Lower Urinary Tract Symptoms (LUTS)

Question 1

What is the most common cause of male LUTS?

Answer 1

BPH

Question 2

What are the lower urinary tract symptoms?

Answer 2

Before:
Frequency and Urgency
Nocturia
Incontinence- overflow and urge

During:
Hesitancy
Poor flow- weak or intermittent
Passing small volumes of urine

After:
Post Micturition dribble
Not fully emptying bladder

Start by asking about the biggest problem to the patient?

Question 3

What is considered abnormal levels of urination?

Answer 3

Passing urine more than 6-8 times per day

Waking at night to pass urine

Question 4

What useful questionnaire can you ask patients to fill in when assessing the severity of LUTS?

Answer 4

International prostate symptoms score sheet. (IPSS Score)

This asks patients about the severity of their symptoms and how it is affecting their quality of life.

Question 5

How might LUTS be classified?

Answer 5

Storage problems: Urgency, Frequency, Nocturia, Incontinence

Voiding problems: Poor stream (weak or intermittent), Post micturition dribble, Not fullying emptying the bladder, Passing small volumes, Hesitancy

Question 6

When assessing frequency what should you ask?

Answer 6

How often have they been going? Are they going at night? Are they passing large or small volumes?

Important to ask about fluid intake

Question 7

How should you ask about urgency?

Answer 7

Do you find that you have to rush to go to the toilet? Does this every cause you to go when you don’t want to?

Note- if dysuria is also present this indicates a UTI.

Question 8

How should you ask about nocturia?

Answer 8

Do you find that you’re having to get up at night to go to the toilet? How many times? Is this to pass large or small volumes of urine?

Question 9

How should you ask about incontinence?

Answer 9

Do you ever find that urine leaks out or comes out when you don’t want it to? Do you ever need to change your underwear because of this?

Question 10

How should you ask about hesitancy?

Answer 10

Do you ever find it difficult to start urinating when you want to go? Is there a delay before you start urinating?

Question 11

How should you ask about post-micturition dribble?

Answer 11

Do you ever find that after urinating you have to wait a a short while for urine to stop coming out? Or after urinating does some more urine every come out?

Question 12

How should you ask about incomplete voiding?

Answer 12

After you’ve been to the toilet do you feel like your bladder is completely empty?

Question 13

What red flag questions would you want to ask about when assessing a patient with LUTS?

Answer 13

Blood in the urine
Weight loss
Pain or discomfort
Lower back pain
Tenesmus
Fatigue and lethargy 

Urinary tract cancers are associated with smoking and exposure to some chemicals- ask about work.

Question 14

Apart from symptoms what else is important to ask about when assessing LUTS?

Answer 14

Frequency might just be caused by increased fluid intake

It is therefore important to ask about fluid intake and what they’re drinking. For example caffeine and alcohol are diuretics.

Question 15

What should you examine when assessing a patient with LUTS?

Answer 15

Abdomen- Bladder palpation and percussion
External genitalia- Phimosis (can cause bladder outflow obstruction), Meatal stenosis, palpate to feel for thickening which could indicate a urethral stricture
Spine- Previous spinal surgery (could be neurological cause)
DRE-
Enlarged, smooth, boggy = BPH
Craggy, hard = Cancer
Tender= Prostatitis
Check anal tone and saddle sensation
Neurological examinations if indicated

Question 16

How can bladder palpation help to assess if urinary attention is acute or chronic?

Answer 16

Acute- palpation if painful

Chronic- palpation is painless

Question 17

What are some findings on a DRE?

Answer 17

Smooth, enlarged and boggy= BPH
Hard, craggy = Cancer
Tender = Prostatitis

Ask patient to bear down or cough to check anal tone- could be a neurological lesion.

Question 18

What tests should be requested if a prostate feels abnormal on DRE?

Answer 18

PSA Testing

Transrectal ultrasound guided biopsy of the prostate

Question 19

What investigations might be requested for patients with LUTS?

