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Only 20% of GPs use this.
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Should we be using it more often?
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Causes of Outflow Obstruction:
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BPH, Urethral Stricture, Severe Phimosis,
Idiopathic Bladder Outlet Obstruction,
Bladder Neck or Sphincter Dyssynergia.
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Inflammatory Conditions:
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UTI, Bladder Stone, Prostatitis,
Interstitial Cystitis.
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Neoplastic:
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Bladder or Prostate Cancer.
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Bladder Storage Disorders:
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Overactive Bladder Syndrome,
Underactive Detrusor.
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Neurological Conditions:
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MS, Parkinson’s, CVA
Conditions causing Polyuria:
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Diabetes, Congestive Cardiac Failure.
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What would you like to do?
DRE – anal tone, size of prostate &
abnormalities (hard, nodular, irregular, or fixed
= carcinoma vs. smooth & regular)
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Focused neurological examination.
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Abdominal examination.
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Distended palpable bladder or other causes e.g.
abdominal/pelvic mass
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PSA – more on this later!
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Urinalysis:
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Renal function tests:
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Exclude UTI, Haematuria, Glucose.
All patients presenting with LUTS.
If renal impairment needs Renal USS
to check for hydronephrosis.
Flow rate studies:
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Can be helpful to confirm diagnosis,
objectively measure severity,
monitor response to treatment.
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You diagnose mild BPH with no complications,
what treatment option(s) will you discuss?
Watchful Waiting:
As not severely troubled by symptoms.
 Advise reducing fluid intake particularly caffeine
& alcoholic drinks.
 Review medications e.g. diuretics
 Preventing constipation
 Advise to return if symptoms deteriorate
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Aims of treatment are:
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Relieve symptoms.
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Improve quality of life.
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Attempt to prevent progression of disease
& development of complications.
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Symptoms worsened.
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Embarrassing episodes of urge incontinence.
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Worries about leaving the house.
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Wants to try medical therapy now.
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He has heard of using saw palmetto & wants to
know if this is ok to try.
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What can we offer him?
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Alpha antagonists = 1st line.
Work by relaxing smooth muscle in prostate &
reduces urinary outflow resistance.
Benefits:
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Act rapidly usually 48hrs, symptomatic relief
immediately noticeable.
70% respond to treatment, expected in 3/52.
Evidence:
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Many RCT & systematic review – similar efficacy
between drugs & formulations.
Choice dependant on tolerability & those with preexisting cardiovascular co-morbidity or comedication.
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Side effects:
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Cardiovascular – postural hypotension, dizziness, headaches.
GU – failure of ejaculation.
CNS – somnolence, dizziness.
Compliance better with newer once daily sustained
release e.g. Flomax MR, Xatral XL.
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No effect on prostate volume.
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Recommendations:
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Suitable for moderate-severe LUTS, low risk of disease
progression.
Tamsulosin has best cardiovascular side effect profile = 1st line.
Alfuzosin.
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Reduces production of dihydrotestosterone
& arrests prostatic hyperplasia.
Two licensed for use in UK.
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Similar clinical efficacy & safety profile.
Warn patients that shrinkage takes time – 6/12
& no noticeable symptom improvement for
this period.
Side effects:
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Finasteride (Proscar)
Dutasteride (Avodart)
ED, loss of libido, ejaculatory disorders, gynaecomastia, breast
tenderness.
Recent drug alert issue – link to male breast cancer.
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Recommendations:
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Suitable for moderate-severe LUTS & obviously
enlarged prostate & those more likely to have
progressive disease.
NB – reduces PSA levels by half – need to
adjust when interpreting results for suspected
prostate cancer.
Risk factors for disease progression
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Age >70yrs, IPSS >7, Prostate volume >30mls, PSA
level >1.4ng/ml, QMax <12ml/s, Post void RV
>100mls.
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For those patients with increased risk of
disease progression & symptomatic.
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Increased side effects.
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Remember the saw palmetto:
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Is a plant extract.
