Male BPH LUTS

Question 1

BPH-LUTS Definitions

Answer 1

-BPH-LUTS is a common male condition, describing a combination of bothersome voiding and storage symptoms, BPH, and reduced QoL
-BPH describes hyperplasia of stroma & epithelium of TZ (Transition Zone) of prostate

-BPH (Benign Prostatic Hyperplasia): Histological Dx
-BPE (Benign Prostatic Enlargement): Clinical Dx
-BOO (Bladder Outflow Obstruction): Clinical Dx
-LUTS (Lower Urinary Tract Symptoms): Constellation of symptoms, neither gender specific, nor organ-specific

Increased transition zone volume/ total prostate volume = increased level of BOO

Question 2

Prevalence and aetiology of BPH-LUTS

Answer 2

Prevalence of Histological BPH:
~42% of men age 51-60y
-80% of men age >70y

-Aetiology: Conversion of Testosterone to DHT (5 alpha dihydrotestosterone)by 5 alpha reductase

Question 3

Presentation of BPH-LUTS

Answer 3

-Voiding: hesitancy, straining, intermittency, poor stream, terminal dribbling, sensation of incomplete emptying
-Storage: frequency, urgency, nocturia, urge incontinence
-Post-micturition dribbling
-Complications: UTI, retention, obstructive uropathy

Question 4

Related conditions and complications of BPH-LUTS

Answer 4

-Urinary Retention: AUR, CUR
-Obstructive Uropathy/Nephropathy: HDN + AKI
-Recurrent UTIs
-Bladder Stones
-Haematuria

Question 5

BPH-LUTS Assessment

Answer 5

Focused History:
=LUTS, CCF, CKD, DM, CVA, Sp injury, pelvic surgery, Medication, EtOH
=IPSS

-Examination:
=Abd: ?palpable bladder
=Legs: ?peripheral ankle oedema (esp with Nocturia)
=DRE: Prostate volume, consistency (benign / malignant)
=Neuro: LL examination (incl anal tone) esp if no precipitating cause of AUR

-UA: urinalysis: ?UTI. Urinary frequency-volume chart

-Bloods: U+E (if palpable bladder or hydronephrosis, chronic retention), consider PSA
=Flow Studies: FT (Qmax) + BS (PVR

Question 6

Common causes for LUTS

Answer 6

-Urethra
=Phimosis
=Urethral stricture
=Urethral stone

-Prostate
=BPH
=Prostatitis (acute or chronic)
=Prostate cancer

-Bladder
=Bladder tumour
=Bladder stone
=Cystitis
=Contracted bladder
=Hypocontractile bladder
=Detrusor hypersensitivity

-Ureter
=Lower ureteric stone

-Kidney
=Nephrogenic DI

-Other
=Neurological causes
=Cerebrovascular accidents
=Parkinsonism
=Spinal injury
=Autonomic neuropathy (DM)
=Pelvic nerve damage (post-operative)
=Endocrine (DM, DI)
=Cardiac and resp (HF, Obstructive sleep apnoea)
=Psychological (polydipsia, high evening fluid intake)

Question 7

Drugs which may worsen LUTS or precipitate urinary retention

Answer 7

-Antimuscarinics
-TCAs, Antipsychotics
-Opioids – constipation
-BDZs
-Bronchodilators
-Sympathomimetics (pseudoephedrine, ephedrine)
-Diuretics – storage LUTS

Question 8

BPH-LUTS Examination

Answer 8

Prostate examination

Question 9

BPH-LUTS: GP Assessment

Answer 9

-Structural abnormality
=Phimosis, stricture, prev prostate surgery
-Functional abnormality
=UI, PVR>250ml
-VH, NVH
-AKI
-Digital rectal exam, inspection of foreskin and urethral meatus
-Urine analysis, flow rate, post-void bladder scan, PSA, frequency volume chart

Refer to urology of:
=Prior prostate surgery
=Suspicion of cancer
=Tight urethral meatus or foreskin
=History or haematuria
=Incontinence
=Persistent/ recurrent UTI

