Outpatient- LUTs Flashcards
How would assess a male patient with LUTS?
- assess at a routine prostate assessment clinic, ask patient to provide urinalysis, 3 day bladder diary and completed IPSS questionnaire.
- Confirm patient name, DOB and introduce myself.
- Focussed Urol hx:
- -duration of LUTs, storage vs voiding symptoms
- -associated incontinence, UTIs, STI, trauma, flank pain
- -incomplete bladder emptying
- -red flags: VH, bony pain, wt loss, night sweat, neuro symptoms suggestion advanced disease
- -fluid hx- caff drinks, carbonated drinks, ETOH
- -PHx- performance status, prev urol or pelvic surg/radiation
- -Dhx- prev meds tried and tested, anticoags, allergies
- -Shx- risk factors -smoking/occuptional hazards
Assessment:
- general inspection
- Abdo exam: scars, distended bladder
- with chaperone: scrotum, foreskin, glans, meatus, DRE
Initially Ix:
Bloods: PSA, FBC, U&Es CRP [if infection]
Uroflowmetry
What is tamsulosin and finasteride?
Tamsulosin:
Alpha blockers, block alpha 1 adrenergic receptors located in the smooth muscles in the bladder. Results in relaxation of the bladder neck, prostate, urethra and ureter allowing better flow.
Contraindications: orthostatic hypotension, recent cataract surgery [risk of floppy iris syndrome]
SEs: allergy, dizziness, sexual dysfunction
Finasteride:
5 alpha reductase inhibitors. Inhibits the enzymes what converts inactive testosterone to active dihydrotestosterone. so inhibits further growth and proliferation of prostate.
Contraindications: nil
SEs: sexual dysfunction, skin allergy, breast abnormalities, testicular pain, infertility [rare]
What is the IPSS questionnaire?
Internationally validated questionnaire assessing patient LUTs.
7 questions with score 1-5 assessing voiding and storage symptoms
Further QoL question scoring 1-6
Mild- 0-7
Moderate: 8-19
Severe: 20-35
When would you perform a USS renal or cystoscopy in a man with LUTs?
Indications for USS renal:
- rUTIs or complicated UTIs
- renal dysfunction
- macro/microscopic VH
- flank pain
- chronic retention
Indications for flexi:
- macro/microscopic VH
- rUTIs or complicated UTIs
- profound symptoms
- pain
What are the normal Qmax flow rates for males and females?
Males:
>60= >10ml/sec
40-60= >18ml/sec
<40= >21ml/sec
Female:
<50= >25ml/sec
>50= >18ml/sec
What are the indications of Urodynamics?
- Previously failed Rx for LUTs surgically
- Failed medically and planning to offer surgical options
- Voiding volumes <150ml
- PVR >300ml
- <50 or >80 in men
- neurological disease
- Equivocal Qmax flow >10ml/sec
What would you find on UDs in a patient with BOO?
- detrusor stability
- increased intrabdominal and detrusor pressure with poor urinary flow
Can be demonstrated on a ICS normogram [Abram- Griffith normogram
What are the indications for TURP and HoLEP?
According to EAU:
- recurrent and refractory urinary retention
- recurrent VH refractory to 5 alpha reductase inhibitors
- renal insufficiency
- bladder stones
- rUTIs due to BPH
- Chronic high pressure urinary retention
How would you consent for a TURP?
Confirm patient name dob
ideally patient would have had BAUS prior to consenting process
explain indications and alternatives [LTC, ISC, medical therapy, HoLEP]
Explain procedure including risk and complications:
-bleeding [transfusion 1-2%], infection [sepsis up to 3%], retrograde ejaculation, ED, incontinence [2-10%], urethral stricture and Bladder neck stenosis, redo surgery
What is TUR syndrome?
Triad of fluid overload, dilutional hyponatremia and neurotoxicity which can happen during excessive irrigation with hypotonic 1.5% glycine.
- Osmotic diuresis causes sodium shift from the body therefore dilutional hyponatremia.
- Glycine metabolises into ammonia which can cause encephalopathy
- Glycine is a inhibitory retinal neurotransmitter, so too much glycine slows down the transmission of impulses from retina to cerebral cortex, so patients may complaining of visual disturbances.
How would manage TUR syndrome?
PREVENTION
- reverse hyponatremia prior to TURP
- consider bipolar diathermy with saline irrigation
- keep fluid no higher than 60cm above patient’s chest
DURING
- have patient on spinal anaesthesia so can assess visual disturbances or confusion
- breath test- not often done but can inject 1% ethanol in irrigation and analyse the breath for alcohol
- Recognise flags: early [HTN, fluid overload], late [hypotension, arrhythmias, decreased O2 sats]
- Avoid surgical time >90mins and prostates >45g
- Immediately finish procedure if prostatic capsule is ruptured.
MANAGEMENT
- IV furosemide 40mg while waiting for definitive blood results back. Give more depending on Na levels
- Finish the operation asap and achieve haemostasis
- Input from anaesthetic and ITU team asap for a multidisciplinary approach. Further access might be needed [central/arterial line] and possible intubation depending on GCS levels.
- avoid fast reversal of hyponatramia due to risk of central pontine myelinolysis
Are you aware of any other surgical options apart from TURP for BOO?
HoLEP
- Holmium Laser enucleation of the prostate.
- Only done in specialised centres
- endoscopic equivalent of an open prostatectomy
- compared TURP there is less risk in bleeding
Greenlight laser
-vaporisation of the prostate tissue
TURIS
- TURP using saline irrigation
- avoids TUR syndrome
Urolift
- Minimally invasive procedure which can be done as a day care and preserves sexual function
- NICE recommends for men >50 years, prostate size <100cc and no obstructing middle lobe