Others: Pumpkin seeds, stinging nettle root, cactus
flower extracts, South African star grass, African
plum tree.
Currently NOT recommended (be aware of
Oxford Handbook of GP).
Advise patient:
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Although some evidence in studies shows benefits
LUTS, it has not undergone same scrutiny for
efficacy, purity or safety.
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Presents with painful inability to pass urine.
Has tried several times to go without success
since last night.
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No Hx of voiding difficulties.
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No back pain/sciatica.
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Has been constipated last few days.
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PMH – Osteoarthritis.
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He has a palpable bladder.
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DRE – large prostate, normal perineal sensation
& anal tone.
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Acute urinary retention.
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This is urological emergency.
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Admit for catheterisation.
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Based on NICE guidelines.
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Urgent if:
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Soon:
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Acute or chronic urinary retention.
Renal failure.
Any suspicion of neurological dysfunction.
Haematuria – see next presentation.
Suspected malignant prostate.
Recurrent UTI.
Routine:
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Unclear diagnosis.
No improvement on initial medical therapy.
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Presents with wife requesting PSA test.
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No symptoms.
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Concerns as advancing age.
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Has friends in USA of similar age that are
screened for prostate cancer annually.
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Asking if similar NHS screening programme.
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PMH: Hypertension, low back pain.
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Back to basics – history & examination.
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Ask about LUTS, sexual dysfunction, ICE(!)
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Red flags:
Weight loss, bone pain, haematuria.
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DRE:
Hard, irregular prostate, loss of sulcus,
palpable seminal vesicle.
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He is concerned about prostate cancer.
Because there is a family Hx.
Assessing risk:
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If one 1st degree relative <70yr: RR 2.
Two 1st degree relatives (one of them) <65: RR 4.
Three or more relatives: RR 7-10.
Risk factors:
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Increasing age (85% diagnosed >65yrs).
Ethnicity: highest rates in black ethnic group (lowest
Chinese).
Diet: Evidence that high in dairy products & red
meat linked to increased risk.
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There is no prostate screening programme in
the UK.
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Men can request a PSA test.
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www.cancerscreening.nhs.uk = good website
with pt info leaflet.
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What is prostate cancer?
Gland lies beneath bladder
 Each
yr 22,000 men are
diagnosed with prostate cancer
 Rare in men <50yrs
 Average age of diagnosis is
75yrs
 Slow growing cancers are more
common than fast growing
ones –no way of telling
between two
 May not cause symptoms or
shorten life
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What is the PSA test?
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Blood test.
Many causes of raised levels.
2/3 of men with raised PSA do NOT have cancer.
May lead to unnecessary anxiety and further
investigations when no cancer is present.
Can provide reassurance if normal.
May miss diagnosis too (false reassurance).
Does not distinguish between aggressive and nonaggressive tumours.
May detect early stage of cancer when treatments
could be beneficial.
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If raised, examine to check prostate or repeat
test in few months.
If referral to specialist:
Prostate biopsy (TRUS).
 Complications: uncomfortable, bleeding & infection.
 2 out of 3 men who have prostate biopsy will not
have prostate cancer.
 However, biopsies can miss some cancers.
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Treatment options:
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Depends on classification (localised to prostate,
locally advanced, metastatic).
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No strong evidence to suggest treatment of
localised cancer reduces mortality.
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Main treatments have significant side effects &
no certainty that treatments will be successful.
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Before PSA men should not have:
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Active UTI (wait 1/12).
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DRE (in previous week).
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Recent ejaculation (previous 48hrs).
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Vigorous exercise (previous 48hrs).
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Prostate biopsy (previous 6/12).
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A good screening test should fulfil WilsonJungner Criteria (1968, WHO).
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The only criterion met = prostate cancer is
important health problem.
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No good understanding of natural history of
condition, no acceptable level of sensitivity or
specificity of test, no clear demonstrable benefit
of early treatment.
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No means to detect which ‘early’ cancers
become more widespread.
