VOIDING DYSFUNCTION IN ELDERLY MALE CURRENT STATUS

Transcription

1 VOIDING DYSFUNCTION IN ELDERLY MALE CURRENT STATUS DR. FRANCIS LEE

2 Voiding dysfunction Storage Emptying

3 Common voiding dysfunction in elderly male Emptying BPH Storage Incontinence Overactive bladder Post-prostatectomy

4 BPH is the fourth most diagnosed condition in men aged 50 years in the US CAD and hyperlipidaemia 51.3% Hypertension 45.2% Type 2 diabetes Enlarged prostate Osteoarthritis 13.5% 13.3% 17.5% Arrhythmias Cataracts GERD Bursitis Prostate cancer 8.8% 8.6% 8.4% 8.0% 7.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Prevalence (%) Issa MM et al. Am J Manag Care 2006;12 (4 Suppl):S83 94

5 Prevalence of BPH with age 50% of man at age of 60 80% of man at age of 80 25% of them have significant loss of quality of life

6 Classification of LUTS Symptom type Storage symptoms (previously called irritative) Voiding symptoms (previously called obstructive) Post micturition symptoms Symptom Increased daytime frequency Nocturia Urgency Urinary incontinence Slow stream Splitting or spraying Intermittent stream Hesitancy Straining Terminal dribble Feeling of incomplete emptying Post micuturition dribble Abrams P et al. Neurourol Urodyn 2002;21:

7 Diagnosis of BPH Symptoms International Prostate Symptom Score (IPSS score) Rectal examination (> 20 gm) Uroflowmetry (< 10 ml/sec) Residual urine volume MSU PSA

8 BPH Prevalence

9 Age-specific prevalence of LUTS/BPH (%) Age-specific incidence of LUTS/BPH (per 1000 men years) The incidence and prevalence of LUTS due to BPH increase with age >84 Age Age Verhamme KMC et al. Eur Urol 2002;42:

10 Prevalence of moderate-to-severe LUTS Proportion of men with IPSS >7 (%) increases with age 50% 40% 37.4% 41.2% 30% 30.1% 20% 20.0% 10% 0% Age (years) Nø rby et al. Eur Urol 2005;47:

11 LUTS Pathophysiology of BPH Symptoms

12 100 Voiding symptoms are most common and storage symptoms are most bothersome Prevalence* Bothersomeness Voiding symptoms Peters TJ et al. J Urol 1997;157:885 9 Storage symptoms *Reported that symptom occurs at least occasionally Symptom reported to cause at least a bit of a problem 12

13 Health-related QoL score (age-adjusted means)* LUTS diminishes various aspects of quality of life according to symptom severity No symptoms Mild symptoms Moderate symptoms Severe symptoms Bother Interference General Sexual health satisfaction Scale: 0 1 (health status: 0=best; 1=worst) *Higher scores indicate worse health status for all measures Girman C et al. Urology 1998;51:

14 The presence and severity of LUTS are risk factors for sexual dysfunction Sexual activity is common in a majority of men aged years and is an important component of quality of life Men with moderate-to-severe LUTS are at increased risk for Erectile dysfunction Ejaculatory dysfunction Hypoactive desire Rosen R et al. Eur Urol 2003;44: Rosen R et al. Eur Urol 2005;47:

15 Incidence (%) Ejaculatory dysfunction is strongly associated with LUTS severity Reduced ejaculation No ejaculation Effect of LUTS severity Effect of LUTS severity Effect of LUTS severity Age effect years years years Rosen R et al. Eur Urol 2003;44:

16 Risk factors for BPH The Baltimore Longitudinal Study Of Aging Obese men (BMI kg/m2) (OR 1.27) Severely obese men (BMI 35 kg/m2) (OR 3.52) Waist > 90cm (OR 3.37) Elevated fasting glucose (>110 mg/dl)(or 2.98) A diagnosis of diabetes(or 2.25) Parsons et al. AUA 2006 Abstract 1344

