More mens bits LUTS Hugh Alberti January 20171

More mens bits… LUTS Hugh Alberti January 20171

Case studies in 2 groups Case 1: Mr G. Land is a 72 year old farmer. He rarely attends. But today he comes to discuss his waterworks. He is asking if anything can help him as getting up at night for a pee is making getting up at dawn to sort the cows out more difficult. Also, he’s fed up having to wipe the toilet clean (or his wife is) every time he has a wee. Where do you go from here? Case 2: Mr I. P. Allott is a 55 year old gentleman, a new patient to the practice. On his first consultation with you he tells you he has had urinary problems getting worse over 2 years since he stopped work. His last doctors couldn’t help him. He has to go all the time, and occasionally doesn’t make it. He gets up frequently at night. Life is intolerable. Groups of 4 5, one person roleplay the patient (with the answers) the others alternate roleplaying the doctor. 2

Overview l How common are the problems? Increases with age; maybe 30 -40% over the age of 50. You will not see all of these people 3

What are L. U. T. S. ? Lower urinary tract symptoms is a term of convenience that encompasses storage, voiding and post-micturition problems. It’s a term and not a diagnosis. 4

L. U. T. S. consists of Storage problems l Voiding problems l Detrusor problems l Retention l Incontinence l 5

Clinical Presentation History of problem l Examination l Exclude other causes l Judicious use investigations l When do we refer? l 6

How the prostate feels Walnut sized Satsuma sized Like the gruffalo’s head 7

N. I. C. E. says • At initial assessment, offer men with LUTS an assessment of their general medical history to identify possible causes of LUTS, and associated co-morbidities. Review current medication, including herbal and over-the-counter medicines, to identify drugs that may be contributing to the problem. • At initial assessment, offer men with LUTS a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE). • At initial assessment, ask men with bothersome LUTS to complete a urinary frequency volume chart. • Refer men for specialist assessment if they have LUTS complicated by recurrent or persistent urinary tract infection, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer. 8

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Management Why treat? l How to treat watchful waiting life style management drug therapy surgery l 11

Intake advice, retraining and urethral milking… 12

Drug Therapies Voiding… l Alpha – 1 selective adrenergic antagonists l 5 alpha – reductase inhibitors l Combination therapy Storage… l Antimuscarinics 13

LUTS: Drug treatment Cause Treatment Review LUTS Alpha blocker 4 -6 w then 6 mly OAB Anticholinergic 4 -6 w then 6 mly LUTS + prostate >30 g 5 ARI (Finasteride) 3 -6 m then 12 mly Bothersome LUTS + >30 g AB + 5 ARI 4 -6 w then 6 mly Unresponsive LUTS Add anticholinergic 4 -6 w then 6 mly

Plus? Remember all drugs only partially effective l BPH not a risk factor for Ca, but Ca may present with LUTS l Nocturnal polyuria – (>35% output) l – ? Late afternoon diuretic ? ? desmopressin l ? Tadalafil for LUTS (“not recommended”) 15

Don’t expect miracles though This would be unlikely 16

Surgical Intervention Surgery is effective l N. I. C. E. has advised which are the best surgical options. l Be cautious though regarding surgery for storage symptoms l A urologist is likely best placed to discuss some of the options l 17

Any questions from the cases… http: //www. bmj. com/content/357/bmj. j 1493 (10 m in consultation LUTS in an older man) 18

References NICE clinical guideline 9 ‘The management of lower urinary tract symptoms in men’ Issue date: May 2010 Benign prostatic hyperplasia. Part 1—Diagnosis, Timothy J Wilt, James N’Dow BMJ 2008; 336: 146 -9. Part 2—Management BMJ 2008; 336: 206 -10 Lower urinary tract symptoms in men. BMJ 2007; 334: 2 Extracts from “Clinical Evidence” Benign prostatic hyperplasia BMJ 2001; 323: 1042– 6 10 minute consultation. Prostatic symptoms Andrew Farmer. BMJ 2001; 322: 1468 Managing urinary incontinence in older people Subashini Thirugnanasothy BMJ 2010; 341: c 3835 19