More men would be found with prostate
cancer than would die or have symptoms from
it.
Not clear if early treatment enhances life
expectancy.
No strong evidence that PSA testing reduces
mortality from prostate cancer.
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PSA = 4.5 ng/ml.
DRE – hard craggy prostate.
What will you do?
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2WW referral:
 DRE: hard irregular prostate typical of prostate cancer.
Include PSA result with referral.
 DRE: normal prostate, but rising/raised age-specific PSA
with or without LUTS.
 Symptoms & high PSA levels.
 Asymptomatic men with borderline age-specific PSA rpt test
after 1-3 mo. If still rising refer.
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Age-related referral values for total PSA levels recommended by the
Prostate Cancer Risk Management Programme.
Age
50–59
60–69
70 and over
PSA referral value (ng/ml).
≥ 3.0
≥ 4.0
> 5.0
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His Gleason score = 7
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What does this mean?
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Moderate chance of cancer spreading
Gleason score characterises prostate cancers on
basis of histological findings.
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Used with T part of TNM staging to stratify
risk of risk of progression.
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Watchful waiting:
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Low risk patients.
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Monitoring with annual PSA/rectal examination.
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Increase in PSA or size of nodule triggers active
treatment.
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Active surveillance:
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Low or intermediate risk, localised prostate cancer.
PSA surveillance & at least one re-biopsy.
Treatment of choice if estimated life expectancy of
<10yrs.
Radical prostatectomy:
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Intermediate & high risk.
Potential for cure, but up to 40% have evidence of
incomplete tumour removal.
Complications: impotence, incontinence.
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Radical radiotherapy
radiotherapy:
&
external
beam
Aims to achieve cure, but persistent cancer found in
30% on biopsy.
 Short term side effects: bladder & bowel related
(dysuria, urgency, frequency, diarrhoea).
 Long term side effects: impotence, incontinence,
diarrhoea & bowel problems, occasional rectal
bleeding.
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Brachytherapy.
Hormone therapy:
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In conjunction with radiotherapy or following
surgery.
LHRH analogues e.g. Goserelin: given by
subcutaneous injection every 4-12 wks.
 Side effects: Impotence, hot flushes, gynaecomastia, local
bruising, infection around injection site.
 When starting LH initially increases causing ‘flare’ –
counteracted by prescribing anti-androgens e.g. flutamide for
few days prior to administering LHRH & for first 3/52.
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Anti-androgens can be used as monotherapy.
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Bony metastases:
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1st line LHRH or bilateral orchidectomy.
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If hormone refractory.
 MDT: palliative care as needed.
 Chemotherapy.
 Corticosteroids.
 Spinal MRI.
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Bisphosphonates.
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All
patients
should
be
offered
phosphodiesterase
type
inhibitors
e.g.
sildenafil for impotence.
5 yrly flexible sigmoidoscopy to look for bowel
cancers following radiotherapy.
Hot flushes can be helped with short blasts of
progesterones (2wks).
PSA should be checked annually in primary
care once pt stable for at least 2yrs (discharged
from hospital).
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Presents with Dysuria,
Frequency &
Urgency symptoms.
Feverish.
Low back pain.
Supra-pubic pain.
Perineal pain.
Painful to open bowels.
PMH: Type 2 Diabetes, Angina.
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UTI.
Acute prostatitis.
Urethritis.
Cystitis.
Pyelonephritis.
Acute epididymo-orchitis.
Local invasion from prostate, bladder or rectal
cancer.
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Temp 37.8
Abdomen – soft, tender suprapubic, no loin
tenderness.
Urine dipstick +ve leucocytes & nitrites.
DRE – Tender prostate.
You diagnose acute prostatitis & discuss with
urology for urgent referral.
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Start antibiotics immediately (whilst waiting
MSU results):
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Ciprofloxacin 500mg BD.
Ofloxacin 200mg BD.
Treat for 28 days (prevent chronic prostatitis).
