Management of Voiding Problems in Older Men. Dr. John Fenn Consultant, QEH 10 th October, 2005

Management of Voiding Problems in Older Men Dr. John Fenn Consultant, QEH 10 th October, 2005

Voiding Problems Poor stream Hesitancy Straining Incomplete emptying Intermittent micturition Terminal dribbling Acute urinary retention

Voiding Problems Frequency Nocturia Urgency Urge incontinence

Older men 50

Etiology Benign Prostatic obstruction Detrusor Instability Detrusor Underactivity Neurogenic bladder

Exclusion criteria Less than 50 years of age Prostate cancer Previous invasive treatment for BPO Poorly controlled diabetes and diabetic neuropathy

Exclusion criteria History or physical examination suggestive of neurological disorder Pelvic surgery or trauma Sexually transmitted disease Use of drugs which have potential effects on bladder

Anatomy

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia Benign prostatic enlargement Benign prostatic obstruction

Pathophysiology

Clinical studies in USA, Canada, Europe, Scotland, Netherlands, France, Germany and Japan suggested that Mild urinary symptoms are very common among man over 50 Mild symptoms are associated with little bother Moderate and severe symptoms are associated with increasing inconvenience and interference with living activities

Clinical studies in USA, Canada, Europe, Scotland, Netherlands, France, Germany and Japan suggested that The correlation between symptoms, prostate size and urinary flow rate is relatively low. BPH is a progressive disease as shown by Decrease in maximum flow rate Increase in residue volume Increase in prostate size Deterioration in symptom score

Risk factors Developing the disease Age Hormonal status Isaacs Jt. Prostate 1989

Risk Factors Surgical treatment increases with age and the degree of clinical symptoms at baseline. Nocturia and change in urinary stream seem to be the most important predictive symptoms

Diagnostic Work-up of Men Presenting with LUTS suggestive of Benign Prostatic Obstruction

Diagnostic tests have been classified as Mandatory: This test should be done in every patient Recommended: this test is of proven value in the evaluation of most patients and is strongly encouraged during initial evaluation Optional: this test is of proven value in selected patient and done at the discretion of the clinician Not recommended: there is no evidence to support the use of this test

Mandatory tests

History Nature, duration Previous surgical procedures General health issues Patient fitness

Quantification of Symptoms Symptom score 0-7 mild 8-19 moderate 20-35 severe Quality of life Assessment

Physical Examination and Digital Rectal Examination Focused Examination on 1. Bladder distension 2. Hernia 3. Phimosis 4. Anal tone 5. Prostatic abnormalities 6. Motor and sensory function

Recommended Diagnostic tests Urinalysis Serum creatinine Serum Prostatic Specific Antigen 1. Cancer, BPH, infection, trauma, age, race may influence PSA 2. Level of PSA correlates with volume of prostate gland 3. Probability of prostate cancer correlates with PSA level 4. Test recommended because it may change the therapeutic option

Probability of prostate cancer among men with normal DRE. Adapted from Barry. PSA (ng/ml) 0-2.4 Not known 2.5-4 12-23 4.1-10 25 > 10.0 > 50 Probability of prostate cancer (%) PSA = prostate-specific specific antigen

Recommended Tests Flow Rate Recording Maximum urinary flow rate is the best single measure (Q max) At least two Q max, both with a volume >150ml voided volume Residue Urine Transabdominal Ultrasonography Voiding Diary

Flow rate and post void residue 尿流率測定及殘餘尿

Predictive ability of Qmax for a voided volume of 150ml or more Flow rate ml/ s Number Pressure flows Obstructed Not obstructed <10 135 (38%) 119 (89%) 16 (12%) 10 to 15 130 (37%) 92 (71%) 38 (29%) >15 91 (26%) 44 (48%) 47 (52%) Total 356 (100%) AG number = pdet, qmax-2qmax 255 (71%) 101 (28%)

Voiding diary 泌尿日誌

Optional Tests Pressure flow studies prior to surgical treatment 1. Younger men <50 2. Elderly patient >80 3. Post void residue urine >300ml 4. Qmax >15ml/s 5. Suspicion of neurogenic bladder dysfunction 6. After radical pelvic surgery 7. Previous unsuccessful invasive treatment