17 Family History of BPH BPH (%) [*] Relatives All first-degree male relatives Frequency of Clinical Age-Adjusted Significance Case Relativ es Control Relative s Odds Ratio (unadjusted) [ ] Relative Risk of Clinical BPH [ ] Chi- Square P Value ( ) 4.4 ( ) * Percent of informative male relatives with history of prostatectomy (open or transurethral) for BPH (60 case relatives and 105 control relatives). Chi-square analysis of proportions; Taylor 95% confidence intervals in parentheses. Cox proportional hazards survival model. Censored outcome prostatectomy. Time variable age at death or current age. Values in parentheses indicate 95% confidence intervals. Sanda et al. J Urol 1994;152:

18 Familial BPH Larger prostate size mean prostate volume 82.7 ml in men with hereditary 55.5 ml in men with sporadic BPH Earlier onset of symptoms More severe symptoms Pearson et al. Urology 2003; 61:

19 Risk factors for BPH Frequency of ejaculation has no effect on LUTS, peak urinary flow rates, or prostate volume No definite correlation with hypertension, alcohol or smoking Results of studies on the relationship of BPH with diet varied a diet with less meat and diary products and more vegetable may be protective

20 Natural history of BPH 107 men with LUTS due to BPH & no treatment FU for 5 yrs 31 improved 50 unchanged 26 worsened 10 TURPs (2 for AUR) Ball et al. BJU :613

21 Progression of BPH MTOPS placebo arm Fitzpatrick BJU S2:3

22 Symptom progression in patients presenting with mild symptoms (IPSS<8) Cumulative incidence (%) Moderate symptoms (IPSS 8 18) Severe symptoms (IPSS 19 35) Months Djavan B et al. Urology 2004;64:

23 Changes of BPH symptoms over 3 yrs in a Scottish study Lee AJ etal. Eur Urol 1996;30:11-17

24 Who is at risk of BPH progression?

25 Age and symptom severity Age (years) Chute CG et al. J Urol 1993;150:

26 Age and incidence of AUR Age (years) Meigs JB et al. J Urol 1999;162:

27 BPH in old age Progression to urinary retention in 5 years 10% in 70 s 33% in 80 s Jacobsen et al. J Urol 1997; 158: 481

28 Relative risk (unadjusted) Relative risk (unadjusted) Symptom severity and urinary flow rate vs. risk of AUR AUA-SI 7 AUA-SI >7 Qmax >12 ml/sec Qmax 12 ml/sec Jacobsen SJ et al. J Urol 1997;158:

29 Post-void residual urine volume Incidence rate (events per 100 Pyr) 8.0 Post-void residual urine volume <39ml 39 ml p< p=0.003 p=0.034 p= Overall BPH progression MTOPS 4-point AUA SS progression AUR 1.7 Invasive therapy Crawford ED et al. J Urol 2006;175:

30 Prostate volume and BPH progression Men with large prostate glands (>50 ml) compared with men with normal-sized or small prostate glands are: 3.5 times more likely to have moderate or severe symptoms 2.5 times more likely to have decreased flow rates 3 4 times more likely to suffer AUR 4 times more likely to need medical or surgical intervention Emberton M et al. Int J Clin Pract 2008:62: Anderson JB et al. Eur Urol 2001;39:

31 Prostate volume and BPH progression Incidence rate (events per 100 Pyr) Overall BPH progression MTOPS Total prostate volume <31 ml p< p=0.001 p=0.034 p= point AUA SS progression 31 ml AUR 2.0 Invasive therapy Crawford ED et al. J Urol 2006;175:

32 Prostate volume vs. AUR & Surgery ARIA, Dutasteride Phase III Trial A MTOPS, Medical Therapy of Prostatic Symptoms PLESS, Proscar Long-Term Efficacy and Safety Study PCPT, Prostate Cancer Prevention Trial

