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Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
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Family Physician's Approach to Lower Urinary Tract Symptoms

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Dr Ho Siew Hong lectured to Family Physicians on 22 Oct 08 at Serangoon Garden Country Club as part of the Continous Medical Education Program

Dr Ho Siew Hong lectured to Family Physicians on 22 Oct 08 at Serangoon Garden Country Club as part of the Continous Medical Education Program

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    • 1. Approach to Lower Urinary Tract Symptoms (LUTS) in Males Dr Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital
    • 2. What is LUTS ?
      • Symptoms described by patient or care-giver
      • 3 groups a. Storage b. Voiding c. Post micturition
      International Continence Society, American Urological Association, European Urological Association
    • 3. LUTS
      • Storage day time frequency, nocturia, urgency, incontinence
      • Voiding slow, splitting, intermittent, hesistancy, straining, terminal dribbling
      • Post micturition sensation of incomplete voiding, post micturition dribbling
    • 4. Causes of LUTS in males
      • Bladder
      • Prostate
      • Urethra
      • Infection
      • Stone
      • Enlargement
      • Stricture
      • Malignancy
      • Neurogenic
      • Drugs
    • 5. Anatomy of BPH Normal BPH Prostate Bladder Urethra Hypertrophied detrusor muscle Obstructed urinary flow
    • 6. Epidemiology of BPH: histological prevalence around the world Adapted from Roehrborn CG, McConnell JD. Etiology, Pathophysiology, Epidemiology, and Natural History of BPH. In: Walsh P, editor. Campbell’s Urology. 8th ed. Philadelphia: WB Saunders Co. 2002. p. 1308 Prevalence (%) 100 80 60 40 20 0 20–29 30–39 40–49 50–59 60–69 70–79 80–89 Age (years) Average Linear average
    • 7. Risk of AUR versus other diseases (60 year old male) 10-year cumulative risk (%) 20 15 10 5 0 AUR Hip fx Hip fx Diabetes Stroke MI (women) (men) Jacobsen S. Urology 2001;58(6A):5
    • 8. IPSS / AUA Symptom Score
    • 9. Estimate size of prostate, Exclude nodule Detect hematuria, pyuria Creatinine
    • 10. Watchful waiting
      • Regular monitoring to avoid the need for therapy
      • Physicians and patients can see if the symptoms improve or deteriorate
      • Watchful waiting is often more suitable for those with low symptom scores which are less bothersome and have a low risk of progression
    • 11. Alpha-blockers
      • Doxasozin (Cardura™)
      • Terazosin (Hytrin™)
      • Alfuzosin (Xatral) R educ es smooth muscle tone of muscle around the bladder neck and the prostate which is under symphathetic nerve control mediated by receptors do not reduce prostate size may delay the occurrence of AUR and BPH-related surgery, they do not reduce the overall risk
    • 12. Alpha-blocker tolerability
      • Majority of side effects are minor and mild
      • Common alpha-blocker adverse events include
        • dizziness/malaise
        • abnormal ejaculation
        • headache
        • asthenia
        • postural hypotension
        • palpitations
        • nausea/gastrointestinal effects
        • nasal congestion
      Walsh PC et al. Campbell’s Urology, 7th Edition. Philadelphia: WB Saunders Co., 1998; Flomax SmPC; Hytrin SmPC; Cardura SmPC; Xatral SmPC
    • 13. Alpha blockers and PDE 5 Inhibitors
      • Warning label in Viagra
      • Similar in Cialis and Levitra
      • May cause a BP change of 7mm Hg if consumed within 4 hours of each other
      • Avoid PDE 5 I within 4 hours of consuming alpha blockers
    • 14. 5 alpha reductase inhibitor
      • Finasteride (Proscar TM )
        • inhibitor of type 2
      • Dutasteride (Avodart TM )
        • inhibitor of both type 1 and type 2
      • Avodart TM is 2.5x more potent against type 2 isoenzyme than finasteride
      Structural compression Testosterone DHT + Androgen receptor 5 alpha reductase Prostate Tissue
