1. Lower Urinary Tract Symptoms in the Aging Male Ross Moskowitz, MD Resident Physician Atreya Dash, MD Assistant Clinical Professor

2. Objectives Definitions Epidemiology Symptomatology Evaluation Treatment

3. Definitions Benign Prostatic Hyperplasia (BPH) –Refers to a histological finding –No inherent clinical meaning Many men will have BPH but no symptoms –Presence of BPH increases with age

4. Definitions Modern term (more appropriate than BPH or prostatism) is Lower Urinary Tract Symptoms (LUTS) –Removes implication that symptoms have organ specific cause LUTS divided into two categories: –Voiding or obstructive symptoms –Storage or irritative symptoms

5. Definitions International prostate symptom score (IPSS): Validated subjective questionnaire for LUTS Seven symptoms evaluated: Each scored 0-5 –Total score 0-7 Mild; 8-19 Moderate; 20-35 Severe LUTS Bother score: Single concluding question evaluating quality of life with LUTS, heavily weighed when determine whether or not to intervene, scored 1-6 -Weak flow of stream -Intermittency -Difficulty initiating stream -Nocturia -Straining to void -Frequency -Urgency

6. Definitions Bladder Outlet Obstruction (BOO) may develop from progressive BPH and worsen LUTS, especially voiding symptoms Non-invasive uroflowmetry may provide some objective diagnostic data –Patient voids into weighed receptacle to measure volume and rate of flow

7. Definitions Urine flowmetry values: –Max flow rate ≥15 mL/s normal –Between 10-15 mL/s equivocal –Max flow rate < 10 mL/s obstructive –Important: Obstruction may be anatomical (i.e. from enlarged prostate) or functional (i.e. diminished detrusor contractility)

8. Uroflowmetry Examples Normal voiding curveObstructed voiding curve Total Vol: 317ml Max flow: 21ml/sec Total Vol: 122ml Max flow: 4ml/sec

9. The Post Void Residual Measured in mls, elevated in BOO –Should be near zero in normal voiding, but no specific cut-off for an elevated PVR Can either be measured by ultrasound or in/out catheterization Bladder Scanner: ultrasonic machine dedicated to measurement of bladder volume

10. Epidemiology In men > 40 years-old half will develop BPH and increase with age –Prostatic enlargement may progress and lead to BOO –30-50% will have bothersome LUTS –Therefore nearly ¼ male population will develop BPH-related bothersome LUTS

11. Symptomatology Voiding Symptoms –Weak force of stream –Hesitancy –Intermittency –Straining –Terminal dribbling

12. Symptomatology Storage symptoms –Urgency –Frequency –Nocturia –Urge incontinence

13. The Evaluation History & Physical –Include digital rectal exam Assessment of severity of LUTS –At minimum qualitative –Consider International Prostate Symptom Score (IPSS) Labs: Urinalysis and PSA Consider voiding diary with frequency and volume

14. The Evaluation Complicated LUTS  Specialty evaluation referral Indications: –History prostate cancer or elevated PSA –Hematuria –Bladder stones –Bladder cancer –Urethral stricture –Neurologic disease –Prostatitis –Urinary retention –Recurrent UTI –Failed medical therapy or interest in surgery

15. The Evaluation Uncomplicated LUTS Low Bother score –IPSS at office visit(s) –Lifestyle modification –Consider medical management –Reassurance and follow

16. Treatment Uncomplicated LUTS with bothersome symptoms –Review specific symptoms and/or voiding diary –Modify medications, especially diuretics or procholinergics –Modify fluid intake or diet Caffeine, alcohol, spicy/acidic foods can worsen LUTS –Address underlying medical conditions Treat constipation Leg edema: elevation prior to bedtime to treat nocturia –Bladder training –Medical therapy Pursue specialty consultation if above fails

17. Treatment Medical Therapy Alpha adrenergic receptor blockers –Treat bladder outlet obstruction –Dynamic effect on bladder neck and prostate Target alpha adrenergic smooth muscle receptors –Side effects: hypotension, fatigue, dizziness, nasal congestion, ED, abnormal ejaculation –Selective versus non-selective to minimize side effects Selective α1a: tamsulosin and silodosin Non-selective α1: terazosin, doxazosin, alfuzosin

18. Treatment Medical Therapy 5α-reductase inhibitors (5-ARIs) –Treat bladder outlet obstruction by treating enlarged prostate Decreases prostate volume, takes up to six months for maximal effect –Inhibits intraprostatic conversion of testosterone to dihydrotestosterone –Type 1 and 2 isoenzymes –More useful in large prostates > 30 cc size (surrogate of size is ≥ PSA 1.5 ng/mL)

19. Treatment Medical Therapy 5 ARI side-effects –Decreased libido, ejaculatory dysfunction, ED, gynecomastia –Hair growth: finasteride is the same medication, different dose, as Propecia ® Combination therapy –Use of both alpha blockers and 5-ARIs –Better than single drug but more side effects

20. Treatment Medical Therapy Anti-muscarinics –Treats storage symptoms –Better effect in combination with alpha blocker –Bladder has M2 and M3 muscarinic receptors M2 receptors also in salivary glands, CNS, cardiovascular, GI: explains side effects: dry mouth, dry eyes, constipation –M3 selective medications may have fewer side effects than non-selective targeting M2 and M3 M3: darifenacin, solifenacin M2: oxybutynin, tropsium, tolterodine, fesoterodine

