1. COMMUNITY CONTINENCE ADVISORY SERVICE SHIRLEY BUDD CONTINENCE CLINICAL LEAD Continence Assessments 1

2. Aspects of male LUTS Collaborative working with Community Continence Advisory Service (CCAS) Assessment Treatment Management 2

3. Male LUTS 3 LUTS in men increases as men get older. Bothersome LUTS occur in up to 30% of men over 65 years (NICE 2013) Men are as likely as women to suffer from OAB Mostly OAB dry (OAB wet: 16% in men compared to 55% in women) so less likely to seek help.

4. Male LUTS 4 Estimates for severe incontinence in men in their 70’s and 80’s is still only about half of that in women Most men will not seek medical attention for evaluation or treatment due to embarrassment or belief that no effective treatment is available There is a large group of men potentially needing treatment = unmet need

5. Male assessment 5 Assessment of men tends to focus on voiding symptoms 60% of men with LUTS who are under 60 years are not likely to have an enlarged prostate or a history of BPH Approximately 50% of men with BPH also will have detrusor overactivity (DO) when evaluated with urodynamics

6. OAB is a male problem 6 Only 50% of men with preoperative DO will have resolution of DO after outlet reduction surgery Therefore they will have OAB symptoms: Sudden urgency that they cannot deny Possible urgency incontinence Frequency Nocturia

7. 7 It is important to make a correct provisional diagnosis So what can the Community Continence Service offer GP surgeries?

8. Men referred to CCAS 8 Long term conditions: neurological conditions are likely to have an impact on bladder and bowel Diabetes, stroke, MS, MND etc. Dementia related conditions Troublesome bladder symptoms Referrals from urology: Post urological assessment, post radical prostatectomy

9. Assessment of men in the community 9 Adult pathway Collaborative working with GPs and Urology Symptom Profile/SystmOne template Ratified tools: IPSS and ICIQ Patient perception of their problem Bothersome level of symptoms Bladder diaries Treatment options

10. Symptom Profile 10 Ratified assessment tools Quick tick box assessment Identify bothersome symptoms and therefore direction of treatment An opportunity for holistic assessment as people often leave things out such as bowel problems Able to compare before and after treatment and therefore efficacy of treatment Good for short consultation

11. 11 Urine I leak urine when I cough or sneeze I need to wear a pad I go to the toilet frequently I have to go to the toilet to pass urine in a hurry I leak urine before I get to the toilet I am up in the night passing urine at least twice My urine stream is slow I leak urine after I have finished emptying my bladder I can feel dragging or a bulge in my vagina Bowels/stool type My stools are hard I have to strain to pass stools My stools are loose My bowels have changed in the last few months

12. Referrals to CCAS 12 Identify main patient concerns Assessment: Long term conditions and medication fluid type and volume Diet Stool form Bladder diary Urinalysis Examination Bladder scan

13. Urinalysis 13 Urgency often indicates a urine infection If older people do not have bladder symptoms urinalysis is not recommended as they are likely to have some bacteriuria that would not be advisable to treat

14. Urinalysis 14 Early morning sample to prevent possible false negative for nitrites as urine needs to have incubated for 4 hours in bladder Specific gravity: all the parameters are normal so if urine colour doesn’t match dip test reading apply additional assessment options, e.g. bladder diary, fluid intake history, condition of tongue

15. UTI 15 Older people may exhibit different symptoms: Loss of mobility, unsteady on feet Feeling unwell Anorexia, nausea and vomiting Abdominal pain Mental capacity changes Incontinence/worsening incontinence Offensive smelling urine

16. UTI 16 Older people may become acutely ill very quickly: 4 hours In men a UTI is always a red flag condition and should be referred to Urology following assessment

17. Bladder Diary 17 Key assessment information Supports accurate diagnosis Identifies nocturnal polyuria (>third of daily urine output) Identifies Overactive bladder (frequency, urgency, nocturia, small voids). Typical voids from 50mls to 200mls

18. Bladder diaries: frequency and volume measure 18 3 day diary Identify patient bladder patterns objectively Normal: 300 to 500mls voids 7 or 8 voids per day Red flag diaries: very high frequency Normal fluid intake: DoH recommend 2 litres

19. 19 PATIENT ’ S WEIGHT stones kgs MLS FLUID OZ ’ S PINTS MUGS 6 381,190422.14 7451,275492.55 8511,446562.755-6 9571,786633.16 10641,981703.57 11702,179773.757-8 12762,377844.28 13832,575914.59 14892,773984.910

20. 20