EAU 2020 Non-Neurogenic Male LUTS Flashcards
Definition:
Acute urinary retention
Acute retention of urine is defined as a painful, palpable or percussible bladder, when the patient is unable to pass any urine.
Definition:
Chronic urinary retention
Chronic retention of urine is defined as a non-painful bladder, which remains palpable or percussible after the patient has passed urine. Such patients may be incontinent.
Definition:
Bladder outlet obstruction
Bladder outlet obstruction is the generic term for obstruction during voiding and is characterised
by INCREASED DETRUSOR PRESSURE and REDUCED URINE FLOW RATE. It is usually diagnosed by studying the
synchronous values of flow-rate and detrusor pressure
Definition:
Benign prostatic obstruction
A form of BOO and may be diagnosed when the cause of outlet obstruction is known to be BPE.
Definition:
Benign prostatic hyperplasia
Benign prostatic hyperplasia is a term used (and reserved) for the typical histological pattern, which
defines the disease.
Definition: Detrusor overactivity (DO)
Detrusor overactivity (DO) is a urodynamic observation characterised by INVOLUNTARY DETRUSOR CONTRACTIONS during the FILLING PHASE which may be spontaneous or provoked.
Definition:
Overactive bladder syndrome
Overactive bladder syndrome is characterised by urinary URGENCY, with or without urgency urinary incontinence, usually with INCREASED DAYTIME FREQUENCY and NOCTURIA, if there is no proven infection or other obvious pathology
Frequency volume charts record:
A bladder diary records:
FVC: volume and time of each void
Bladder diary: FVC + fluid intake, use of pads, activities during recording, symptom scores
___ and ___ day FVCs provide reliable measurement of urinary symptoms in patients with LUTS.
Three and seven day FVCs.
Recommendation:
Use a bladder diary to assess male LUTS with:
A prominent storage component or nocturia.
Recommendation:
Tell the patient to complete a bladder diary for at least ____ days.
Three
DRE has ______ correlation to actual prostate volume, especially where volume > 30 mL.
Poor correlation
Recommendation:
Perform a physical examination including ____ in the assessment of male LUTS.
DRE
Recommendation: Use urinalysis (by \_\_\_\_ or \_\_\_\_\_) in the assessment of male LUTS.
Dipstick or urinary sediment
Age-specific criteria (PSA level) for detecting men with prostate glands > 40 mL:
50s: ___
60s: ___
70s: ___
50s: > 1.6 ng/mL
60s: > 2.0 ng/mL
70s: > 2.3 ng/mL
Recommendation:
Measure prostate-specific antigen (PSA) if: ___ and ___
If a diagnosis of prostate cancer will change management
AND
if it assists in the treatment and/or decision making process.
Recommendation:
Assess renal function if: ___
Renal impairment is suspected based on history and clinical examination, or in the presence of hydronephrosis,
OR
when considering surgical treatment for male LUTS.
The diagnostic accuracy of PVR measurement, using a PVR threshold of ______, has a PPV of 63% 3 and a NPV of 52% for the prediction of ____.
50 mL
BOO
Uroflowmetry:
Key parameters (2): ____, ____
Voided volume should be: _____
Repeat uroflow if (2): ____ or _____
Key parameters : Qmax, flow pattern
Voided volume should be: >150mL
Repeat uroflow if (2): <150 mL voided volume or abnormal flow pattern
Recommendation:
Perform uroflowmetry in the initial assessment of male LUTS and _______.
Prior to medical or invasive treatment.
Is VCUG recommended in the routine diagnostic workup of male LUTS?
No.
BUT, it may be useful for the detection of vesico-ureteral reflux, bladder diverticula, or urethral pathologies. RUG may be useful for stricture evaluation.
Patients with (3) ______ who present with LUTS should undergo urethrocystoscopy.
Micro or gross hematuria
Urethral stricture
Bladder cancer
Recommendation:
Perform urethrocystoscopy in men with LUTS prior to ____ if _____.
Prior to minimally invasive/surgical therapies if the findings may change treatment.
