LUTS & Cancer pathway Mr Francis Thomas Urology Consultant DRI &BDGH
Topics Male and female LUTS Urinary retention Post void Residual urine Referral pathway LUTS Raised PSA Hematuria Services in community
Causes of LUTS in men BPE Life style habits Detrusor muscle weakness or overactivity, Prostate inflammation, UTI Prostate cancer Neurological diseases Medical causes Medications Renal BOO Pituitary LUTS Cardiac CNS BPE
Initial assessment History Predominant symptoms Life style General medical history Drug history Physical examination Abdomen DRE Genitalia IPSS score Urine dipstick
Initial assessment PSA- Abnormal prostate Patient concerns Serum creatinine- Suspect renal impairment Palpable bladder Nocturnal eneuresis Recurrent UTI H/o Renal stones USS KUB Suspecting renal failure
Conservative Management Reassurance and further information Life style interventions- mainly for storage symptoms Fluid balance Decrease tea/coffee/ alcohol/fizzy drinks Decrease night time drinks Bladder training Treat bowel constipation Reduce weight
Drug treatment Alpha blocker for moderate to severe LUTS ( eg: Tamsulosin, Alfuzosin) Anticholinergics for OAB (Solifenacin, Tolteridine etc) 5 alpha reductase (Finasteride, Dutasteride) Prostate >30gm PSA >1.4ng/ml High risk for progression Combination therapy (alpha blocker+5 alpha reductase) Bothersome moderate to severe LUTS Prostate >30gm PSA >1.4ng/ml High risk for progression Alpha blocker+ Anticholinergic Persistent storage symptoms after treatment with alpha blocker alone
% Improvement in max Flow Improvement in Flow Q max Prazosin, Alfuzosin, Tamsulosin, Terazosin 40 35 30 25 20 15 10 5 0 Buzelin 93 Buzelin 97 Lee 97 Na 98
Effect of finasteride on prostate volume Effect&of&finasteride&on&prostate&volume 20% 32% N"Engl"J"Med"
Mainly Voiding symptoms Mainly storage symptoms Voiding +storage symptoms Voiding symptoms +Erectile dysfunction Alpha blocker Life style advise Alpha blocker + anticholinergic+/- life style advise Alpha blocker + PDE5 inhibitor Large prostate PSA>1.4 Symptoms not improved Anticholinergics Alpha blocker + 5 alpha reductase
SCENARIOS 60 YEAR OLD MAN presenting with Slow stream, hesistancy, frequency Urinalysis negative PSA- 0.4 PR- moderate size BPE
55 year old man with urgency, frequency, hesitancy Urine positive for Nonvisible hematuria PR- moderate size bpe
Review after 4-6 weeks Continue active monitoring (reassurance and lifestyle modifications) Active intervention Drug therapy Referral to specialist
Referral Bothersome LUTS Not responded to drug treatment Complicated LUTS UTI Retention Renal impairment Lower urinary tract dysfunction Suspected malignancy Hematuria Abnormal prostate Raised PSA
Nocturia Waking to pass urine during the main sleep period Causes Nocturnal polyuria (It is defined as passing more than one third of your 24-hour urine output at night ) BPE UTI Medications Medical causes- cardiac failure Sleep apnoea-sleep disturbances
Nocturia-assessment History- Identify causative factors Lifestyle habits Fluid intake Assess with Frequency volume chart Urinalysis
Nocturia Lifestyle modifications Less fluid intake after 6 pm Reduce salt and sugar in diet Simple evening leg elevation or compression stockings can redistribute third space fluid Continuous positive airway pressure (CPAP) Alpha blockers- for BPE Anticholinergics-minimal effect Afternoon diuretics Desmopressin- oral or nasal spray ( monitor Sodium)
Retention of urine Acute retention < 1000 ml urine Painful Acute on chronic retention >1litre urine Painful Chronic retention RV>1 L, Palpable bladder painless High pressure chronic retention Painful or painless Renal failure, Hydroureteronephrosis (on USS KUB) Investigations +assessment Prostate examination Check U&E USS KUB if renal failure Management Acute retention Catheterise- GP practice/rdash/hospital Alpha blocker before TWOC (after 48hrs) C/C retention with symptoms ISC catheter Surgery C/C retention without symptoms (not catheterised) Active surveillance- monitor PV RV USS kidneys Serum creatinine
Retention of urine High pressure chronic retention Renal failure, Hydroureteronephrosis RX Catheterise Admit in hospital for monitoring LTC/Surgery