=Dipstick haematuria
=Post-void scan >250ml
=Elevated age-specific PSA
=Renal impairment thought to be due to lower urinary tract dysfunction

Question 10

BPH-LUTS: Urology Assessment

Answer 10

-IPSS (International Prostate Symptom Score)
=Assesses male LUTS (max 35, mild 1-7, mod 8-19, severe 20-35)
=QoL/ Bother score (0-6)
=Incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia, QoL

-Consider cystoscopy + renal USS if recurrent UTI, haematuria, sterile pyuria, pain, suspected urethral stricture
-Check serum creatinine and renal USS if chronic retention (post micturition residue >250ml)
-Catheterise if hydronephrosis or impaired renal function associated with retention
-Definitive surgery/ long-term catheter: LUTS affecting QoL or bladder stone or recurrent UTI
-Video urodynamics recommended of evidence of bladder outflow obstruction, TURP

Question 11

Conservative/ lifestyle measures

Answer 11

-EtOH restriction
-Caffeine restriction
-Evening fluid restriction
-Avoid cold environment (cold reduces ADH release and precipitates freq)
-Optimisation of contributing medical problems: LVF,CKD, DM, OSA

Question 12

BPH-LUTS: Medical Management

Answer 12

-Alpha Antagonists: Tamsulosin, Alfuzosin
=Relieves voiding difficulty by relaxing smooth muscle around the prostate

-5aRI (5-alpha Reductase Inhibitors): Finasteride / Dutasteride
==Inhibits proliferation and reduces the size of the prostate

-Antimuscarinics for Storage LUTS: Solifenacin, Fesoterodine, Oxybutynin

-Mirabegron (β-3 adrenergic agonist) for Storage LUTS

-Arginine vasopressin analogues: desmopressin acetate, relieves polyuria/ nocturia

Question 13

Efficacy of medical management

Answer 13

~40% of patients have sig improvement of LUTS
-SEs: Retrograde Ejaculation, Dizziness, Postural Hypotension, Headache, Nasal Congestion, ED, Asthenia (weakness); reduced libido (5aRI)

Question 14

BPH-UTS: Surgical management

Answer 14

-Surgical Rx of BPH aims to remove obstructing prostate TZ adenoma, either with cauterising loop, or laser

-TURP (Trans Urethral Resection of the Prostate); BNI(Bladder Neck Incision)

-Laser Prostatectomy:
=HoLEP (Ho Laser Enucleation of the Prostate)
=KTP Prostatectomy (Green Light Laser -Vaporisation)

-Open Prostatectomy (Millin): now superseded by HoLEP

-Success Rates BPH Surgery:
=Improvement Voiding LUTS in 90%
=Improvement Storage LUTS in 60%
=Improvement Nocturia in 30-40%

-SEs & Complications BPH Surgery:
=Retrograde Ejaculation (75%), ED (10%), UI (1%)

Question 15

Acute retention (AUR) & Chronic retention (CUR)

Answer 15

-Symptoms
=Painful (A) vs typically painless
-Bladder volume
=AUR: 350-500ml/ CUR: 750-1500ml
-Precipitating factors
=AUR: pain, UTI, constipation, drugs EtOH, MS, Neuro
=CUR: pain, UTI, constipation, drugs, EtOH, MS, neuro but sometimes no cause identifiable
-Renal function
=Normal vs may be abnormal

Question 16

Low pressure & high pressure chronic retention

Answer 16

-LPCR (low pressure chronic retention)
=Palpable bladder unless obese
=No nocturnal enuresis
=Low normal bladder and upper urinary tract pressure
=No hydronephrosis
=Normal real function
=No post-operative diuresis
=Long term management: consider TWOC/ medical Rx or BPH surgery

-HPCR (high)
=Classically tense and distended palpable bladder
=Preceding nocturnal enuresis may be present
=High bladder and upper urinary tract pressure
=Hydronephrosis
=AKI
=Post-obstructive diuresis
=Not for TWOC, for either LTC or BPH surgery

