Lower Urinary Tract
Symptoms in Men
Dr Simon Chong SJ
MB BCh BAO, MRCS (Edinburgh), MMed (Surgery), FAMS (Urology)
Consultant, Department of Urology, Tan Tock Seng Hospital
Program Director, NHG Urology Residency Program
Senior Clinical Lecturer, Yong Loo Lin School of Medicine, NUS
EXCO Member and Honorary Treasurer of the Society for Men’s Health, Singapore
SHP symposium - 13 Jul 2013
Scope
• Approach to Lower Urinary Tract Symptoms in men
• Medical management of BPH
• PSA as a screening tool
SHP symposium - 13 Jul 2013
LUTS
• Voiding symptoms
• Storage symptoms
•
“Blocked flow”
•
“Cannot store”
•
Hesitancy
•
Frequency
•
Poor flow
•
Urgency
•
Dribbling
•
Nocturia
•
Interrupted flow
•
Sensation of incomplete
voiding
SHP symposium - 13 Jul 2013
EAU Guidelines 2013
SHP symposium - 13 Jul 2013
Campbell-Walsh Urology 10th edition
LUTS ≠ Prostatism ≠ BPH
SHP symposium - 13 Jul 2013
History
• Past medical history – DM, CCF, Parksinson’s etc.
• Past surgical history – TURP, bladder stone, IDC etc.
• Medication history – Diurectics, anti-psychotics etc.
• Social history – Tea, coffee, alcohol, smoking etc.
• Duration of LUTS.
• Gross haematuria.
• Urinary incontinence.
SHP symposium - 13 Jul 2013
Examination
• Gait
• Abdominal mass
• Distended bladder
• Inguinal hernia
• Penis – phimosis, hypospadius
• DRE
• Prostate size, consistency, nodule, tenderness
• Rectal / pelvic mass
• Anal tone
SHP symposium - 13 Jul 2013
Investigations
• Urine
• * Urine labstix or
UFEME
• Urine culture
• Urine cytology
• Blood
• Creatinine level
• * PSA level
• Imaging
• XR KUB
• US kidneys &
bladder
• IVU
• CT KUB / Urogram
• MRI prostate /
Urogram
SHP symposium - 13 Jul 2013
0 – 7 : Mild
8 – 19 : Moderate
20 – 35 : Severe
QOL
SHP symposium - 13 Jul 2013
SHP symposium - 13 Jul 2013
SHP symposium - 13 Jul 2013
SHP symposium - 13 Jul 2013
Bladder capacity
Compliance
Detrusor overactivity
Sensory urgency
BOO
Others
SHP symposium - 13 Jul 2013
SHP symposium - 13 Jul 2013
Treatment
•
Stop smoking
•
Lose weight if BMI is high
• Nocturia
•
Control other medical
conditions
Cut down fluid intake at
night.
•
Sleep with legs raised.
•
Modify drinking habit
•
Bladder training
•
Restrict certain beverages,
food.
•
Type of LUTS
• BPE
• OAB
•
SHP symposium - 13 Jul 2013
α1-blockers
•
3 subtypes of α1-receptors:
•
• A,B & D
• D present in SM of blood
vessels
IPSS decreases by about 3540%
•
Prostate volume and risk of
ARU remain the same.
•
Postural giddiness,
hypotension, retrograde
ejaculation & anejaculation
•
Intra-operative floppy iris
syndrome
•
Acts by relaxation of SM in
prostate, bladder neck and
blood vessels.
•
Terazosin / Hytrin
•
Alfuzoxin XL / Xatral XL
•
Tamsulosin OCAS /
Harnal OCAS
• During cataract surgery
• Avoid prior to surgery
SHP symposium - 13 Jul 2013
5AR-Is
•
5AR converts T to DHT.
•
•
DHT plays a role in prostatic
growth.
Decrease in prostate volume by
about 18-28% after 6-12 months.
•
IPSS decreases by about 2030%.
•
Decreases risk of ARU after >1
year of treatment.
•
Reduces PSA by 50% after 6-12
months.
•
Decreased libido, ED,
ejaculatory disorders, mastalgia,
gynaecomastia.
•
•
•
2 subtypes of 5AR
Finasteride (5mg OD) blocks
5AR type 2.
Dutasteride (0.5mg OD) blocks
both 5AR type 1 & 2.
SHP symposium - 13 Jul 2013
Anti-muscarinics
•
Muscarinic receptors present in
bladder
• M2 & M3
•
Reduces SM contractions.
•
Oxybutynin
•
Tolterodine / Detrusitol
•
Tolterodine SR / Detrusitol SR
•
Solifenacin / Vesicare
•
Trospium / Spasmolyt
•
Propiverine / Mictonorm
•
Treat OAB and secondary Detrusor
Overactivity
•
Improvement of:
•
•
•
•
IPSS
Voiding frequency
Nocturia
Episodes of urge incontinence
•