Effect of medical therapy on the development of AUR Effect&of&medical&therapy&on&the& development&of&aur Incidence:of:AUR/100:patient: years 6 5 4 3 2 1 0 36/1503 7/134 4/252 *14/1513 1/172 3/237 *1/126 2/179 0/249 4/811 placebo finasteride alpha7blocker PLESS ALF ALFIN PREDICT TAM Michel&MC.&Drugs&Today&2000J36(Suppl.F):11P13
75 year old man presents with difficulty passing urine through out night. Fit and well O/E palpable bladder
AUR/TWOC Community pathway -RDASH AUR in community DRI Urology Department Patient presenting with AUR in communityrefer to unplanned care services for catheterisation and then seen in RDASH clinic for assessment /TWOC and further referral to Urology Patients discharged from hospitals with catheter referred to RDASH clinic for TWOC or for further catheter care Patients given clear advise and support with catheter passport and contact details of RDASH clinic TWOC from community RDASH/ UNPLANNED CARE ISC/CATHETER PROBLEMS TWOC from hospital
Post void scans /USS KUB Post void residuals No minimal or maximum values Take into consideration Symptoms UTI Renal function Treatment depends on whether symptomatic or not Renal function
Surgery- mainly storage symptoms Failed conservative and drug treatment Urodynamic studies to assess bladder Botulinum toxin injection Sacral nerve neuromodulation Cystoplasty Willing and able to self catheterize Detrusor overactivity Small capacity bladder Artificial sphincter- stress UI Urinary diversion Failed cystoplasty Failed sacral nerve stimulation
Surgery- voiding symptoms -Severe voiding symptoms -Failed drug and conservative treatment TURP Monopolar/bipolar Green light Prostate embolisation HoLEP Uro-lift Aqua ablation Open prostatectomy->80-100 gm prostate
Female LUTS Mr Francis Thomas Consultant Urologist DRI &BDGH
Definitions Urgency -a sudden compelling desire to urinate that is difficult to delay Urgency UI is involuntary urine leakage accompanied or immediately preceded by urgency Stress UI is involuntary urine leakage on effort or exertion or on sneezing or coughing. Mixed UI is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or coughing. Overactive bladder (OAB) is defined as urgency that occurs with or without urgency UI and usually with frequency and nocturia. OAB that occurs with incontinence is known as OAB wet OAB that occurs without incontinence is known as 'OAB dry
History Duration Type of incontinence Triggering factors- uti, stress Obstructive symptoms Pads usage numbers, size, wetness Lifestyle factors-caffeine, smoking, alcohol Menstural/obstetric Bowel habits Previous pelvic surgery/radiotherapy Drugs Medical problems diabetes etc
Assessment Frequency volume chart Minimum of 3 days to include rest days and working days Fluid dairy Urinalysis Post void residuals Pelvic and speculum examination Cough test USS pelvis
Specialist opinion Haematuria Recurrent UTI Persisting bladder or urethral pain Pelvic mass/palpable bladder Urogenital fistula Previous continence surgery Fecal incontinence Neurological disease Previous Pelvic cancer Previous pelvic radiotherapy
Treatment Categorise the symptoms and diagnose the type of incontinence SUI,UI,MIXED OR OAB Treat the predisposing and precipitating factors UTI, Constipation, Loose weight (BMI>30) Lifestyle advice Reduce caffeine/fizzydrinks/smoking Fluid intake 1.5-2litres Bladder training exercises Pelvic floor exercises If mixed incontinence start treating the predominant symptom SUI with OAB Treat OAB symptoms prior to treatment of SUI Prolapse that is symptomatic and is visible and or below the introitus should be treated
Treatment-Conservative measures BLADDER TRAINING -6 weeks-3 months There are many different regimes, but they all involve suppressing the feelings of urinary urgency. Require a few months training to reach its full potential. Timed voiding Pelvic floor muscle training(pfmt) Assess pelvic muscle tone Supervised PFMT- 3months 8 contractions each held for 8 seconds three times a day RDASH clinic and physiotherapy department- offers bladder training and PFMT advice
Treatment PADS/CATHETERS/URINALS -Use them only as Coping strategy pending assessment and treatment An adjunct to ongoing treatment When all treatment options have been explored and failed