Question 17

Overview of BPH-LUTS: LUTS

Answer 17

-Assessment: Hx, IPSS, Examination, DRE, UA, FT & BS

-Lifestyle Changes:
=Restriction of Caffeine / EtOH / Evening fluids EtOH restriction
=Optimisation of contributing medical problems: LVF, CKD, DM, OSA

-Medical Rx:
=Alpha Antagonists: Tamsulosin, Alfuzosin decrease smooth muscle tone of prostate and bladder, side effects dizziness, postural hypo, dry mouth, depression)
=5aRI (5-alpha Reductase Inhibitors): Finasteride / Dutasteride if at high risk progression, side effects ED, reduced libido, ejac problems, gynaecomastia)
=Antimuscarinics for Storage LUTS: Solifenacin, Fesoterodine, Oxybutynin (when persists after treatment with alpha-blocker alone)

-Failed Medical Rx (No improvement LUTS, or if SEs of Rx intolerable):
=consider BPH Surgery (TURP: transurethral resection of prostate, laser prostatectomy)

Question 18

BPH-LUTS: AUR management

Answer 18

-Abnormal renal function: daily fluid balance and renal function monitoring, if fit elective TURP, if not long term catheter
-If not Benign prostate on DRE: prostate cancer investigation
-If no retention <1 litre// no previous UTS/ precipitating factors: discharge for elective TURP, teach catheter care
-Consider alpha-blockers, finasteride, outpatient flow rate and residual volume estimation, antibiotics, laxatives, TWOC at 48 hours

Question 19

BPH-LUTS: CUR management

Answer 19

-Measure renal function and perform renal USS
-Abnormal renal function or upper tract dilatation: catheter insertion, monitor for diuresis if fit (TURP) if not (LTC/CISC)
-If symptomatic or complications present: urodynamic, good detrusor function

Question 20

Overview of TUR syndrome

Answer 20

-May occur with TURP due to excess absorption of Glycine irrigant

-Triad of
=fluid overload
=dilutional hyponatraemia
=cerebral toxicity
-Spectrum of symptoms either during surgery (if under spinal anaesthetic), or post-operatively: confusion, irritability, N&V, visual disturbances (flashing lights), altered consciousness, convulsions

-Mx:
=Stop surgery
=Normal saline
=Thiazide diuretic
=Urgent U&E
=Consider ITU

-Chances of TUR Syndrome increase with prolonged resection (>60min), or if large volume of irrigant used (>20L)
-Does not occur with laser prostatectomy (0.9% saline irrigant)

Question 21

Overview of post obstructive diuresis

Answer 21

-Polyuria resulting from relief of chronically obstructed kidneys (disobstruction), typically after catheterisation for HPCR
-Excess Urine O/P: 3L/24h is considered polyuria; >300ml/h is considered clinically significant and would indicate potential need for IVI fluid replacement

-Pathophysiology: ranges from physiological process to salt-wasting process
=Physiological Diuresis: 2ry to excretion of retained Urea, Na, H2O after disobstruction, usually resolves in 48h with PO fluids
=Pathological Diuresis: 2ry to impaired concentrating ability of renal tubules due to inability to maintain solute gradient (LoH effectively washed out)

-Mx:
=Admit patient, Hourly fluid monitoring, CVS status, U&E
=If diuresis significant (>200ml/h; postural drop in BP; dizziness/syncope) or elderly frail patient: administer 50% IV fluid replacement with 0.9% saline (ie replace 50% of urine o/plosses with N saline)
=Closely monitor Hourly fluid monitoring, CVS status, U&E

Question 22

Describe PSA testing

Answer 22

-Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate epithelial cells
-Age 50-59: 3
-Age 60-6: 4
-Age >70: 5

Question 23

Causes of raised PSA levels

Answer 23

benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract

around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men
around 20% with prostate cancer have a normal PSA
various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)

Question 24

International Prostate Symptom Score (IPSS)

Answer 24

tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
Score 20-35: severely symptomatic
Score 8-19: moderately symptomatic
Score 0-7: mildly symptomatic