2008

Causes of symptoms
Hyperplasia of epithelial and stromal

components of prostate
Progressive obstruction of urinary
outflow
Increased activity of detrusor muscle
Causes
Frequency, nocturia
Poor flow , intermittent stream
Hesitation, terminal dribbling

Prevalence
Men > 50 = 41% have

symptoms of LUTS
Only 18% have a diagnosis
Only 10% aware of drugs or
surgery that will help it

Risk factors
Age
? obesity

Differential diagnosis
Poorly controlled diabetes
Neurological disorders
Urinary tract infections
Abacterial prostatitis
Overactive bladder
Drugs diuretics, anticholinergics,

antidepressants
Lifestyle factors caffeine, alcohol, xs
fluids

Abnormal symptoms
The presence of the following

symptoms indicates referral to

urologist for futher assessment
Urinary incontinence
Retention
Dysuria
Haematuria
Acute change in symptoms

Examination
Palpation of abdomen for
enlarged bladder
enlarged kidneys
constipation

Rectal examination for

Size and consistency of prostate

gland

Investigations
Blood tests
Fbc esr
U&es
Fasting blood sugar
? PSA level rises with increasing

volume of prostate gland

Urinalysis
Infection
haematuria

Investigations
Additional tests as

appropriate by GP
Ultrasound for residual urine

volume
Urinary diaries

Specialist
investigations
Reasons for doing them
Patient reassurance
Patient explanation
Objective assessment of symptoms
Diagnostic precision
Ranking of treatment options
Prediction of treatment outcome

Specialist
investigations
Uroflowmetry
max flow rate and volume of residual urine

after voiding low flow rate indicates need for

TURP

Bladder pressure studies

pressure measurement during filling and

emptying (cystometry) gives information on

over/under activity of detrusor muscle and
obstruction of bladder outlet. Predicts response
to treatment. Use antimuscarinics for over
activity and turp for bladder outlet obstruction

Specialist
investigations
Urinary tract imaging
Ultrasound to estimate residual urine

Urethroscopy
Visual inspection of bladder and uerethra

is used in dysuria or haematuria

Assesment
A validated questionnaire using

international prostate symptom scale.

Completion gives total score of 35
1 7 mild
8 19 moderate
20 35

severe

Response to the quality of life

questionnaire strong predictor or

whether intervention is necessary

Scoring system
Ask 7 questions. Answers on scale 0 5

depending on severity of symptoms

For first 6 questions scores are

Not at all = 0
< 1 in 5
=1
< half the time = 2
About half the time
> half the time = 4
Almost always = 5

=3

Q7
Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4,
5x = 5

Questions
In last month how often have you
1. Had sensation of not emptying bladder
completely
2. Had urge to urinated < 2 hours after previously
finished
3. Found you stopped and started again several
times
4. Found it difficult to postpone urination
5. Had a weak stream (compared to when aged 30)
6. Had to push or strain to begin urination
7. How many times did you get out of bed per
night to urinate

Quality of life
If you were to spend the rest of your

life with your urinary condition the way

it is now, how would you feel about
that?
Delighted

0
Pleased
1
Mostly satisfied 2
Mixed feelings
3
Mostly dissatisfied
Terrible
5

Management
Lifestyle modification
Reduce fluid intake
Stop diuretics if poss
Avoid xs night time fluid

intake/caffeine /alcohol
Empty bladder before long
trips/meetings

Management
Treat co morbid contributing

conditions
Diabetes
uti

Management
Drug therapy
Alpha blockers
Improve bladder and prostate
smooth muscle tone
More effective than 5 alpha
reductase inhibitors
All work equally well
Tamsulosin and alfuzosin require no
dose titration

Management
Drug therapy
5 alpha reductase inhibitors
Reduce prostate volume
Reduces risk of prostate cancer, increases
risk of high grade disease
Combined therapy
Men with large prostate > 40g or PSA >4 or
moderate to severe symptoms combined
therapy will prevent 2 episodes of clinical
progression per 100men over 4yrs. Much
less effective for men with smaller
prostates

Management
Drug therapy
Storage problems
Men with symptoms of urinary urgency,
frequency, small, urine volumes and
nocturia in the absence of serious
obstructive symptoms are categorised as
over active bladder
Bladder training
Biofeedback
Antimuscarinic drugs ( oxybutinin,
tolteridine) alone or in combination with
treatment for obstructive symptoms

Management
Surgery
TURP
Greatest improvement in symptoms
5% severe haemorrhage risk
Requires GA
Alternative energy sources for TURP
Ultrasound
Laser
microwave

Management
Surgery
Adverse effects of surgery
Loss of ejaculation
Erectile dysfunction
Retrograde ejaculation
Incontinence
Stricture formation
Urinary retention