The symptoms and management of lower urinary tract symptoms (LUTS) in men

1. The symptoms and management of lower urinary tract symptoms (LUTS) in men Gillian Nottidge Continence nurse specialist

2. Objectives • Understand function of the prostate • Discuss urinary symptoms in men • Understand prostate related problems • Treatment and management

3. Some statistics • LUTS are a major burden for the ageing male population. The prevalence of LUTS increases as men get older(NICE 2010) • 90% of men aged 50 to 80 years suffer from potentially troublesome LUTS (NICE 2010) • Histological disease (BPH) is present in 60% of men over 60 years (Kirby & McConnell 2002)

4. LUTS • One should remember the ancient Chinese proverb that the ‘bladder is the mirror of the soul’ and that LUTS can result from not only bladder dysfunction or prostatic pathology but also from a number of other pathophysiological processes, e.g., metabolic, hormonal, cardiac, and respiratory. This avoids a local prostate focused approach. (Chapple 2010) • Aiming for patient-centred care

5. Voiding symptoms Slow stream Splitting or spraying Intermittent stream Hesitancy Straining Terminal dribble Incomplete emptying (NICE 2010) LUTS

6. LUTS Post-void symptoms • Post-micturition dribble • Feeling of incomplete emptying Storage symptoms • Urgency • Frequency • Urge incontinence • Nocturia

7. The prostate Slightly smaller than a golf ball Normally weighs about 20g Lies beneath the bladder and surrounds the urethra Produces a fluid that is a component of semen Relies on testosterone for normal health and function Naturally enlarges with age

8. Main disorders of the prostate • Benign Prostatic Hyperplasia (BPH) enlargement of the prostate gland • Cancer suspected if the prostate feels hard or irregular, or if the PSA is elevated • Prostatitis inflammation of the prostate – may be caused by infection

9. BPH

10. Initial assessment Medical history Medication review Bladder diary Physical examination including DRE Urinalysis Discuss implications of PSA test U&E if indicated Offer IPSS score sheet Refer for specialist assessment Recurrent or persistent UTI Retention Renal impairment caused by LUTS Suspected malignancy Red flags Haematuria Abnormal prostate on DRE

11. Size matters ! BAUS guidelines Size over 30g MTOPS study says over 25g PSA greater than 1.4 ng/ml in the absence of CaP Early intervention with 5-ARI Can reduce need for surgery by about 50% Has been shown to reduce risk of progression to acute retention by 55%

12. Conservative management Active surveillance Urethral milking for post-micturition dribble Bladder training and fluid advice Pelvic floor exercises for post-prostatectomy stress incontinence Do not offer penile clamps for men with storage LUTS/incontinence Offer alternative collecting devices eg. sheaths Offer ISC where appropriate Offer containment products only after individual assessment Refer for long-term catheterisation only as a last resort (NICE 2010)

13. Management • Watchful waiting • Alpha-blocker • Dual therapy • Fast-track referral • Normal referral to a Urologist • Referral to other eg. ED Nurse Specialist, Physio, further tests

14. Drug treatment • Only offer drug when conservative management options have been unsuccessful or are inappropriate • Take into account co-morbidities, current treatment and current medication when offering drug treatment for LUTS(NICE 2010)

15. Offer an alpha-blocker to men with moderate to severe LUTS (NICE 2010) Alpha-blockers Alfuzosin Doxazosin Tamsulosin Terazosin Relaxes prostatic smooth muscle Can reduce blood pressure (postural hypotension) – caution in elderly Retrograde ejaculation Drowsiness Nasal congestion Review after 4-6 weeks Drug treatment

16. 5-alpha reductase inhibitors Offer a 5-ARH to men with LUTS and prostate >30g or a PSA >1.4ng/ml, and who appear to be at risk of progression (eg. Older men)(NICE2010) (BAUS 2004) Finasteride Dutasteride Review after3-6 months Reduces prostatic volume Reverses BPH process Reduces risk of requiring surgical intervention Reversal of male-pattern balding!! Erectile dysfunction Decreased libido Reduced volume of ejaculate Gynaecomastia Reduces PSA by 50% after 6 months treatment 5-alpha reductase inhibitor

17. Combination therapy • Consider offering a combination of an alpha blocker and a 5-ARH to men with bothersome moderate to severe LUTS, and prostate >30g or a PSA level >1.4ng/ml (NICE 2010) • Combination therapy is more effective in delaying the clinical progression of the disease and in improving LUTS and flow rate than either drug alone(BAUS 2004)

18. Other causes of LUTS • Overactive bladder • Stress incontinence • Urethral stricture • Constipation • Post-operatively

19. Other medication • Offer an anticholinergic to men to manage the symptoms of Overactive bladder • Consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker • Consider offering a loop diuretic to men with nocturnal polyuria • Consider offering oral Desmopressin to men with nocturnal polyuria if other causes have been excluded and other treatments have not been of benefit. • Review after 4-6 weeks (NICE 2010)

20. Management in primary care • This would help to reduce the economic burden of BPH given that procedures and associated costs undertaken in secondary care are estimated to be almost 60% higher than primary care drug treatment. (ProState of the Nation report 2009)

21. National initiatives and policies • Referral guidelines for suspected cancer. • (NICE cg 27 2005) • Prostate cancer: diagnosis and treatment. • (NICE cg 58 2008). • Primary care management of male lower urinary tract symptoms (LUTS) (BAUS 2004) • Lower urinary tract symptoms – The management of lower urinary tract symptoms in men (NICE 2010)

23. Thank you Gillian Nottidge Continence Nurse Specialist 01274 322210 Gillian.nottidge@bradford.nhs.uk