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LUTS

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.

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LUTS

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  1. LUTS Shawket Alkhayal Consultant Urological Surgeon Benenden Hospital Tunbridge Wells Nuffield Hospital

  2. 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.

  3. 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

  4. Voiding Symptoms • Weak or intermittent urinary stream • Hesitancy • Straining • Sense of incomplete emptying • Terminal dribbling

  5. Storage Symptoms • Frequency • Urgency • Urge incontinence • Nocturia • Enuresis

  6. 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)

  7. Examination • General examination • Examination of the abdomen • External genitalia • Digital Rectal Examination (DRE)

  8. 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

  9. Conservative ManagementStorage Symptoms • Bladder training for OAB symptoms • Advice on fluid intake • Lifestyle advice • Containment products if they are incontinent

  10. Drug Therapyfor 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

  11. 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

  12. Specialist Assessment • History review • Examination including DRE • Bladder diary • IPSS • Flow test and check residual volumes

  13. 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

  14. Urodynamic Assessment • Predominantly storage symptoms • Men under 40 or over 85 • Previous pelvic surgery • Neurological disease

  15. Cystoscopy • Recurrent infection • Sterile pyuria • Haematuria • New storage symptoms • Bladder pain • Dysuria

  16. Imaging of the Upper Urinary Tract • Chronic retention • Haematuria • Recurrent infection • Sterile pyuria • Profound symptoms or pain

  17. 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

  18. Management of OABif 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

  19. New treatments • PDE5-inhibitors (Tadalafil 5mg) for patients with LUTS and ED • Beta 3 agonist (Mirabegron) for OAB • PTNS- for OAB symptoms

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