LUTS A plea for a holistic approach. HUBERT GALLAGHER, MCh; FRCSI, FRCSI(Urol) Head of Urology Beacon Hospital

LUTS A plea for a holistic approach. HUBERT GALLAGHER, MCh; FRCSI, FRCSI(Urol) Head of Urology Beacon Hospital

LUTS- Classification Men LUTS can be divided into: Storage Voiding Frequency Nocturia Urgency +/- incontinence Enuresis Leaking/SUI Weak flow intermittency Hesitancy Straining Postmicturition Incomplete emptying Post micturition dribbling Women

LUTS The Storage Symptoms Problem LUTS has traditionally concentrated on men with prostate trouble and women with bladder trouble. Both men and women report storage and postmicturition symptoms suggesting that Storage LUTS are not sex specific and are not related to the prostate. LUTS are a common problem and cause considerable impact on QoL.

LUTS and Gender Both men and women suffer nearly equally from voiding symptoms traditionally regarded as prostate symptoms. In women this may represent detrusor underactivity whereas in men it may be DUA and/or BOO. Women suffer significantly more storage type symptoms and incontinence as might be expected. Stress incontinence is mainly a female symptom in the absence of prior prostatic surgery. Storage symptoms are often much more bothersome than voiding symptoms

Why do LUTS occur? Aging Cardiovascular disease Obstructive sleep apnoea Obesity Metabolic Syndrome Diabetes Smoking Infections Neurogenic cause Reduction in functional abilities

MetS/CVD and LUTS/BPH Metabolic Syndrome Insulin resistance Hormonal changes Pelvic atherosclerosis Inflammation High insulin level High IGF-1 level Lower IGF-1 binding High cytosolic free Ca++ in smooth muscle and neural cells Increased oestradiol Lower testosterone Ischaemia Cytokine release Sympathetic nervous system activation Increased smooth muscle tone LUTS/ BPH

Preventing LUTS/BPH by preventing/treating CVD CVD and LUTS occur in the same population and increase with age and an aging population. Risk factors for CVD are also risk factors for LUTS and BPH Smoking Obesity Diabetes Metabolic syndrome Hyperlipidaemia Diet high salt and fat intake Hypertension

Preventing LUTS/BPH by preventing/treating CVD Treating LUTS like CVD as a lifestyle issue may improve or prevent deterioration. Exercise has been shown to reduce mediators of inflammation Regular exercise has been shown to reduce the risks of LUTS/BPH by 24-40% A diet including vegetables, chicken and bread were associated with less OAB symptoms whereas carbonated drinks, smoking and obesity were associated with OAB in women. Dietary Lycopenes, B-carotene, carotenoids and Vitamin A reduced LUTS by 40-50% perhaps by an anti-inflammatory effect. Multiple studies show that statins delay or reduce LUTS 1-2 standard measures of alcohol daily is a associated with a 20-40% risk reduction and LUTS!

OSA and Co-morbidities Obstructive breathing and its associated co-morbidities may lead to bothersome nocturia Hypertension Nocturia has a detrimental effect on quality of sleep and quality of life By treating obstructive breathing, LUTS can improve. Diabetes OSA NP Obesity CPAP reduces nocturia episodes Lifestyle advice may also improve obstructive breathing and nocturia If you don t ask you won t find!! Cardiovascular events

Association between obstructive breathing and LUTS Mechanism 1 Increased airways pressure Hypoxia Pulmonary vasoconstriction Increased ANP production Increased right atrial transmural pressure Increased sodium and water excretion Nocturnal polyuria NOCTURIA

Association between obstructive breathing and LUTS Mechanism 2 Increased airways pressure Hypoxia Increased Catecholamines Glycosuria Increased Insulin Resistance Increased water excretion Nocturnal polyuria NOCTURIA

When to refer to urology? Many patients can be managed in primary care provided a careful history and physical examination (including DRE) are performed. Allows the GP to assess the severity and bothersomness of LUTS IPSS score is helpful for initial assessment and for assessing response to treatment Referral is mandatory for the following patients: 1: Haematuria 2: Urinary infection in men and recurrent infections in women 3: Nocturnal enuresis of recent onset (likely chronic retention) 4: Straining to void, intermittency or deteriorating flow 5: Failure to respond to initial treatment and persisting symptoms 6: Pneumaturia (implies colo- or entero-vesical fistula 7: Raised PSA or abnormal DRE 8: Concomitant neurological conditions

LUTS - Severity IPSS Scores allow easy assessment of symptom severity and bothersomness Easy to apply, reproducible Can be used to determine alterations in symptoms and responses to treatment Many men minimize symptoms and underestimate their symptoms IPSS Score 0-7 Mildly symptomatic IPSS Score 8-19 Moderately symptomatic IPSS score 20 35 Severely symptomatic

Medical Management of LUTS/BPH Voiding symptoms Predominantly voiding symptoms Storage symptoms Predominantly storage symptoms Small prostate (<40cc) Exclude urinary infection/haematuria Alpha-blocker (male) Frequency volume chart Large prostate (>40cc) Lifestyle advice Alpha-blocker Fluids 5-ARI Caffeine Combination therapy Pre-emptive voiding Mixed storage and voiding symptoms Add in anti muscarinic Beta-3 alpha adrenergic receptor agonist (mirabegron) Travel-john Bladder retraining Pelvic floor physiotherapy Refractory or persisting symptoms Trial of an either an anti muscarinic or mirabegron

Patient 1 Assessment/History 72 year old man Increasing PSA over 10 years (9.5ng/mL) MRI and negative biopsy 2014 N x 2; Frequency+ Small volumes Urgency+ Occasionally Flow slow but steady Father TURP; CaP age 94 Smoker Moderate Claudication/PVD Moderate to large BPH on DRE Investigations 3T mpmri prostate 65cc gland; no suspicious lesion Repeat PSA 11.9ng/mL Calcified lesion in bladder Flexible Cystoscopy very obstructive prostate; Intravesical middle lobe; bladder calculus; trabeculated bladder with diverticulae. UTI while waiting for TURP Histology 31.5g resection; BPH with acute and chronic prostatitis.

Flow Rates Pre-op Flow Rate Post Op Flow Rate

Patient 2 Assessment/history Investigations 63 yo Female P2 G2; infrequent attender; post menopausal FVC: functional capacity 450mls, output ~2L/day; N x 2; D x 6-7 Constant desire to void, followed by urgency and incontinence x 6/12 Tolterodine no help, mirabegron significantly improved things N x 2; D 4-5; flooded on occasion; no GSI; currently with Meds N x 1 and D 3. No cystitis. Water: a reasonable amount; Tea 8/day Ongoing low back pain aggravated by movement and when bad aggravates urinary symptoms Impression: Sensory urgency due to low back discomfort and increased tone in pelvic musculature; failure to relax pelvic muscles. US Kidneys and pelvis normal MSU Normal Flexible cystoscopy normal; no prolapse; normal introitus, no GSI Post void residual: Nil Advices: Reduce caffeine intake Continue mirabegron for moment aim to stop after pelvic floor physiotherapy. Refer for pelvic floor physiotherapy Over active abdominal muscles with bracing of diaphragm and poor pelvic floor excursion and good vaginal tone and power. Soft tissue work on abdomen and reeducation of breathing technique