Male Lower Urinary Tract Symptoms: Management in primary care and beyond Daniel Cohen PhD FRCS(Urol) Consultant Urological Surgeon 1
LUTS Very common: 1/3 men over age of 50 have moderate to severe LUTS 80% of 70-80 years old will have histological evidence of BPE 2
Storage Symptoms Voiding Frequency Urgency Urge Incontinence Nocturia Poor flow Straining Intermittency Hesitancy Incomplete Emptying Nocturnal enuresis Renal impairment and palpable bladder Sterile pyuria / UTI Hard prostate / Elevated PSA Haematuria 3
Mild 0-7 Moderate 8-19 Severe 20-35 4
Storage Symptoms: Treatment in Primary care Lifestyle - caffeine, carbonated drinks, ETOH Nocturia - decreasing evening fluid consumption - Heart failure, Dementia, Parkinson s Disease, sleep apnoea - Drugs PPIs, Calcium channel blockers, SSRIs, Diuretics Medical management: Anticholinergic e.g Tolterodine/ Solifenacin B3 agonist - Mirabegron 5
Medical Management Voiding symptoms 1. Trial of Alpha blocker Tamsulosin or Alfuzosin Efficacy - 30-40% improved symptoms / 16-25% improved flow rate, average 3ml/s Side effects Hypotension/Dizziness/Retrograde Ejaculation/ Floppy Iris Syndrome (Cataracts) 2. If prostate large or no benefit after 6 weeks offer a 5 ARI - Finasteride or Dutasteride Combination therapy more effective than either drug alone Reduces prostate volume ~20-30% and Improves symptom scores ~15% Maximal effect only after 6 months but durable effect lasting at least 10 years Side effects - Reduced libido/ ED(5%) Reduced ejaculate volume / rash and breast symptoms (~1%) PSA halves after 6-12 months 6
Risk factors for clinical progression Elevated PSA Increasing Age High IPSS at presentation (>20) Larger prostates on DRE Poor flow 7
Royal Free LUTS clinic NEW! Two dedicated clinics per week at Barnet and Royal Free Assessment and treatment of Male LUTS Uroflowmetry / IPSS TRUS volume assessment Referral for Urodynamic investigation and Flexible Cystoscopy if required Current and future options for further management 8
Treatment TURP (Bipolar) Traditional surgical treatments - TURP Rezum Urolift PAE 9
HoLEP Holmium Laser Enucleation Now accepted to be the gold standard procedure Anatomical Enucleation of Prostate Less bleeding Shorter catheterisation and hospital stay Move towards daycase / <24 hour stay Larger volume prostates can be treated Durable - Reoperation rate low: 1-4% at 10 years 10
Urolift Daycase / Smaller Prostates (under 80cc) / largest study on men with moderate LUTS Preserves sexual function and continence. IPSS improvement 36% at 5 years 14% reoperation at 5 years (on a cohort of small volume prostates) 11
Rezum 3 year outcomes 97 men with moderate LUTS and prostates under 80cc 50% IPSS improvement; minimal adverse effect on continence and sexual function Catheter for 4-7 days; Dysuria very common for first 2 weeks. Improvements not seen immediately can take 6-8 weeks 12
Prostate Artery Embolisation UK ROPE Study Daycase in 70% men Local anaesthetic Mean IPSS reduced by 10 NICE approved Larger prostates Outcome inferior to TURP Reoperation rate 14% 2 years 13
Summary Multiple treatment options for LUTS Medical management may suffice in many men Surgical options include HoLEP and Bipolar TURP at Royal Free Urolift and Prostate Artery Embolisation in near future Rezum is being assessed for suitability Daniel.cohen@nhs.net 14