Recommendation:
Perform PFS in the following situations (5):
- Previous unsuccessful (invasive) treatment for LUTS)
- Considering invasive treatment but cannot void >150mL
- Considering surgery, predominantly voiding LUTS, Qmax > 10 mL/s
- Considering invasive therapy, bothersome voiding LUTS with PVR > 300 mL
- Considering invasive treatment, bothersome voiding LUTS >80years old or <50years old
Recommendation:
Do NOT offer ________ as an alternative to ______ for diagnosing bladder outlet obstruction in men.
Non-invasive tests
Pressure flow studies
” It was found that specificity, sensitivity, PPV and NPV of the non-invasive tests were highly variable. Therefore, even though several tests have shown promising results regarding non-invasive diagnosis of BOO, invasive urodynamics remains the modality of choice.”
Watchful waiting is usually a safe alternative for:
Men who are less bothered by urinary difficulty
OR
who wish to delay treatment.
The treatment failure rate over a period of five years was 21%; 79% of patients were clinically stable.
Recommendation:
Offer WW to men with (2):
- Mild/moderate symptoms
- Minimally bothered by their symptoms
💊 ⍺1-blockers
MOA: Inhibit the effect of endogenously released noradrenaline on smooth muscle cells in the prostate and thereby reduce prostate tone and BOO
Efficacy: Reduces IPSS and improves Qmax; does NOT reduce prostate size, does NOT prevent AUR
Safety: Intraop floppy iris syndrome (IFIS), abnormal ejaculation, orthostatic hypotension
Do ⍺1-blockers cause retrograde ejaculation?
Thanos FAQ
No. Only abnormal ejaculation.
“Originally, abnormal ejaculation was thought to be retrograde, but more recent data demonstrate that it is due to a decrease or absence of seminal fluid during ejaculation, with young age being an apparent risk factor.”
Recommendation:
Offer ⍺1-blockers to men with:
Moderate-to-severe LUTS.
5-ARI type predominant in the prostate:
5α-reductase type 2: predominant expression and activity in the prostate.
Dutasteride inhibits both types 1 and 2. Finasteride: only type 2.
💊 5-ARIs
MOA: Androgen effects on the prostate are mediated by dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5α-reductase.
Efficacy: Improve IPSS by approximately 15-30%, decrease 1b prostate volume by 18-28%, and increase Qmax by 1.5-2.0 mL/s in patients with LUTS due to prostate enlargement.
Prevents AUR and need for surgery.
Adverse events: reduced libido, ED, retrograde ejaculation, decreased semen volume, gynecomastia.
Recommendation:
Use 5α-reductase inhibitors in men who have: ____.
Counsel patients about onset of action of 5-ARIs: ____ months
Moderate-to-severe LUTS and an increased risk of disease progression (e.g. prostate volume > 40 mL).
Counsel patients about the onset of action (three to six months) of 5α-reductase inhibitors.
💊 Muscarinic receptor antagonists: MOA
Blocks muscarinic receptors (M2 and M3 are predominant in the detrusor) which are stimulated by neurotransmitter acetylcholine from parasympathetic nerves.
Efficacy: monotherapy can improve urgency, UUI, daytime frequency;
Safety: may increase PVR; AUR is rare in men with PVR < 150 mL at baseline
Recommendation:
Use muscarinic receptor antagonists in men with:
Moderate-to-severe LUTS who mainly have bladder storage symptoms.
Recommendation:
Do not use antimuscarinic overactive bladder medications in men with:
PVR > 150 mL.
💊 PDE5Is
MOA: Increase intracellular cyclic guanosine monophosphate, thus reducing smooth muscle tone of the detrusor, prostate and urethra.
Efficacy: Improve IPSS and IIEF score, but not Qmax.
Safety: contraindicated in patients using nitrates, nicorandil, doxazosin and terazosin, stable angina pectoris, recent MI, poorly controlled BP, hepatic or renal insufficiency
Recommendation:
Use phosphodiesterase type 5 inhibitors in men with:
Moderate-to-severe LUTS with or without erectile dysfunction.