Urodynamics Study 尿流動力學檢查

Cystometrogram 膀胱壓力容積曲線

Cystometrogram 膀胱壓力容積線

Cystometrogram 膀胱壓力容積線

Optional Tests Ultrasound image of prostate 1. Only recommended in selected patient 2. Usually done with random sextant biopsies to rule out prostate cancer

Optional Tests Imaging of upper urinary tract (USG or IVU) 1. Not recommended in uncomplicated benign prostate obstruction 2. Recommended in patient with upper urinary tract infection, hematuria, urolithiasis and renal insufficiency

Cystoscopy 膀胱尿道鏡檢查

Optional Tests Diagnostic cystoscopy 1. Not recommended because benefits do not outweigh the harm of the invasive study 2. Recommended at the time of surgical intervention

Tests Not Recommended Retrograde urethrogram Urethral pressure profilometry Voiding cystourethrography Electromyography

Video-Cystourethrography 動態放射學檢查

Video-Cystourethrography 動態放射學檢查

Management strategy Imperative indications for surgical intervention 1. Refractory urinary retention 2. Recurrent bleeding prostate 3. Renal failure 4. Bladder stones 5. Recurrent urinary tract infection 6. Large bladder diverticula

Management strategy Watchful waiting if no imperative indications for surgery and symptoms not bothersome Shared decision if symptoms bothersome Pressure flow studies when Qmax >10ml/s and interventional therapy is considered

Treatment

Watchful waiting 1. Mild to moderate uncomplicated LUTS which do not bother the patient 2. Yearly reassessment of symptom score, bothersome, flow rates and post-void residue

Medical Therapy 1. Regular follow up for progress, adverse events and alternate treatment 2. Yearly reassessment if stable

Adrenergic Receptor Antagonistic Acceptable option in patients Symptoms improved by 30-40% Flow rate improved by 16-25% No significant relief of obstruction Treatment should be discontinued if no improvement in symptoms after an 8-week trial

α Adrenergic Receptor Antagonistic All α blockers can cause dizziness, headaches, asthenia, orthostatic hypotension, drowsiness, nasal congestion and retrograde ejaculation Patient should be informed about the side effects and the need for long term use Efficacy of all contemporary agents is similar though the side-effect profiles might be different

5 α reductase inhibitor Acceptable treatment in patient with clinically enlarged prostates and bothersome symptoms only Capable of reducing prostate volume 20-30%, improving symptom scores 15% and flow rates 1.3 --1.6ml/s Maximum benefits at 6 months Can alter the natural history of symptomatic BPH Side effects are diminished ejaculation, diminished libido and impotence Affect the PSA serum level

Phytotherapeutic agents Mode of action unknown Biological effect unclear Encouraging results in some clinical trials

Surgical management

Indications Refractory urinary retention Recurrent urinary tract infection Recurrent bleeding prostate Bladder stone Large bladder diverticulum Renal Failure

Choice of surgical treatment Transurethral bladder neck incision Transurethral resection of prostate Open prostatectomy Transurethral vaporization of prostate

Transurethral Resection of Prostate 經尿道前列線切除術

Transurethral Bladder Neck Incision 經尿道膀胱頸切開術

Outcome TURP mean increase Qmax 115% (+9.7ml/s) range 8.7-11.2 ml/s TUBNI 100% (+7.8ml/s) range 4-11.6 ml/s Open prostatectomy range 2-22.6ml/s All have a reduction of post void residue >50%

Complications Mortality <0.25% TUR syndrome 2% Blood transfusion 2--5% Stress Incontinence TUBNI 1.8%, TURP 2.2%, Open Prostatectomy 10% and TUVP 5%

Complications Bladder neck contracture and urethral stricture 1.8%, 4% and 0.4% after open prostatectomy, TURP and TUBNI 2.6%, 3.8% and 0.4% for open prostatectomy, TURP and TUBNI respectively

