Management of LUTS. Simon Woodhams February 2012

Transcription

1 Management of LUTS Simon Woodhams February 2012

2 The management of lower urinary tract symptoms (LUTS) in men Implementing NICE guidance May 2010 NICE clinical guideline 97

3 Background Lower urinary tract symptoms (LUTS) comprise storage, voiding and postmicturition symptoms and have many possible causes. They reduce quality of life and may point to serious pathology of the urogenital tract. LUTS are a major burden for the ageing male population. There is uncertainty and variation in clinical practice in the UK.

4 Symptoms Storage- Urgency, frequency, nocturuia, incontinence Voiding Weak stream, straining, intermittency, incomplete emptying Post- micturition Post mict dribble

5 IPSS Score

6 Initial assessment IPSS score including bothersome General history Causes of LUTS, comorbidities etc Drug history Include herbal remedies, antipsycotics, dieuretics Examine General exam, abdomen, external genitalia, DRE Frequency/volume chart Urine dipstix Blood, glucose protein, leucocytes, nitrites PSA Creatinine

7 Some common comparisons to help assess prostate size Walnut Ping Pong Ball Golf Ball Clementine Tennis Ball 4cm diameter 3.2cm diameter Approx 33cc Approx 20cc 4.3cm diameter Approx 40cc 5cm diameter Approx 65cc 6.3 diameter Approx 130 cc A 30 cc prostate is approximately the size of a ping pong ball

8 NAME : DATE:

9 Frequency volume chart Timing, type and volume of drinks Functional bladder capacity Frequency Nocturia Polyuric OAB Incontinence

10

11

12 1. Accessed 20th May 2010 NICE Recommendations on Initial Assessment Do not routinely offer: Cystoscopy to men with no evidence of bladder abnormality Imaging of the upper urinary tract to men with no evidence of bladder abnormality Flow-rate measurement Post void residual volume measurement

13 Max Flow Rate 32.9 ml/s Flow Time 11 s Average Flow Rate 17.8 ml/s Time to Max Flow 2 s Voided Volume 198 ml Residual Urine 0 ml Voiding Time 20 s

14

15 Who to refer? Bothersome LUTS that don t respond UTIs Retention Renal impairment Suspected cancer

16 Conservative Rx Mild symptoms Lifestyle advice Adjust fluids, legs up etc Overactive bladder Bladder training, advice on fluid intake, caffeine/alcohol

17 Drug treatment Mod to severe symptoms/bothersome Alpha blocker 5alpha reductase inhibitor >30cc or PSA>1.4 Anticholinergic if overactive bladder Combination- Avodart, alphablocker plus anticholinergic

18 Management NICE Guidelines Voiding symptoms moderate to severe α-blocker Review after 4-6/52 LUTS & large prostate & high risk of progression 5 α-reductase inhibitor (5ARI) Review 3/12 Storage symptoms Consider adding anticholinergic

19 BPH Medical Therapy of Prostate Symptoms (MTOPS) 4.5 years Placebo, Doxazocin, Finasteride, combination Clinical progression AUA score > 4 - Incontinence, UTI s Retention - renal insufficiency

20 BPH Results Prostate size < 25ml Doxazosin as good as combination Prostate size > 25ml Doxazosin and Finesteride better

21 BPH ComBAT 4 year study, 4,800 men Tamsulosin, Dutasteride or combination Primary end point AUR or BPH-related surgery Secondary end points - BPH clinical progression

22 BPH Combination better than tamsulosin (but not dutasteride) for reducing risk of retention or need for surgery Combination best symptom relief at 4 years side effects No placebo arm

23 Risk stratification Baseline variables Dynamic variables Old age Severe LUTS Low peak flow High residual vol (PVR) Enlarged prostate High PSA Worsening LUTS Persistence of bothersome symptoms Increasing PVR

24

25

26 Indications for operation No absolute Repeated episodes of acute retention Chronic retention, upper tract dilatation, renal impairment Recurrent UTIs assoc with residual Stones Haematuria

27 Operations TURP Greenlight laser HoLap HoLep

28 Green light laser

29 Laser fiber down cystoscope

30 Fiber Handling

31 What s different about PVP? Day Case Bloodless Fast No fluid shifts Catheterless ( on selected patients) Rapid return to normal activity

32 Conclusion- Lasers No bladder irrigation Catheter free less than 24 hours Patients can return to work within 2 days Relatively short learning curve Very effective Greenlight Goring Hall Holmium Worthing

33

34

35

36 The Role of Screening in Prostate Cancer WHO Principles 1968 Important health problem Treatment Facilities for treatment and diagnosis Latent stage Acceptable test Understand natural history Agreed policy on who to treat Cost should be economically balanced Case finding should be continuous

37 The Role of Screening in Prostate Cancer WHO Principles 1968 Important health problem Treatment Facilities for treatment and diagnosis Latent stage Acceptable test Understand natural history Agreed policy on who to treat Cost should be economically balanced Case finding should be continuous

38 The Role of Screening in Prostate Cancer

39 The Role of Screening in Prostate Cancer ,693 men 10 US Centre's Randomized Usual Care Screening 4 Yearly PSA and DRE

40 The Role of Screening in Prostate Cancer Usual care Screening in control group 40% in 1 st year 52% in 6 th year Deaths from prostate cancer 50 in screening group 44 in control group

41 The Role of Screening in Prostate Cancer

42 The Role of Screening in Prostate Cancer Initiated in early 1990 s 182,000 men in 7 Countries Randomized PSA and DRE every 4 years No Screening Study ended December

43 The Role of Screening in Prostate Cancer Death from prostate cancer reduced by 20%

44 The Role of Screening in Prostate Cancer Need to screen 1410 men Treat additional 48 to prevent 1 Death

45 The Role of Screening in Prostate Cancer

46 The Role of Screening in Prostate Cancer Conclusions No significant decrease in prostate cancer specific mortality in Meta-Analysis Any screening benefits only seen after >10 years Men with life expectancy < no benefit and has harms