Diagnostic approach to LUTS in men Prof Dato Dr. Zulkifli Md Zainuddin Consultant Urologist / Head Of Urology Unit UKM Medical Center
Classification of LUTS Storage symptoms Voiding symptoms Post micturition symptoms Altered bladder sensation Increased daytime frequency Nocturia Urgency Urinary incontinence Hesitancy Intermittency Slow stream Splitting/spraying Straining Terminal dribble Feeling of incomplete bladder emptying Post micturition dribble Abrams P et al. Neurourol Urodyn 2002;21:167-78
Evolution in view on male LUTS Male LUTS Past: problems related to the prostate Currently: problems related to prostate, bladder and/or other organs
Conditions or diseases behind LUTS OAB/ detrusor overactivity BPE/BOO prostatitis nocturnal polyuria ureteral stone detrusor underactivity LUTS bladder tumour neurogenic bladder dysfunction urethral stricture UTI foreign body bladder stone Gravas S et al. EAU guidelines 2016, available at www.uroweb.org
LUTS can be associated with body systems outside the lower urinary tract Speakman MJ. Eur Urol Suppl 2008;7:680-9; Chapple CR and Roehrborn CG. Eur Urol 2006;49:651-9
Conditions associated with LUTS prostate-related BPE All aged men BPH BPO / BOO Abrams P et al. Urology 2003;61:37-49; Chapple CR and Roehrborn CG. Eur Urol 2006;49:651-9
Routine assessment of male LUTS History (+ sexual function) Symptom score questionnaire Urinalysis Physical examination PSA* Measurement PVR *if diagnosis of PCa will change the management or if PSA can assist in decision-making in patients at risk of progression of BPE Gravas S et al. EAU guidelines 2016, available at www.uroweb.org
Symptom score questionnaires International Prostate Symptom Score (IPSS) Americal Urological Association Symptom Score (AUA-SS) International Consultation on Incontinence Questionnaire (ICI-MLUTS) Danish Prostate Symptom Score (DAN-PSS)
IPSS score
Symptom score questionnaires - IPSS Score / Severity 0 to 7 Mild 8 to 19 Moderate 20 to 35 Severe Index of symptom severity BUT weighted towards voiding Gravas S et al. EAU guidelines 2016, available at www.uroweb.org
IPSS QoL: the most important question If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
The physical examination 1. Abdominal examination rule out other possible urinary or rectal conditions 2. Digital Rectal Examination (DRE) fundamental method for assessing the shape and the volume of the prostate
Uroflow to assess the Effect of BPH 20 Flow rate (ml/sec) normal 10 obstructed 30 60 Time (seconds)
Uroflowmetry Measures peak urinary flow rate (Qmax), voided volume and micturition time. A micturition volume of at least 150ml is required for an adequate analysis Interpretation of maximum urinary flow rate values: > 15 ml/s normal 10-15 ml/s equivocal < 10 ml/s obstructed
(a) Normal Flow rate tracing (b) Flow rate tracing showing in reduction in the maximum flow rate in a patient with bladder outflow obstruction due to BPH
BLADDER SCAN
Serum Prostate-Specific Antigen (PSA) Measurement recommended for patients with at least 10-year life expectancy and for whom knowledge of the presence of prostate cancer would change management PSA is also a proxy of prostate size but its variability is high. Recent studies suggest that it may be used to predict the risk of AUR and BPH-related surgery.
Serum Prostatic Specific Antigen
Transrectal ultrasound guided biopsy of the Prostate
Rate per 100 PYR 6 5 4 Association of baseline PSA and risk of clinical progression of BPH Placebo group p<0.0001 p=0.0003 PSA (ng/ml) < 1.4 1.4 3.9 4.0 3 2 1 0 p<0.0001 Progression > 4 point rise AUR MTOPS (2002)
Incidence (%) PSA as a predictor of surgery and AUR (placebo-treated BPH) 21 18 15 12 9 6 3 0 6.2 9.9 Surgery 14.6 Baseline PSA tertiles 0 1.2ng/mL 1.3 3.2ng/mL >3.2ng/mL 2.9 5.8 AUR 11.6 Roehrborn CG et al. Urology 1999;53:473 80
PSA and its role in therapeutic decision making PSA and PV are powerful predictors of risk of BPH progression PSA values of >1.6ng/mL predict a PV >40mL, PSA values of >1.4ng/mL predict a greater risk of BPH progression PSA can be used to identify candidates for intervention with appropriate therapy in order to reduce an increased risk of BPH progression and improve their QoL EAU BPH guidelines Madersbacher S, et al. Eur Urol 2004;46:547 54 Roehrborn CG, et al. Urology 1999;53:581 89 Roehrborn CG, et al. Urology 1999;53:473 80 Jepsen JV, Bruskewitz RC. In: Lepor H, editor. Prostatic Diseases. Philadelphia: WB Saunders, 2000. p. 127 42
Urinalysis UTI Microhaematuria Diabetes Mellitus Recommended in most guidelines.
Routine assessment of male LUTS: EAU guideline recommendations A medical history must be taken from men with LUTS 4 A A validated symptom score questionnaire with QoL assessment should be used during the assessment of male LUTS and for re-evaluation of LUTS during treatment Physical examination including DRE should be a routine part of the assessment of male LUTS Urinalysis (dipstick/urinary sediment) must be used in the assessment of male LUTS PSA measurement should be performed only if a diagnosis of PCa will change the management or if PSA can assist in decisionmaking in patients at risk of progression of BPE Measurement of PVR in male LUTS should be a routine part of the assessment LE GR 3 B 3 B 3 A 1b A 3 B Gravas S et al. EAU guidelines 2016, available at www.uroweb.org
Ultrasound
Frequency volume chart Recording of volume and time of each void Additional information: fluids intake, use of pads, activities, symptoms score : Bladder Diary Relevant in nocturia Duration: 3 days or longer
Urodynamics Invasive Offered only when conservative treatment have failed Neurologic Disease
Cystoscopy Invasive Not responding to treatment Tumour Stricture
Assessment algorithm of LUTS in men 40 yr Gravas S et al. EAU guidelines 2016, available at www.uroweb.org
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