21. Treatment Other considerations –Phytotherapy Saw Palmetto (Seranoa repens) ineffective in a randomized trial –Phosphodiesterase 5 inhibitors Some effect in relieving LUTS, besides use in erectile dysfunction Only tadalafil approved –Surgery: Resection, vaporization or removal of prostatic tissue Performed in patients who are appropriate candidates, failed or did not tolerate medical management, and whose quality of life significantly impacted by LUTS

22. Problem based learning (PBL) Cases Here we will present three cases of LUTS with different plans of management based on etiology and severity of symptoms

23. PBL Cases 72 year old male, retired professor, with history of hypertension and diabetes, with complaints of slow urinary stream, frequency, nocturia twice per night, and occasional double voiding No dysuria, no gross hematuria, no incontinence, no history of UTI

24. PBL Cases IPSS: 12 (moderate symptoms), Bother score 3/6 Patient non-smoker, drinks 5 cups coffee per day DRE: 30-40gms, smooth Hgb A1c=8.5, UA negative, PSA 1.33

25. PBL Cases Interventions: –Decrease caffeine intake –Limit fluids after dinner –Improved diabetes control –Patient had already started taking saw palmetto and would like to see how that works

26. PBL Cases 6 month follow up: –IPSS 9, Bother 2/6 –Self discontinued saw palmetto (no improvement) –Decreased frequency and nocturia –Last Hgb A1c 6.4 –Still not satisfied with symptoms –Trial on tamsulosin 0.4mg/daily

27. PBL Cases Next follow up: –IPSS 5, Bother 1/6 –Satisfied with symptom control –No complaints of dizziness or orthostatic hypotension with tamsulosin, but thinks he may be having some retrograde ejaculation –Plan: Continue current management

28. PBL Cases 63 year old male, business executive, with history of low back pain with spinal surgery three years ago, with worsening LUTS, mainly bothered by frequency, slow stream, and double voiding No dysuria, no hematuria, no incontinence, has had one UTI in the past two years

29. PBL Cases IPSS: 25 (severe symptoms), Bother score 5/6 Patient non-smoker, drinks 2 cups coffee per day DRE: 70-80gms, smooth UA negative, PSA 2.8

30. PBL Cases Interventions: Initially started on tamsulosin, with slight improvement of symptoms Few weeks later started on finasteride Patient considering surgical management, but would like to allow medications, specifically finasteride, more time to work Uroflowmetry obtained: –Obstructive voiding pattern, max flow 6ml/s, voided 210cc, 135cc post void residual by ultrasonic bladder scan

31. PBL Cases 6 month follow up: –IPSS 19, Bother 4/6 –Patient tolerating tamsulosin and finasteride, some complaints of decreased libido but still able to get erections –Patient now interested in surgical management Urodynamic study obtained in scenario of spine surgery to differentiate between functional and anatomical obstruction

32. PBL Cases Urodynamics (Cystometrography): –Measure intra-abdominal pressure and intravesical pressure while bladder is filled in a retrograde fashion with a catheter, and having patient then void –Detrusor pressure (bladder squeezing) is calculated by subtracting abdominal pressure from vesicular pressure –Anatomical obstruction will have high detrusor pressure with low voiding rate –Functional obstruction will have low detrusor pressure with low voiding rate

33. PBL Cases This patient confirmed by urodynamics to have high detrusor pressure during slow voiding rate, and so believed to benefit from relieving the anatomical obstruction Patient proceeded with transurethral resection of the prostate (TURP): –Endoscopic operative procedure to widen the prostatic urethral channel

34. PBL Cases Postoperative follow up: –IPSS 8; Bother 2 –Uroflowmetry: Voided 312 cc, max flow rate 17ml/sec, post void residual by bladder scan 36cc –Overall patient very satisfied with LUTS management and has discontinued tamsulosin and finasteride –Postoperative hematuria has resolved, and some urinary urgency has continued to improve –Does have anticipated retrograde ejaculation

35. PBL Cases 69 year old, retired trucker, history of hypertension and hyperlipidemia, with gradually worsening LUTS over past few years, mainly bothered by frequency and strong urgency No dysuria, no hematuria, treated for two UTI in the past few years, rare urinary dribbling with urgency

36. PBL Cases IPSS: 17 (moderate symptoms), Bother score 4/6 Patient smokes 1ppd x 35 years, no caffeine DRE: 50-60gms, smooth PSA 1.7 UA: 15rbc, 3wbc, negative nitrite, positive leukocyte esterase UCx: no growth

37. PBL Cases Interventions: Initially started on tamsulosin with no improvement of symptoms Repeat urinalyses obtained with continued microscopic hematuria Urine cytology obtained, found urothelial cells concerning for malignancy

38. PBL Cases Interventions: Hematuria work-up completed –CT Urogram (includes iv contrast with delayed renal excretory phase) –Urine cytology –Cystoscopy In-office cystoscopy revealed area within bladder velvety red/erythematous

39. PBL Cases Operative intervention: Cystoscopy with biopsy and electrocautery fulguration –Pathology: Carcinoma in-situ (CIS) of the bladder Can present with irritative voiding symptoms Usually initially managed with intravesical agents; refractory or multifocal CIS managed with radical cystectomy

40. References McVary KT, Roehrborn CG, Avins AL et al: American Urological Association Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010. Abrams P, Chapple C, Khoury S et al: Evaluation and Treatment of Lower Urinary Tract Symptoms in Older Men. J Urol 2009; 181: 1779.

41. Thank You