Contraindicated in glaucoma,
intestinal obstruction etc.
•
Dry eyes, dry mouth, constipation
•
About 3% risk of ARU especially if
large prostate or high PVRU.
SHP symposium - 13 Jul 2013
Antidiurectic
•
Increases water re-absorption
and decreases urine output.
•
Increase interval between
nocturnal voids.
•
Nocturnal polyuria
•
Headache, nausea, diarrhoea,
abdominal pain, dizziness,
dry mouth, and
hyponatraemia
•
Monitor serum Na closely
• Nocturnal urine output / total
24 hrs urine output > 33%
•
•
Desmopressin / Minirin 0.1
- 0.4 mg ON.
Decreases the number of
nocturnal voids by 0.8 – 1.3
times.
• D3, D7, 1 month, then 3-6
monthly
•
Peripheral oedema and
hypertension
SHP symposium - 13 Jul 2013
PDE5-I
•
•
•
•
Relaxes SM in the detrusor,
prostate and urethra.
Influences the
neurotransmission of the
micturition cycle.
Sildenafil, Vardenafil,
Tadalafil.
Tadalafil / Cialis 5mg OD.
•
IPSS decreases by 17-35%.
•
No data on risk of ARU.
•
Greater benefit in men with
ED and LUTS.
•
C/I: Nitrates
•
Headache, myalgia,
flushing, giddiness,
dyspepsia, nasal congestion.
SHP symposium - 13 Jul 2013
Phytotherapy
•
•
Anti-inflammatory,
antiandrogenic, or
oestrogenic effects
In proliferation of prostatic
cells
•
Inhibit a-adrenoceptors, 5areductase, muscarinic
cholinoceptors etc.
•
Improve detrusor function;
•
Neutralise free radicals
•
Permixon (Saw Palmetto)
•
Meta-analyses – Not more
effective than placebo.
•
Heterogenous and poorly
designed studies.
SHP symposium - 13 Jul 2013
Combination therapy
•
A1-blocker + 5ARI
• MTOPS and CombAT
A1-blocker + antimuscarinic
• Better symptom
improvement compared to
monotherapy
• Better symptom
improvement compared to
monotherapy
• Decrease risk of ARU same
as 5ARI monotherapy
• About 3% risk of ARU
• Decrease need for BPErelated surgery
•
•
A1-blocker + 5ARI + antimuscarinic
• Not data
•
Cost / Benefit / Side-effects
SHP symposium - 13 Jul 2013
When to refer on?
•
Red flags:
• Gross haematuria
•
Complications of BPE:
• Urinary incontinence
• Renal failure secondary to
BOO.
• Abnormal DRE
• ARU
• Raised PSA
• Bladder stone
•
Not responding to medical
treatment.
•
Unable to tolerate sideeffects of treatment.
• Recurrent UTI
• Recurrent gross haematuria
SHP symposium - 13 Jul 2013
Minimally-invasive therapy
•
Balloon dilatation
•
Prostatic stents
•
•
•
Transurethral Needle
Ablation (TUNA)
Transurethral Microwave
Thermotherapy (TUMT)
Transurethral WaterInduced Thermotherapy
(WIT)
•
High Intensity Focused
Ultrasound (HIFU)
•
Radiofrequency ablation
(RFA)
•
Botox injection
•
Ethanol injection
Surgical therapy
•
TURP
• Bipolar
• Monopolar
•
•
Laser vapourisation (PVP,
HOLAP)
Laser enucleation (HOLEP)
•
TUBNI
•
TUVP
•
TUEP
•
Open prostatectomy
PSA & prostate cancer
•
Serum glycoprotein.
•
Raised in:
• Prostate cancer
• BPH
• Prostatitis,
• Catheterization, cystoscopy,
biopsy
• Urinary retention
• Vigorous prostatic massage
•
Surrogate for BPH
progression (>1.5 ng/ml)
•
Baseline test for PCa.
•
Absolute number
• PSA < 1, next check after 8
years.
• PSA > 4
• PSA > 20
SHP symposium - 13 Jul 2013
SHP symposium - 13 Jul 2013
PSA & prostate cancer
•
PSA trend
•
Free/Total PSA
•
Prostate health index
• Pro-PSA, free-PSA and total
PSA.
•
Risk of prostate cancer
• Increasing age (>50)
• Ethnic origin
• Genetic predisposition
• 1 1st-line  2X
• >1 1st-line  5-11X
SHP symposium - 13 Jul 2013
Who to offer PSA testing to?
•
At risk groups.
•
Good co-morbidity.
•
Life expectancy > 10 yrs.
•
Risk of PSA testing:
•
General screening not
advocated.
•
Proper discussion about
PSA test
• Biopsy
• PSA anxiety
• Complications from PCa
treatment
SHP symposium - 13 Jul 2013
AUA statement

