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Lower Urinary Tract Symptoms (LUTS) and Management of Benign Prostatic Obstruction. Julian Mander. Old Terminology. “ Prostatism ” = any voiding symptoms Rx TURP all men with LUTS
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13.6% impotent Practice Guidelines )
73.4% retrograde ejaculation
3.1% urethral stricture
0.5 - 3.3% mortality <90 days
outcomes of new diagnostic terminology and therapeutic approaches.
Benign prostatic obstruction
Malignant prostatic obstruction
Stones and bladder cancer
Bladder neck dyssynergia
External sphincter dyssynergia (neuro)
Primary bladder pathology
Inflammatory - UTI and prostatitis
Neoplastic - Bladder cancer and CIS
Secondary to extravesical influence
Bladder outflow obstruction - (BOO)= BPO, Urethral stricture, MPO
Stones upper urinary tract
Abrams et al World J Urol 1989; 6: 233 - 453
New words for old: lower urinary tract symptoms for
“Prostatism” Abrams Br Medical J 1994; 308 929 - 30
6/11 failed to account for age as confounding factor
75% Australian GPs surveyed one year after guidelines published said patients expected PSA testing if they had LUTS c/f if they had no LUTS.
50% GPs surveyed in 1999 support PSA screening in men with LUTS.
Attempts to define BOO on flow rate<10 ml/sec max, post void resid volume>80ml and IPSS.
Lepor “The Pathophysiologyof LUTS in the Aging Male Population” BJU 1998 81 Suppl 1 29-33
Involves smooth muscle activity, or other neurological elements affected by alpha- blockers ?sensory input ?bladder alpha1D receptor input
40% BPH is smooth muscle JUrol1982 - 40% alpha tone, 53% static obst.
TURP helps symptoms from BPO = problem bladder neck, prostate
Nocturia x1 50s from Abrams, Bristol
x2 60s Note nocturnal polyuria = >35% total urine output during sleep look for
x3 70s medical cause.
Peak age for BPO symptoms is 63 years, with many spontaneously
resolving over future years.
Typically BPO symptoms are quite variable in severity, worse during the
night and in cold weather
Small group not responding or shortlived response to alpha blockers generally have middle lobe enlargement, representing true mechanical obstruction, generally leading to TURP surgery - recent BJU study SX correlate more with extent of intravesical prostate seen on U/S c/f size prostate or residual volume
Over the past month Not at Less than Less than About half More than Almost Your
how often have you.. All 1 time in 5 half the time the time half the time always score
1. had the sensation of not emptying your 0 1 2 3 4 5
bladder completely after you finished urinating?
2. had to urinate again less than two hours 0 1 2 3 4 5
after you finished urinating?
3. stopped and started again several times when 0 1 2 3 4 5
4. found it difficult to postpone urination? 0 1 2 3 4 5
5. had a weak urinary stream? 0 1 2 3 4 5
6. had to push or strain to begin urination? 0 1 2 3 4 5
And finally.. None Once Twice 3 times 4 times 5 times
7. Over the past month, how many times did you typically get 0 1 2 3 4 5
up to urinate from the time you went to bed at night until the time you got up in the morning?
Add up your score and write it in the box TOTAL
0 -8 mild symptoms 8 - 19 moderate symptoms 20 - 35 severe symptoms
MSU (or urinalysis) everyone with LUTS
U/S urinary tract NB appearance/size prostate meaningless
NB residual inaccurate if bladder is overdistended
Flexible cystoscopy if significant irritativeLUTS and considering non surgical therapy, to
rule out bladderneoplasm.
Serum creatininenotuseful unless kidneys abnormal on U/S
Videourodynamics if considering surgery with possible neuropathic component
e.g. Parkinsons disease or post stroke LUTS
Bladder diary useful where problem may be polyuria, esp diabetics( > 3 li/24 hours)
Urine flow rates unhelpful
IPSS unhelpful generally - research tool
usually 500 – 1,000 ml +/- impaired renal function.
2) Retention, usually after failed TOV on medical therapy.
1) Reason for presentation - generally fear of cancer related to media misrepresentation - DRE and informed
consent for PSA test.
2) LUTS ? Obstructive or irritativeLUTS leading to correct investigation and diagnosis.
3) Diagnose BPO - MSU and U/S probably adequate unless frank haematuria or marked irritative symptoms =
4) Decision to treat is determined by the patient, given degree of “bother” vsrisk/benefit of treatment strategies.
5) Alpha blockers or Phytoestrgen trial of medical therapy is initially appropriate.
6) Failed medical therapy - refer for surgical management.
suggestion that reduced SE due to slower absorption of tamsulosin.
increased peak flow 2.0 - 4.8 ml/sec over baseline
before the days of symptom scores, deemed effective treatment BPO
5/6 studies showed benefit over placebo by symptom score
5/6 studies showed improved flow rates c/f placebo
1 study showing similar improvement in symptom score c/f prazosin
Wilt et al J Urol 2002; 167: 177-183
Non competitive inhibitor of type I 5-alpha reductaseuncompetitively inhibits type II isoenzymeof
5-alpha reductase (c/f dutasteride- selective competitive inhibitor type II 5-alpha reductase).
