Family Physician's Approach to Lower Urinary Tract Symptoms

Approach to Lower Urinary Tract Symptoms (LUTS) in Males Dr Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital

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

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

Causes of LUTS in males
Bladder
Prostate
Urethra
Infection
Stone
Enlargement
Stricture
Malignancy
Neurogenic
Drugs

Anatomy of BPH Normal BPH Prostate Bladder Urethra Hypertrophied detrusor muscle Obstructed urinary flow

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

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

IPSS / AUA Symptom Score

Estimate size of prostate, Exclude nodule Detect hematuria, pyuria Creatinine

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

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

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

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

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

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

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

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)

Is combination therapy for every patient?
Individualized treatment
Efficacy of treatment v/s side effects
Convenience
Cost
Surgery is still an option

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

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

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

What about the storage symptoms? TRABECULATION FREQUENCY NOCTURIA

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

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)

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

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

Thank you

Family Physician's Approach to Lower Urinary Tract Symptoms

by Siewhong Ho on Oct 26, 2008

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