Complications Retrograde ejaculation Open Prostatectomy 80% TURP 65-70% TUBNI 40% Retreatment rate 1-2% per year for TURP,TUBNI and prostatectomy

Other Interventional Therapies Urethral stents Thermotherapy >45ºC Transurethral Microwave Thermotherapy Transurethral Needle Ablation Laser-coagulation Technique High Intensity Focused Ultrasound Balloon dilation Hyperthermia <45ºC

Recommendations for Treatment 1. Watchful waiting for patients with mild symptoms that have minimal or no impact on their life 2. Αlph-ablocker is a treatment option for patients with bothersome LUTS and no absolute indication for surgery 3. Surgical treatment is the first line treatment for patients with an absolute indication for treatment of LUTS 4. ILC with significant post operative morbidity and disappointing long term data is not recommended as a first line treatment

Recommendations for Treatment 5. Holmiun Laser resection of prostate is promising new technique 6. Transrectal High Intensity Focused Ultrasound is still investigational 7. TUNA is not recommended as first line therapy due to significant treatment failure rate 8. Transurethral microwave therapy should be reserved for patients who refused surgery

Follow up Watchful waiting First follow up at 6 months and then annually with IPSS and uroflowmetry 5-α reductase inhibitors Initial 12 weeks, 6 months and then annually with IPSS and uroflowmetry

Follow up Surgical management First postoperative visit at 6 weeks, then 6 months and then annually with histology, IPSS and uroflowmetry Alternative therapies First postoperative visit at 6 weeks, then at 3 months, 6 months and then annually with IPSS and uroflowmetry

Methodology 800 copies of questionnaire, a local Chinese translation of the World Health Organization approved International Prostate Symptom Score were distributed to men over 60 from 4 community centers in Hong Kong in August 1995

Prevalence 42 of male over 60 have moderate to severe urinary symptoms

Conclusion 168000 men in Hong Kong over 60 are suffering from moderate to severe urinary symptoms IN SILENCE 96000 and 72000 have moderate and severe symptoms respectively.

Conclusion These amount to 24% and 18% of the total male population over 60 Symptoms may be taken as a matter of aging Ignorance of availability of treatment Public education

Local Data From 01/10/2000 to 31/9/2001 Acute Urinary Retention Lower Urinary Tract Symptoms No. of patients 142 253 Total 395

Distribution of patients Profile of patients with TURP done from 1 st January to 31 st December, 2001 Refracto ry ARU (averag e age of patients) ARU with proven BOO (average age of patients) LUTS with proven BOO (average age of patients) LUTS (average age of patients) BNS Bleeding CaP Grand Total With DM 2 (67) 4 (77.5) 6 (70.5) 0 Without DM 33 (74.3) 10 (76) 31 (70.1) 31 (68.5) Total 35 (73.9) 14 (76.4) 37 (70.6) 31 (68.5) 22 5 6 150

Average Qmax, voided volume and post void residue of LUTS patients before surgery were 7.8mL/s, 219mL and 123.3mL

Post Void Residue Volume There was a mean reduction of post-void residue of 72%

Treatment outcome The mean increase of Qmax following TURP for LUTS was +138% (range -22.7% to +587%) in absolute terms +9.7mL/s (range -2.3 to +39.9) The mean increase of Qmax for acute urinary retention was +15.2mL/s (range +1.3 to +38.7mL/s)

Complications There was no mortality The need for transfusion was 3 out of 109 (2.75%) No patients developed TUR-syndrome

Long term complications None of the patients became incontinence at the end of one year after surgery

Bladder neck contracture and urethral stricture The incidence of bladder contracture and urethral structure was 3 out of 109 (2.75%).

Hospital Stay The median hospital stay was 3 days

Conclusion TURP remains the surgical standard to which other interventional therapies are compared A pathology specimen is always available TURP is clearly durable Surgical techniques that remove obstructing tissue provide the greatest relief of both symptoms and urodynamic obstruction for patients with moderate to severe symptoms The interval to relief of symptoms, length of catheterization and re-catheterization rates are shorter with surgical than thermotherapy techniques