1. 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

2. Structure of the talk Red flag symptoms & signs & aetiology of LUTS
Presenting symptoms & signs- DRE & PSA
Management of symptoms
Summary

3. Is the patient’s LUTS caused by cancer?
If not what is the cause and can it be treated?

4. 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

5. Underlying causes Prostate enlargement Infections Overactive bladder
Bladder/urethral tumour
Bladder Stones/foreign body
Abdominal operations/spinal problems/rarely growth outside bladder/prostate

8. Basic evaluation History and symptom assessment
Abdominal and Rectal examination
Urinalysis
Serum creatinine and ? PSA
Post void residual volume (PVRV) bladder scan

9. 8-19 moderately symptomatic;
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost all the time
Your score
Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 1 2 3 4 5
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?
None
1 time
2 times
3 times
4 times
5 times or more
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 dissatisfied
Unhappy
Terible
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?
Total score:
0-7 Mildly symptomatic
8-19 moderately symptomatic;
20-35 severely symptomatic 9

10. 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

11. DRE for prostate Normal consistency is rubbery and firm,
with smooth surface and
median sulcus palpable between right & left lobes

12. 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. Accessed 20th May 2010 12

13. 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

16. NICE Recommendations on management of mild or moderate LUTS
Bothersome to the patient, or complicated? No
Yes
Active surveillance?
Give reassurance, offer advice on lifestyle interventions and information on their condition.
Offer review if symptoms change.
Active intervention
Conservative management /
drug treatment or surgery
Offer baseline assessment (eg IPSS)
1. Accessed 20th May 2010 16

17. NICE Recommendations Drug Treatment - LUTS
Moderate to severe LUTS
Offer an alpha blocker
Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30g or PSA greater than 1.4 ng/ml
Consider combination treatment with an alpha blocker and a 5ARI
Offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate.
Take into account comorbidities and current treatment when offering drug treatment for LUTS.
Do not offer homeopathy, phytotherapy or acupuncture.
Consider offering a late afternoon loop diuretic for nocturnal polyuria.
Consider offering oral desmopressin for nocturnal polyuria if other medical causes have been excluded and the man has not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.
If LUTS do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery).
1. Accessed 20th May 2010 17

18. NICE Recommendations Conservative management – storage symptoms
OAB Offer
supervised bladder training
advice on fluid intake
lifestyle advice
containment products (if needed)
1. Accessed 20th May 2010 18

19. NICE Recommendations Drug treatment – storage symptoms
OAB
Offer an anticholinergic
Storage symptoms despite treatment with an alpha blocker alone
Consider adding an anticholinergic
1. Accessed 20th May 2010 19

20. 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 symptoms- refer if no improvement
Anticholinergics for signs of overactive bladder- look for side effects