PSA screening in men under age 40 years is not recommended.

Routine screening in men between ages 40 to 54 years at average risk is not
recommended.

For men ages 55 to 69 years, the decision to undergo PSA screening involves
weighing the benefits of preventing prostate cancer mortality in 1 man for every
1,000 men screened over a decade against the known potential harms
associated with screening and treatment. For this reason, shared decisionmaking is recommended for men age 55 to 69 years that are considering PSA
screening, and proceeding based on patients’ values and preferences.

To reduce the harms of screening, a routine screening interval of two years or
more may be preferred over annual screening in those men who have
participated in shared decision-making and decided on screening. As compared
to annual screening, it is expected that screening intervals of two years preserve
the majority of the benefits and reduce over diagnosis and false positives.

Routine PSA screening is not recommended in men over age 70 or any man
with less than a 10-15 year life expectancy.
SHP symposium - 13 Jul 2013
Scenario 1
• A 55 year old chinese male has come for his routine visit to review his hypertension. He complains of difficulty initiating urination and poor stream occasionally for the past 1 month.
• Medication: nifedipine LA 30mg om and simvastatin 10mg on
• Examination : BP 130/74 no palpable bladder
• PR : prostate smooth normal size
SHP symposium - 13 Jul 2013
• Investigations : UFEME 0 RBC 2 WBC 2 EC
SHP symposium - 13 Jul 2013
How would you manage this patient?
1. Start dutasteride and review in 4 weeks
2. Watchful waiting
3. Refer to our friendly urologist for further management
SHP symposium - 13 Jul 2013
Scenario 2
• A 60 year old man is complaining of poor stream and urinary frequency for the past few months. He has been seen by a urologist a few months ago and is currently on dutasteride. He feels the medicine is not working.
• Examination: no palpable bladder
• PR: smooth, 4.5 finger breadth prostate
SHP symposium - 13 Jul 2013
How would you manage this patient?
1. Add an alpha‐blocker and tell him to monitor for improvement of his symptoms.
2. Switch to an alpha‐blocker and review him in 2 weeks.
3. Advise him to go and see his urologist as he probably requires surgery for his condition.
SHP symposium - 13 Jul 2013
Scenario 3
• A 52 year old obese lawyer comes to you requesting for screening tests for prostate cancer. His colleague was just recently diagnosed with cancer and he is worried. His elder brother has an ‘enlarged prostate’
and his uncle has prostate cancer. He is currently asymptomatic.
SHP symposium - 13 Jul 2013
• PR: smooth, normal sized prostate
SHP symposium - 13 Jul 2013
How would you manage this patient?
1. Explain to him that a PSA test is not recommended as a screening tool for prostate cancer and tell him it is unlikely he has cancer.
2. Refuse to do a PSA test as it is poorly correlated with the probability of cancer. Alternatively, refer him to a urologist for ‘other’ screening tests.
3. Order a PSA test and refer him to the urologist if it is >4ng/ml
SHP symposium - 13 Jul 2013
- Approach to Lower Urinary Tract Symptoms in men
- Medical management of BPH
- PSA as a screening tool
A 55 year old chinese male has come for his routine
visit to review his hypertension. He complains of
difficulty initiating urination and poor stream
occasionally for the past 1 month.
Medication: nifedipine LA 30mg om and
Simvastatin 10mg on
Examination : BP 130/74 no palpable bladder
PR : prostate smooth normal size
Investigations : UFEME 0 RBC 2 WBC 2 EC
A. Start dutasteride and review in 4 weeks
B. Watchful waiting
C. Refer to our friendly urologist for further
management
[Default]
[MC Any]
[MC All]
A 60 year old man is complaining of poor stream
and urinary frequency for the past few months.
He has been seen by a urologist a few months
ago and is currently on dutasteride. He feels the
medicine is not working.
Examination: no palpable bladder
PR: smooth, 4.5 finger breadth prostate
A. Add an alpha-blocker and tell him to monitor
for improvement of his systems.
B. Switch to an alpha-blocker and review him in
2 weeks.
C. Advise him to go and see a urologist as he
[Default]
[MC Any]probably requires surgery for his condition.
[MC All]
A 52 year old obese lawyer comes to you requesting for
screening tests for prostate cancer. His colleague was
just recently diagnosed with cancer and he is worried.
His elder brother has an ‘enlarged prostate’ and his
uncle has prostate cancer. He is currently asymptomatic.
PR: smooth, normal sized prostate
A. Explain to him that a PSA test is not recommended
as a screening tool for prostate cancer and tell him it
is unlikely he has cancer.
B. Refuse to do a PSA test as it is poorly correlated with
the probability of cancer. Alternatively, refer him to a
urologist for ‘other’ screening tests.
[Default]
[MCC.
Any]
Order a PSA
[MC All] >4ng/ml
test and refer him to the urologist if it is