“Saw Palmetto for the Treatment of Men with Lower Urinary Tract Symptoms”
Gerber J Urol 2000; 163: 1408 - 1412
mixture of phytosterols.
interference prostaglandin synthesis.
standardization of preparations.
Beta sitosterol for the treatment of benign prostatic hyperplasia: a systematic review Wilt et al BJU 1999; 83: 976-983
8.1 cm reduction detrusor pressure at max flow
1.1 ml/sec improvement in max flow rate
22.8% reduction in prostate volume
Improvement greater in prostates > 40 gm Abrams et al J Urol 1999; 161: 1513
benign prostatic hyperplasia where treatment is initiated by a urologist”
benign prostatic hyperplasia where treatment has been initiated by a urologist”.
take > one year.
generally precipitated by physical activity.
retrospective study published 1998. Seiberet al J Urol 1998; 159: 1232- 1233
group within one year Vs 14% in finasteride treated group.
Foley et al J Urol 2000; 163: 496
decrease in the microvessel density of prostatic suburethraltissue.
Pareeket al J Urol 2003; 169(1): 20-23
Risks: 1% incontinent , 13.6% impotent, 73.4% retrograde ejaculation, 3.1% urethral stricture, 2% blood transfusion,
0.5 – 3.3% mortality < 90 days (Mconnell 1994 USA GovtClinical Practice Guidelines).
relatively high risk of incontinence, up to 20%. (Alternative IDC)
JAMA 1988; 259: 3018)
TUMT trans urethral microwave thermotherapy
TUNA trans urethral needle ablation
HIFU high intensity focused ultrasound
Laser prostatectomy - Coagulation VLAP +/- contact vaporize
Resection Holmium YAG (= TURP)
Now “GreenLight” (KTP) and Thulium laser
TUVP trans urethral vaporization = electrocautery 200W spiked rollerball
but power limited by fibre to 80W or 100W.
KTP = potassium-titanyl-phosphate laser 532 nm wavelength
AMS now refined with water-cooled MoXy side-fire fibre delivering 180W power from
XPS laser machine. MoXywatercooled fibres expensive.
Vaporise or resect.
N Saline irrigant so no glycine toxicity risks.
Relatively good haemostasis.
150W laser either reusable end-fire fibre or single use side-fire fibre.
Holmium-chromium-thulium triple-doped Yttrium aluminium garnet (Ho:Cr:Tm:YAG, or Ho,Cr,Tm:YAG) is an active
laser medium material with high efficiency.
Single-element thulium-doped YAG (Tm:YAG) lasers operate between 1930 and 2040 nm. The wavelength of thulium-based lasers is very efficient for superficial ablation of tissue, with minimal coagulation depth in air or in water. This makes thulium lasers attractive for laser-based surgery.
Max flow improved 11.8 to 15.9 ml/sec
Residual improved 80.2 to 48.5 ml
Yang et al J Urol 2002; 168: 571-574
70.3% improvement in IPSS post TUIP vs 75% post TURP, no difference
in improvement of flow rates.
Less morbidity, esp less bleeding intra and post op, shorter stay
Dorflingeret al Scand J UrolNephrol 1992; 26(4): 333-8
TURP or radical prostatectomy.
Do not do PSA tests in men with acute LUTS.
Rx with antibiotics that work in the prostate – Trimethoprim or Fluoroquinolones (Norfloxacin).
Pain can be present in the perineum, testicles, tip of penis, pubic or bladder area.
Pain may radiate to the back and rectum, making sitting uncomfortable.
Pain can range from mild to debilitating.
Post ejaculatory pain is common.
LUTS commonly associated irritative +/- obstructive.
Sexual dysfunction is common, along with fatigue and depression.
Bacterial infection excluded in an important 2003 study by Lee and Berger Uni Washington.
Wide range of theories:
1. Stress-driven hypothalamic-pituitary-adrenal axisdysfunction.
2. Neurogenic inflammation }
3. Myofascial pain syndrome }
In the last 2 categories 2) and 3), dysregulationof the local nervous system due to past trauma,
infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to
inflammation that is mediated by substances released by nerve cells (such as substance P).
The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become
inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the
Crossover with or differential diagnosis with “interstitial cystitis” is in play.
No distinct objective test.
Peak incidence in men 35 – 45 years age range.
Categorization as “Inflammatory” or “Non-inflammatory” CPPS based on the levels of pus cells in
expressed prostatic secretions (EPS), but these categories are of questionable clinical use.
1) Inflammatory (Category Ⅲa) EPS has WBC
2) Non-inflammatory (Category Ⅲb) EPS has no WBC
Recent studies have questioned the distinction between categories Ⅲa and Ⅲb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.
Prostate massage - common treatment 30 or 40 years ago, no data.
Alpha blockers - especially if LUTS or pain with ejaculation, suggesting BND causative.
Amitriptyline - especially if bladder pain (interstitial cystitis), but do MSU and urine cytology.
NSAIDs - mixed reports
Psychological therapy - treat secondary depression
“paradoxical relaxation” (Jacobsen)