33 Total prostate volume and PSA Age Serum PSA (ng/ml) Roehrborn CG et al. Urology 1999;53:

34 Change in IPSS PSA level and symptom outcomes in the placebo arm in PLESS PSA (ng/ml) Month Roehrborn CG et al. Urology 1999;54:

35 PSA and BPH progression Incidence rate (events per 100 Pyr) p= p= p=0.029 p= Overall BPH progression MTOPS point AUA SS progression PSA level <1.6 ng/ml 1.6 ng/ml AUR Invasive therapy Crawford ED et al. J Urol 2006;175:

36 PSA vs. AUR & Surgery ARIA, Dutasteride Phase III Trial A MTOPS, Medical Therapy of Prostatic Symptoms PLESS, Proscar Long-Term Efficacy and Safety Study PCPT, Prostate Cancer Prevention Trial

37 PSA & BPH 28% with PSA > 4 ng/ml PSA values predict prostate size High PSA predicts symptom progression, urinary retention and surgery

38 Risk factors during watchful waiting Predict symptom progression Predict ARU Qmax <10 ml/s + - PVR >150 ml + - Prostate vol. >30 ml + + PSA >2 ng/ml + + Based on VA, PLESS and MTOPS studies

39 PSA velocity & BPH 594 patient on watch waiting or blockers PSA velocity of > 0.5 ng/ml/year indicated increased in risk for surgery De la Rosette et al. AUA 2005 Abstract 1290

40 Inflammation as cause of BPH MTOPS (Medical Therapy of Prostate Symptoms Trial) Around 40% biopsy specimens had chronic inflammatory infiltrates Mean FU 4.5 yrs Symptom progression occurred in 21% with inflammation 13.2% without inflammation Roehrborn et al. AUA Meeting 2005 Abstract 1277

41 NSAIDs & BPH Olmsted county, Minnesota 796 out of 2,447 men taking daily NSAIDs Less incidence of moderate/severe urinary symptoms (HR 0.73) low maximum flow rate (HR 0.51) Increased prostate volume (HR 0.53) elevated prostate-specific antigen level (HR 0.52) Sauver et al. Am J Epidem 2006; 164:760

42 Europe (EU+non EU) 3,714 patients Latin America 726 patients Asia 848 patients Middle-East 639 patients Canada 407 patients North Africa 190 patients By June 30th 2004, 6,523 men enrolled in an open study with alfuzosin 10mg OD Emberton et al. J. Urol. 2005, 173 (suppl.), 463 (abstract 1708)

43 Impact of Treatment Response AUR BPH Surgery Improvement >6 (n=11) Improvement 3-6 (n=2) 0.4% 0.1% 0.4% (n=13) 0.6% (n=9) *IPSS change (improved vs stable or worse), p <0.01 Improvement 1-2 (n=3) 0.5% 1.0% (n=6) Stable (0) or Worsening 1-3 (n=8) Worsening 4 (n=3) 1.4%* 1.0%* 4.1%* (n=23) 4.9%* (n=14) Intent to treat population (n=5792) Emberton et al. J. Urol. 2005, 173 (suppl.), 463 (abstract 1708)

44 % patients with AUR Impact of Treatment Response on AUR <65 >65 <1.4 >3.3 No Yes <20 >20 Yes No <3 >3 <3 >3 [ ] Age PSA Prior Baseline Treatment Baseline Treatment Unoperated IPSS response bother response AUR (IPSS) (bother) Emberton et al. J. Urol. 2005, 173 (suppl.), 463 (abstract 1708)

45 % patients with BPH surgery Impact of Treatment Response on BPH Surgery <65 >65 <1.4 >3.3 No Yes <20 >20 Yes No <3 >3 <3 >3 [ ] Treatment Age PSA Prior Baseline Baseline Treatment Unoperate IPSS response bother response AUR (IPSS) (bother) Emberton et al. J. Urol. 2005, 173 (suppl.), 463 (abstract 1708)