Medications Start with one with low acquisition cost Most of anticholinergics have same side effect profile Oxybutynin-(not in elderly) Tolteridine - Darifenacin- Solifenacin- Trospium chloride Fesoteridine Mirabegron- beta 3 agonist Mirabegron +anticholinergic Topical oestrogens for vaginal atrophy-6 weeks to 3months OAB DRUGS Counsel about success and associated common side effects Some side effects indicate that the treatment is starting to have an effect May take up to 4 weeks for medicines to start working Need to continue with bladder training /PFMT along with OAB drugs 4 week review and then 6month review Try atleast two drugs before referral to specialist centres
Referral- &secondary care If OAB symptoms, SUI/mixed incontinence not responding to bladder training, PFMT and OAB drugs OAB MDT Urodynamics Intravesical Botulinum toxin Posterior tibial nerve stimulation Sacral neuro modulation Augmentation cystoplasty Urinary diversion-ileal conduit SUI MDT Urodynamics Rectus fascial slings Colposuspension Urethral bulking agents Artificial sphincters Urinary diversion
Hospital pathway Women with bladder symptoms Community pathway- RDASH Urinalysis GP Urinalysis Clinical examination & medications Urology clinic Flow rate & bladder scan Pelvic floor exercise RDASH clinic Flow rate & bladder scan Fluid and dietary advise Clinical examination & medications Fluid and dietary advise Referred for Pelvic floor exercises Referred to Gynaecologist if prolapse etc-- Referred to Urology/Gynaecology MDT as appropriate Discharged if symptoms resolved Clinic revisit 6-8 weeks
Clinical scenarios 40 year old lady presenting with frequency,urgency, incontinence for 3 months. Otherwise fit and well.
40 year old lady presenting with frequency,urgency, incontinence for 3 months. Otherwise fit and well. Already on medications (anticholinergic) for 2 months but symptoms not better.
65 year old lady with frequency, urgency and hesitancy, otherwise fit and well. O/E microscopic hematuria, vaginal atrophy.
Cancer 2 WW Pathways
Hematuria referral 2 ww referral >45 yrs of age hematuria without UTI Non visible hematuria (NVH) >60 yrs and have either dysuria or raised WBC count Non urgent referral Visible hematuria <45 yrs of age Non visible hematuria <60 yrs Recurrent UTI NVH with proteinuria / renal failure Refer renal physician
3 CLINIC VISITS Current pathway Abnormal PSA One stop PSA clinic Abnormal PSA Seen in clinic- 2WW MRI PROSTATE One stop PSA clinic 2WW MRI done and reported same day PROSTATE BIOPSY- same day MRI MDT PROSTATE BIOPSY MDT ONCOLOGY ONCOLOGY MDT CLINIC CLINIC
South Yorkshire, Bassetlaw and North Derbyshire Cancer Alliance Urology Fast Track Referral 2 Week Wait
Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE) 1. Asymptomatic patient requesting PSA test Require two blood tests, at least 4 weeks apart Informed consent: e.g. Prostate Cancer Risk Management Programme (PCRMP) leaflet Refer as 2ww if: Both PSA >3.0 (for all ages) (For raised PSA in men with significant co-morbidities, performance status >3 or life expectancy <10 years, consider discussion with patient/family/carers and/or a specialist before urgent referral.) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/509191/patient_info_sheet.pdf
Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE) 2. Symptomatic patient: Prostatic symptoms/luts Please Wait atleast 6 weeks following treated UTI before undertaking PSA test. Refer if: Abnormal DRE Or Both PSA >3.0 (Obtain two PSA tests, at least 4 weeks apart) (For raised PSA in men with significant co-morbidities, performance status >3 or life expectancy <10 years, consider discussion with patient/family/carers and/or a specialist before urgent referral.) Informed consent: e.g. (PCRMP) leaflet provided
Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE) 3. Symptomatic patient: Suspected distant metastases Refer: If abnormal DRE Or a single PSA >20 In this group of patients if PSA result is between 10-20 suggest repeat and review in 4 weeks with second PSA test. If repeat PSA level <10 Constitutional symptoms are unlikely to be directly due to prostate cancer but consider criteria above.
Prostate Cancer All Patients should have PSA and U&E/eGFR blood tests, urine dipstick and Digital Rectal Examination (DRE) 4. Prostate feels malignant (Firm, hard, nodular or craggy) on (DRE) One PSA is sufficient, Any PSA value