Answer 19

Bloods
PSA
Serum creatinine and eGFR

Patient Questionnaire 
IPSS Score (assesses severity of LUTS)

Urine Tests
Urine Dip
Bladder scan or catheterisation to estimate residual volume
Frequency volume chart- Patient documents fluid intake and about urinated
Urodynamic testing

Imaging-
US KUB- Esp is obstruction could be causes hydronephrosis

Question 20

What blood tests might be requested for all patients with LUTS?

Answer 20

PSA

Serum creatinine and eGFR- to check renal function as can cause obstruction

Question 21

What tests involving urine might you request for patients with LUTS?

Answer 21

ALWAYS DO A URINE DIP AS IT HAEMATURIA MAY INDICATE MALIGNANCY

Frequency volume chart- fluid intake and urine output
Residual volume- either by bladder scan or catheterisation
Urodynamic studies/flow test

Question 22

What do urodynamic studies show in patients with LUTS?

Answer 22

Reduced maximal flow rate

Normal <40 21ml/sec
40-60 >18ml/sec
>60 >13ml/sec

Question 23

What is normal residual volume?

Answer 23

<50mls

Question 24

What are some sinister causes of LUTS?

Answer 24

Malignancy of the urinary tract or prostate
Spinal cord compression or cauda equina syndrome- check sensation in saddle area and anal tone

Cauda equina syndrome causes incontinence or retention.

Question 25

What can cause LUTS?

Answer 25

BPH
Urinary tract malignancy
Prostate malignancy
Extrinsic tumours
Strictures
Meatal stenosis
Phimosis
Penile cancers

Neurological
SCC
Cauda Equina Syndrome

Question 26

What are the features of cauda equina syndrome?

Answer 26

Loss of bowel or bladder control
Sexual dysfunction
Saddle anaesthesia
Lower motor neuron signs in legs- Hyporeflexia, Hypotonia, weakness
Sciatic pain

Question 27

What are some causes of cauda equina?

Answer 27

Lumbar disc herniation
Trauma
Bone metastasis to lumbar spine
Spinal stenosis
Spondylolisthesis

Question 28

What should be done if cauda equina syndrome is suspected?

Answer 28

Urgent spinal MRI

Question 29

What is BPH?

Answer 29

Benign Prostatic Hyperplasia

Question 30

What area of the prostate is affected by BPH?

Answer 30

The transitional zone- called transitional zone as it affects the transitional zone of the prostate.

Question 31

What area of the prostate is affected most commonly by prostate cancer?

Answer 31

Peripheral zone

Question 32

What investigations should be done for someone with suspected BPH?

Answer 32

IPSS Score
Urodynamics
Fluid Intake and Urine output chart
Physical examination- DRE, Abdominal of the prostate
Urine dip- MSU if signs of infection
Residual volume measurements- bladder scan or catheterisation

Bloods- PSA, eGFR, Creatinine

Biopsy- Transrectal biopsy of the prostate gland (everyone with raised PSA should be offered a biopsy)

USS KUB is considering long term obstruction and possible hydronephrosis.

Question 33

What is the management for BPH?

Answer 33

Lifestyle- Decrease caffeine and alcohol intake, relaxation when voiding

Medical

• Alpha blockers e.g. Tamsulosin
• 5 Alpha Reductase inhibitors e.g. Finasteride

Surgical-

• TURP
• Prostatectomy

Question 34

Give an example of an alpha blocker used in the management of BPH?

Answer 34

Tamsulosin 400 mcg OD

Also doxazosin or alfuzosin

Question 35

How does tamsulosin work?

Answer 35

Decreases smooth muscle tone of the prostate and bladder

Question 36

What are some side effects of tamsulosin?

Answer 36

Drowsiness
Diziness
Depression

Decreased blood pressure
Ejaculatory failure

Question 37

Give an example of a 5 alpha reducatse inhbitior

Answer 37

Finasteride 5mg OD

Question 38

How does finasteride work?

Answer 38

Reduces conversion of testosterone to more potent dihydrotestosterone. Anti-androgen effect that shrinks the prostate.

S/E- Impotence and decreased libido.