46 Impact of Treatment Response on BPH Surgery Emberton et al. J Urol :1051

47 Conclusion of Alf-One Study Men who experience no symptom improvement or symptom deterioration during alfuzosin treatment are at increased risk of BPH progression and surgery Emberton et al. J Urol :1051

48 Risk factors for BPH Progression Old age Previous AUR+++ Symptom deterioration while on αblocker Concomitant prostatitis Large prostate size BPH progression Severe LUTS High PSA level Low Qmax High PSA velocity Large PVR ALTESS, PLESS, MTOPS De la Rosette et al. AUA 2005 Abst. 1290Jacobsen et al. J Urol 1997; 158:481 Khastgir et al. Nat. Clin Pract. Urol :422

49 Urinary incontinence in men Survey 7,274 men > 20 yrs 12.4% men had incontinence 4.5% men had moderate to severe incontinence Markland et al. J Urol 2010; 184:1022

50 Prevalence of UI in men by symptom severity Markland et al. J Urol 2010; 184:1022

51 Prevalence of urinary incontinence in men Markland et al. J Urol 2010; 184:1022

52 Risk factors for urinary incontinence in man Age Major depression Hypertension Poor self-rated health Prostate cancer BPH Arthritis Stroke Coronary heart disease 3 or more chronic diseases Markland et al. J Urol 2010; 184:1022

53 LUTS and falls in elderly Urinary incontinence strongest predictors for recurrent falls Tromp et al. J Bone Miner Res 1998; 13:1932 Tromp et al. J Clin Epidermiol 2001; 54: to 50% of falls in institutions are associated with toileting Von Renteln-Kruse et al. Z Gerontol Geriatr. 2004; 37(1):9

54 Types of incontinence Urge Stress Overflow Functional

55 Urge incontinence women men % of urge or mixed incontinence Milsom et al. Am J Manag Care 2000; 6(11 Suppl):S565

56 ICS definition Nocturia Urgency Frequency Urge incontinence OVERACTIVE BLADDER Abrams et al. Neurourol Urodyn, 21:167 (2002)

57 Prevalence of OAB in > 40 yrs Milsom et al. BJU Int 2001; 87:760

58 Prevalence (%) Prevalence of Overactive Bladder Syndrome (OAB) 45 EU SIFO Study 40 US NOBLE Study Men Women Men Women Age (years) Milsom I et al Age (years) Stewart et al, 2001

59 BPH and Overactive Bladder Symptoms

60 BPH and OAB Over 70% men with BPH experienced OAB symptoms 70 80% of men with BPH found these OAB symptoms bothersome Peters et al. J Urol 1997; 157:885

61 OAB & depression 32% patients with OAB reported depression 28% reported to be very depression OAB dry OAB wet Emotional stress 19.6% 36.4% Depression 23.3% 39.8% Irwin et al. BJU Int 2006; 97:96

62 Interference with work Irwin et al. BJU Int 2006; 97:96

63 Post radical prostatectomy incontinence 985 patients after retropubic radical prostatectomy 92.3% 0-1pad/day after 24 months Independent factors predicting incontinence in multivariate study Age at operation Anastomotic stricture Bilateral neurovascular bundles resection Sacci et al. BJU Int 2006; 97:1234

64 Incontinence after robotic prostatectomy Novara et al. J Urol 2010; 184:1028

65 Risk factors for post-robotic prostatectomy incontinence Novara et al. J Urol 2010; 184:1028

66 Continence Age Nerve preservation Surgeon experience Standford et al. JAMA 2000; 283:354 Membranous urethral length Paparel et al. Eur Urol 2009; 55(3):629

67 Improving continence Minimal dissection of tissue distal to apex of prostate Preservation of periurethral tissue and urethral length Bladder neck preservation Reconstruction of bladder neck Nerve preservation

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