Lower Urinary Tract Symptoms (LUTS)

dr. Putra Hendra SpPD

UNIBA BATAM

Definition:
LUTS, or lower urinary tract symptoms , is a

common term used to describe the range of urinary symptoms as frequency, urgencyetc , which was previously called prostatism but this has been replaced by LUTS because the prostate is most often not the cause.

LUTS had been categorized into:

1. Storage (irritative ) symptoms

2. Voiding( obstructive) symptoms

3. Post voiding symptoms

Understanding Lower Urinary Tract Symptoms (after Abrams, Bristol, UK)

Detrusor Instability Bladder Hypersensitivity
Bladder Outlet Obstruction Detrusor Failure

Storage Symptoms Frequency Nocturia Urgency Urge incontinence Bladder Pain

Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining Terminal dribble

Causes of LUTS:
In males: Outflow obstruction
BPH Meatal stenosis

Impaired detrusor function

NM dysfunction Detrusor instability Impaired detrusor contractility Psychogenic voiding dysfunction

CONT

Infection

Cystitis, prostatitis, prostatic abcess and urethral diverticulum.

neoplastic Others:

Prostatic cancer, bladder cancer Bladder diverticulum, stone and interstitial cystitis.

In females :
Mostly storage symptoms
UTI Pregnancy Anxiety Overactive bladder Interstitial cystitis Postmenopausal urogenital atrophy Bladder tumor or stone Genital prolapses or pelvic mass

Mostly voiding symptoms

Age related detrusor muscle weakness Obstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis) Urethritis Drugs ( diuretics, alcohol, lithium, anticholinergics)

What happens with aging?

Smaller bladder capacity increased bladder irritability decreased bladder emptying genitourinary atrophy concurrent conditions
stroke, dementia, PD, BPH, DM

Incidence of Subtypes of Urinary Incontinence in Women

Stress Incontinence 50% Urge Incontinence 20% Mixed 30%

Storage symptoms:
Daytime frequency Urgency: sudden desire for urination that is

difficult to postponed. Nocturia : urinary urgency that awakens the pt. from sleep. Urge incontinence Enuresis: incontinence during sleep.

Voiding symptoms
hesitancy: delay in starting micturation. Intermittent folw Weak stream: diminished force and caliber with
prolonged voiding time. Double voiding Straining to void Terminal dribbling

Post void symptoms

Post void dribbling Feeling of incomplete emptying

GOTTA GO, GOTTA GO!!!!!!!!

Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability, irritable bladder, spastic bladder

Most common cause of UI >75 years of

age Abrupt desire to void cannot be suppressed Usually idiopathic Causes: infection, tumor, stones, atrophic vaginitis or urethritis, stroke, Parkinsons Disease, dementia

Potentially Reversible Causes

D I A P P E R S Delirium Infection Atrophic vaginitis or urethritis Pharmaceuticals Psychological disorders Endocrine disorders Restricted mobility Stool impaction

Medications That May Cause Incontinence Diuretics Anticholinergics - antihistamines, antipsychotics, antidepressants Seditives/hypnotics Alcohol Narcotics -adrenergic agonists/antagnists Calcium channel blockers

Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity
>90%)

Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture Simple (bedside) Cystometrics

Cont.

Investigation

*Assessment ot upper tract:

Only for pt with hematuria , recurrent UTI or history of urinary stones is present. # U/S of the kidneys and bladder #CT urography # (IVU) intravenous urogram

US

Ascending Urethrogram

Cont.

Investigation

2- voiding cystourethrogram(VCUG):
Is performed by filling the bladder with radiographic contrast agent through a urethral catheter or suprapubic tube . The process is monitoring by fluoroscopy .static film are obtained with the bladder full, during micturation and after voiding. . VCUG is excellent method of diagnosing vesical neck obstruction and vesicoureteral reflux.

Cont.

Investigation

*Uroflowmetry:

an electronic flowmeter can provide a recording of urinary flow rate

*Cystourethroscopy * Cystometry:

Endoscopy permits direct visualization of the entire urinary tract .

is continuous recording of bladder pressure during gradual filling and during contraction .indication in any neuralgic disease is suspect

Treatment Options
Bladder training
Patient education Scheduled voiding Positive reinforcement

Pelvic floor exercises (Kegel Exercises) Biofeedback Caregiver interventions

Scheduled toileting Habit training Prompted voiding
2

Pharmacological Interventions
Urge Incontinence
Oxybutynin (Ditropan) Propantheline (Pro-Banthine) Imipramine (Tofranil)

Stress Incontinence
Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed) Estrogen (orally, transdermally or transvaginally)

Surgical Interventions
Surgery is reported to cure 4 out of 5 cases, but success rate drops to 50% after 10 years.