If neither above tolerated, trimethoprim 200mg BD
for 28 days.
Quinolones or trimethoprim effective in most
of likely pathogens & high concentrations in
prostate.
If unable to take oral Abx or severely ill –
admit.
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Treat pain:
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Paracetamol +/- ibuprofen = 1st line.
If severe offer codeine.
If defecation painful offer stool
recommended: lactulose or docusate.
softener
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Advise to seek medical advice if deteriorates.
Reassess in 24-48hrs:
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Review culture results & ensure appropriate Abx.
Refer to urology if not responding adequately to
treatment, consider prostate abscess.
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Potentially serious bacterial infection
prostate.
Urinary pathogens = culprits commonly:
Gram –ve organisms e.g. E.coli, proteus
klebsiella, pseudomonas.
 Enterococci.
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of
sp,
Accompanied
by
UTI,
occasionally
epididymitis or urethritis.
Not sexually transmitted.
Can follow urethral instrumentation, trauma,
bladder outflow obstruction, dissemination of
infection from elsewhere.
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Admit:
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Urgent:
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If acute urinary retention, will need suprapubic
catheterisation.
Deteriorating symptoms despite appropriate Abx,
need to exclude prostatic abscess (transrectal USS or
CT).
If pre-existing urological condition e.g. BPH, or
indwelling catheter.
Immuno-compromised or diabetic.
Consider
referral
when
recovered
–
investigation to exclude structural abnormality.
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6/12 later he returns with continuing pain in
perineum.
Also complains of painful ejaculation affecting
relationship.
Still getting some LUTS – mainly frequency,
urgency and poor stream.
General aches in pelvis – fluctuates, deep, and
sometimes in lower back.
Tired, getting him down.
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Physical examination.
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Exclude other diagnosis.
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DRE: diffusely tender prostate.
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Urine culture.
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Consider PSA – more on this later.
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Prostatic
massage
primary care.
not
recommended
in
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Characterised by at least 3/12 of pain in
perineum or pelvic floor.
Often with LUTS.
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And sexual dysfunction.
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ED, painful ejaculation, post-coital pelvic discomfort.
Can be divided into 2 types.
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Dysuria, frequency, hesitancy & urgency.
Chronic bacterial = 10%
Chronic pelvic pain syndrome = 90%
Management in primary care not dependent on
classification.
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Assess severity of pain, urinary symptoms &
impact on quality of life.
Reassurance not cancer & not STI.
Trend is for symptoms to improve over
months-years.
If defecation painful: offer stool softener.
Consider trial of paracetamol +/- ibuprofen for
1/12.
If Hx of UTI (or episode of acute prostatitis) in
last 12 mo consider single course of antibiotic.
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Quinolones for 28 days, or trimethoprim where not
tolerated.
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Refer cases to urology.
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Can start Abx whilst awaiting review.
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Urologist may consider trial of alpha blocker
for 3/12.
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Consider chronic pain specialist referral.
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BMJ Learning modules: Benign Prostatic Hyperplasia, Prostate cancer risk
management. Accessed via www.learning.bmj.com
Clinical Knowledge Summaries on BPH, acute & chronic prostatitis.
Accessed via www.cks.nhs.uk
GP notebook. Accessed via www.gpnotebook.co.uk
Oxford Handbook of General Practice 2nd Edition
Department of Health. Prostate cancer risk management programme: PSA
Testing
in
Asymptomatic
Men.
Accessed
via
www.cancerscreening.nhs.uk
Prostate Cancer. InnovAiT, Vol 1, No. 9, pp. 642-650, 2008
GP Update Handbook (login access courtesy of Joanna Blyth) via
www.gp-handbook.co.uk
Patient UK – leaflets for patients www.patient.co.uk
Management of prostatitis. BASHH 2008 guidelines. Accessed via
www.bashh.org
UK prostate link www.prostate-link.org.uk
Prostate cancer charity www.prostate-cancer.org.uk
Prostate cancer support association www.prostatecancersupport.co.uk