    • 15. Primary endpoint: Mean change in IPSS from baseline Roehrborn et al . J Urol (In Press) -7 -6 -5 -4 -3 -2 -1 0 0 3 6 9 12 15 18 21 24 Treatment month Adjusted mean change in IPSS from baseline (ITT, LOCF) p<0.001 combo vs . tam p<0.001 combo vs . dut Tamsulosin -4.8 -4.5 -4.4 -4.3 -4.5 -4.4 -4.7 -4.5 Dutasteride -2.8 -3.4 -4.0 -4.2 -4.8 -4.9 -5.0 -4.9 Combination -4.8 -4.8 -5.4 -5.6 -6.0 -6.0 -6.2 -6.2
    • 16. Secondary endpoint: Mean change in Qmax from baseline Roehrborn et al . J Urol (In Press) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 0 6 12 18 24 Treatment month Adjusted mean change in Qmax (mL/sec) from baseline (ITT, LOCF) p<0.001 combo vs . tam p<0.006 combo vs . dut 1.2 0.9 1.1 0.9 Tamsulosin Dutasteride 1.5 1.8 1.9 1.2 Combination 2.0 2.0 2.3 2.4
    • 17. Drug-related adverse events Roehrborn et al . J Urol (In Press) 1.0% 1.2% 1.4% 1.6% 1.7% 1.8% 2.4% 3.4% 4.2% 7.4% Combination (n=1610) 1.0% 0.6% 1.8% 0.7% 1.3% 0.3% 0.5% 2.8% 0.6% 6.0% Dutasteride (n=1623) 0.3% Breast tenderness 0.3% Nipple pain 0.8% Breast enlargement 1.7% Dizziness 0.9% Loss of libido 0.8% Semen volume decreased 0.8% Ejaculation failure 1.7% Altered (decreased) libido 1.1% Retrograde ejaculation 3.8% Erectile dysfunction Tamsulosin (n=1611)
    • 18. Is combination therapy for every patient?
      • Individualized treatment
      • Efficacy of treatment v/s side effects
      • Convenience
      • Cost
      • Surgery is still an option
    • 19. Surgery
      • Surgery may be recommended for patients who fail to respond to medical treatment or as first-line therapy
      • TURP ( transurethral resection of the prostate)
        • the most common surgical treatment
        • the ‘gold standard’ of surgical procedures
        • most patients experience symptom improvement, but postoperative complications (e.g. retrograde ejaculation) may occur
      Benign Prostatic Hyperplasia: Diagnosis and Treatment, Clinical Practice Guideline, No. 8, US Department of Health and Human Services, Publication No. 94-0582, February 1994
    • 20. Postoperative complications
      • Retrograde ejaculation (>70%)
      • Urinary incontinence (1%)
      • Bladder neck contracture (1–2%)
      • Urethral strictures (2–20%)
      • Erectile dysfunction (10–20%)
      • Repeat surgery (2%)
      • Bleeding , transfusion (<5%)
      • Transurethral resection syndrome ( <1 %)
      Benign Prostatic Hyperplasia: Diagnosis and Treatment, Clinical Practice Guideline, No. 8, US Department of Health and Human Services, Publication No. 94-0582, February 1994 Mebust et al. J Urol 1989;141:243
    • 21. Other surgical options
      • Plasma kinetic TURP - isotonic solution - decreases risk of TUR syndrome - better hemostasis, shorter duration of wash out
      • Laser prostatectomy - ablation, resection - less bleeding, better hemostasis
    • 22. What about the storage symptoms? TRABECULATION FREQUENCY NOCTURIA
    • 23. Management of Storage symptoms
      • Up to 50% of patients have day time frequency and nocturia
      • Maybe main symptoms in many situations
      • Storage symptoms increases in aging bladder
      • Generally improves with obstruction relief (alpha blockers or reductase inhibitors), but may take a long time
    • 24. Role of Anti-cholinergics in LUTS with significant storage symptoms
      • Detrusitol, Ditropan (Oxybutinin)
      • Used in conjunction with alpha-blockers in suspected prostatomegaly
      • Single agent therapy in suspected Overactive bladder - younger persons (<50 years old)
    • 25. Anti-cholinergic caution
      • Generally, side-effects are minimal with selective anti-cholinergic agents
      • Dry mouth, constipation, mild giddiness
      • Risk of urinary retention in elderly men with untreated prostatomegaly
    • 26. Take home message
      • Etiology of LUTS in males – mix bag
      • BPH / prostatomegaly predominates in older men
      • BPH can be effectively managed by the family physician
      • Management of storage symptoms are just as important
    • 27. Thank you

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