Urethral Hypermotility

Marshall-MarchettiKantz procedure Needle neck suspension

Intrinsic sphincter
deficiency
Sling procedure

Other Interventions
Pessaries Periurethral bulking agents (periurethral
injection of collagen, fat or silicone) Diapers or pads Chronic catheterization
Periurethral or suprapubic Indwelling or intermittant

Pessarie s

TREATMENT
*Obstructive ureter:
- Suprapubic cystostomy - Ureteric catheter drainage

- Uretheral catheter drainage

Cont

TREATMENT

A. Distal urethra:

*Urethral strictures: -Dilation - - Visual urethrotomy transurethral balloon dilation catheter - Urethroplasty *Meatal stenosis: -Dilation -surgical meatotomy

BENIGN PROSTATE HYPERTROPHY

What causes BPH?

BPH is part of the natural aging process, like getting gray hair or wearing glasses BPH cannot be prevented BPH can be treated

BPH

The size of prostate enlarged microscopically since the age of 40.Half of all men over the age of 60 will develop an enlarged prostate By the time men reach their 70s and 80s, 80% will experience urinary symptoms
But only 25% of men aged 80 will be receiving BPH treatment

Top 10 Diagnosed Diseases in Men Age 50 Years

Rank 1 2 3 4 5 6 7 8 9 10 Disease Coronary Artery Disease/Hyperlipidemia Hypertension Diabetes Mellitus Type 2 Enlarged Prostate Osteoarthritis Arrhythmias Cataract Gastroesophogeal reflux disease Bursitis Prostate Cancer 1-year prevalence (%) (n = 963,452 personyears) 51.3 45.2 17.5 13.5 13.3 8.8 8.6 8.4 8.0 7.8

Issa MM et al. Am J Manag Care. 2006;12(suppl):S83S89.

Anatomy of BPH
Normal BPH

BLADDER

PROSTATE URETHRA

Hypertrophied detrusor muscle Obstructed urinary flow

Roehrborn CG, McConnell JD. In: Walsh PC et al, eds. Campbells Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:1297-1336.

Clinical Presentation of BPH

Obstructive Symptoms Incomplete emptying Intermittency Weak stream Hesitancy

Irritative Symptoms Nocturia Frequency Urgency

Prevalence of BPH
Around 25% in men aged 40-49 years Around 50% in men aged 70 and older
Source: J Urol 1984;132:474

Risk factors
-Age : at late 40s only 3.5% of men at 80s it raise to 35% -Ethnic

groups: African American at high risk

Asian at low risk

-Family history -Medical condition :

Obesity Heart and circulatory disease Type 2 DM

The initial evaluation of all patient presenting with LUTS suggestive of BPH should include:
-Medical history -Digital rectal exam DRE -Neurological exam -Urinalysis

The DRE :
-A benign prostate: Feels smooth Symmetric -Prostate cancer Palpable nodule Feel hard Asymmetric gland

Protocol for the management of BPH

IPSS Score Management
Mild IPSS<7 Flow Rate >15 mls/s Resid vol < 100 mls Watchful Waiting

Moderate IPSS 7-20 Flow rate < 15mls/s Resid vol <200 mls

alpha-blockers: Refer if no improvement

Severe IPSS > 20 Flow rate < 10 mls/s Resid vol > 200 mls

Refer to the Urology Department

Treatment Modalities for BPH

Watchful waiting Medical therapy
Phytotherapy -adrenergic blockers 5-reductase inhibitors Combination therapy

Surgicenter/Hospital-based
treatment
TURP (gold standard) TUIP Open surgery (prostatectomy) TUVP ILC VLAP Prostatic stents

Office-based treatment
TUMT TUNA WIT

Chatelain C et al. In: Chatelain C et al, eds. Benign Prostatic Hyperplasia. Plymouth, UK: Health Publication Ltd; 2001;519-534. McConnell JD et al. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Clinical Practice Guideline, Number 8.

Drugs for Medical Management

Alpha Blockers: Alfuzosin Doxazosin Tamsulosin Terazosin
Hormonal: Finasteride Dutasteride

Combination: Alfuzosin/finasteride Doxazosin/finasteride Terazosin/finasteride

Cumulative Incidence of Progression of Benign Prostatic Hyperplasia

McConnell, J. et al. N Engl J Med 2003;349:2387-2398

Combination Therapy: A Unique Approach

Combination Activates Two Distinct and Complementary Mechanisms of Action

Alpha blockers
Improve symptoms and increase urinary flow rate by relaxing prostatic and bladderneck smooth muscle through sympathetic activity blockade

5-Alpha reductase inhibitors

Improve symptoms, increase urinary flow rate, and prevent BPH outcomes by reducing prostate enlargement through hormonal mechanisms

Source: Roehrborn CG Curr Opin Urol 2001;11:17-25 National Cancer Institute. NIH Publication No. 99-4303, 1999.

ribution of 1-Adrenergic Receptors

Localization of 1-Adrenergic Receptors (1-ARs)

TURP

(transurethral resection of the prostate)

Gold Standard of care for BPH

Uses an electrical knife to surgically cut and remove excess prostate tissue Effective in relieving symptoms and restoring urine flow

Transurethral Microwave Therapy

Microwave energy

causes tissue necrosis Cooling channels in catheter cool urethra

Trans-Urethral Resection of Prostate