Lower Urinary Tract Symptoms K Kuruvilla Zachariah Associate Specialist

Lower Urinary Tract Symptoms K Kuruvilla Zachariah Associate Specialist

Lower Urinary Tract Symptoms Storage Symptoms Frequency, urgency, incontinence, Nocturia Voiding Symptoms Hesitancy, poor flow, intermittency, Straining, terminal dribbling Post Micturition dribbling

Lower Urinary Tract Symptoms Pain UTI Haematuria Painful: Painless: UTI Malignancy, Prostatic

CLINICAL ASSESSMENT History Storage vs Voiding Mixed Symptoms Clinical Examination Abdominal Examination to exclude retention of urine Examine the foreskin and external urinary meatus Rectal examination in males to assess the prostate Consider PSA Testing after counselling.

In Women Vaginal Examination to look for Stress incontinence Prolapse and Pelvic floor contraction Urinalysis?UTI CLINICAL ASSESSMENT

STORAGE SYMPTOMS Excessive intake of liquids (polyuria) Overactive Bladder Voiding Diary Check fluid and Caffeine intake

Bladder diary / Frequency volume chart Time Polyuria Overactive 3 am 300 ml 100ml 5am 200ml 50ml 7.30am 300ml 100ml 9.30am 75 ml 11am 400ml 115ml 12 noon 250 100ml 1pm 400ml 70ml Total 1850 580

Management of LUTS

OVERACTIVE BLADDER Caffeine and Fluid advice first Bladder drill Drug Treatment if no response Antimuscarinics ( Oxybutinin etc.) Beta3 agonists (Mirabegron) Refer to Urologist if drug treatment fails.

POLYURIA Daytime: Restrict liquids Nocturnal Polyuria: if urine output > 30% at night Stop all liquid intake 4 hours before bed for Nocturia Treat Cardiac failure and oedema Small dose of diuretic in the afternoon Refer to endocrinologist

CYSTITIS Frequency Dysuria Urgency Bladder Pain Haematuria Offensive urine

STORAGE SYMPTOMS Urinary Incontinence Definition: Any involuntary leakage of urine

INCONTINENCE Remember 3 Main Types Stress UI: Involuntary leakage of urine on effort or exertion or on sneezing or coughing Urgency UI: involuntary leakage of urine accompanied by or immediately preceded by urgency Chronic retention with overflow

INCONTINENCE Mixed UI: involuntary leakage of urine associated with urgency and Stress incontinence Nocturnal Enuresis: Involuntary loss of urine occurring during sleep

Stress Incontinence Pelvic floor excercises Refer to Physiotherapy Weight Loss if BMI > 30 Refer for Surgery TVT/ TOT Sling operations Colposuspension TREATMENT OF INCONTINENCE

Urgency Urinary Incontinence TREATMENT OF INCONTINENCE Life Style Advice as for Overactive Bladder If no response Antimuscarinics or Beta 3 Agonists as per guidelines If no response refer to Urology Urodynamics to establish exact cause. Further Pharmacotherapy Botox Injection Intravesical Sacral Neuromodulation

Bladder Outlet Obstruction BPH Bladder Neck Stenosis Urethral Stricture Meatal Stenosis and Phimosis Voiding Symptoms Hypocontractile Bladder ( Atonic Bladder) Myogenic e.g. chronic retention Neurogenic e.g. Diabetes Other causes, Drugs, age related, post radiotherapy

Management of Voiding Symptoms Abdominal Examination To rule out distended bladder Rectal Examination to assess prostate Examination of the Foreskin and External Urinary Meatus Renal Function Tests

Management of Voiding Symptoms If abnormal Renal Function or distended bladder Urgent Ultrasound of Urinary Tract Urgent Catheterisation if obstructive uropathy. Urgent referral to Emergency Care If normal renal function and empty bladder IPSS ( International Prostate Symptom Score) Flow rate and Ultrasound Residual Urine (if available) Medical Treatment

Management of LUTS Flow Rate Normal Prostatic Obstruction

Management of Voiding Symptoms MEDICAL TREATMENT Watchful Wait Alpha Adrenergic Blocker (Tamsulosin) 5Alpha Reductase Inhibitor (Finasteride) if enlarged prostate. (Consider PSA testing) Combination Pharmacotherapy

Management of Voiding Symptoms If no response to medical treatment Residual Urine > 300 ml Refer to Urology To consider TURP

Management of Voiding Symptoms URETHRAL STRICTURE Optical Urethrotomy

Management of Voiding Symptoms CHRONIC RETENTION Watchful Wait CISC INDWELLING CATHETER SUPRAPUBIC CATHETER

Management of LUTS ANY QUESTIONS?

Thank you

Weight loss and continence 12 women lost 33% weight and 9 regained continence 138 women lost 50% weight and the rate of incontinence fell from 61% to 12% 195 patients lost 46% weight and 64% reported improved continence

Pelvic floor exercises Stress incontinence and mixed incontinence. At least 8 contractions x 3/day for 3 months Not helpful for OAB