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Lower Urinary TractSymptoms (LUTS)
dr. Putra Hendra SpPD
UNIBABATAM
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Definition:
LUTS, or lower urinary tract symptoms , is a
common term used to describe the range ofurinary symptoms as frequency, urgencyetc ,which was previously called prostatism but thishas been replaced by LUTS because the
prostate is most often not the cause.
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LUTS had been categorized into:
1. Storage (irritative ) symptoms
2. Voiding( obstructive) symptoms
3. Post voiding symptoms
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Understanding Lower Urinary
Tract Symptoms(after Abrams, Bristol, UK)
Storage Symptoms Frequency Nocturia Urgency Urge incontinence Bladder Pain
Detrusor Instability Bladder Hypersensitivity Bladder Outlet Obstruction Detrusor Failure
Voiding Symptoms Slow stream Intermittent flow Hesitancy Straining
Terminal dribble
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Causes of LUTS:
In males: Outflow obstruction
BPHMeatal stenosis
Impaired detrusor function
NM dysfunctionDetrusor instabilityImpaired detrusor contractilityPsychogenic voiding dysfunction
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CONT
InfectionCystitis, prostatitis, prostatic abcess andurethral diverticulum.
neoplasticProstatic cancer, bladder cancer
Others:Bladder diverticulum, stone andinterstitial cystitis.
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In females :
Mostly storage symptomsUTIPregnancyAnxietyOveractive bladderInterstitial cystitisPostmenopausal urogenital atrophyBladder tumor or stoneGenital prolapses or pelvic mass
Mostly voiding symptomsAge related detrusor muscle weaknessObstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis)UrethritisDrugs ( diuretics, alcohol, lithium, anticholinergics)
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What happens with aging?
Smaller bladder capacity increased bladder irritability
decreased bladder emptying genitourinary atrophy concurrent conditions
stroke, dementia, PD, BPH, DM
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Incidence of Subtypes ofUrinary Incontinence in Women
Stress Incontinence 50%
Urge Incontinence 20%
Mixed 30%
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Storage symptoms:
Daytime frequency
Urgency:sudden desire for urination that isdifficult to postponed. Nocturia :urinary urgency that awakens the
pt. from sleep.
Urge incontinence Enuresis:incontinence during sleep.
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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
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Post void symptoms
Post void dribbling Feeling of incomplete emptying
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GOTTA GO, GOTTA GO!!!!!!!!
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Urge Incontinence
Most common cause of UI >75 years ofage
Abrupt desire to void cannot besuppressed
Usually idiopathic Causes: infection, tumor, stones,
atrophic vaginitis or urethritis, stroke,
Parkinsons Disease, dementia
Other Names: detrusor hyperactivity, detrusor instability,irritable bladder, spastic bladder
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Potentially Reversible Causes
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritisP - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction2
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Medications That May Cause
Incontinence DiureticsAnticholinergics - antihistamines,
antipsychotics, antidepressants Seditives/hypnoticsAlcohol
Narcotics -adrenergic agonists/antagnists Calcium channel blockers
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Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity>90%)
Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture
Simple (bedside) Cystometrics
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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
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US
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Ascending Urethrogram
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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 areobtained with the bladder full, during micturation and
after voiding.
. VCUG is excellent method of diagnosing vesical neckobstruction and vesicoureteral reflux.
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Cont. Investigation
*Uroflowmetry:an electronic flowmeter can provide a recording of urinary
flow rate
*CystourethroscopyEndoscopy permits direct visualization of the entire urinary
tract .
* Cystometry:is continuous recording of bladder pressure duringgradual filling and during contraction .indication in anyneuralgic disease is suspect
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Treatment Options
Bladder training Patient education
Scheduled voiding
Positive reinforcement
Pelvic floor exercises (Kegel Exercises) Biofeedback
Caregiver interventions Scheduled toileting
Habit training
Prompted voiding2
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Pharmacological Interventions
Urge Incontinence Oxybutynin (Ditropan)
Propantheline (Pro-Banthine) Imipramine (Tofranil)
Stress Incontinence
Phenylpropanolamine (Ornade) Pseudo-Ephedrine (Sudafed)
Estrogen (orally, transdermally or transvaginally)
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Surgical Interventions
Urethral Hypermotility Marshall-Marchetti-Kantz procedure
Needle neck suspension
Intrinsic sphincterdeficiency
Sling procedure
Surgery is reported to cure 4 out of 5cases, but success rate drops to 50% after10 years.
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Other Interventions
Pessaries Periurethral bulking agents (periurethral
injection of collagen, fat or silicone) Diapers or pads Chronic catheterization
Periurethral or suprapubic
Indwelling or intermittant
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Pessarie
s
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TREATMENT
*Obstructive ureter:
- Suprapubic cystostomy
- Ureteric catheter drainage
- Uretheral catheter drainage
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Cont TREATMENT
A. Distal urethra:*Urethral strictures:-Dilation
- - Visual urethrotomy -transurethral balloon dilation catheter- Urethroplasty
*Meatal stenosis:-Dilation-surgical meatotomy
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BENIGN PROST TEHYPERTROPHY
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What causes BPH?
BPH is part of the naturalaging process, like getting
gray hair or wearing glasses
BPH cannotbe prevented
BPH canbe treated
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The size of prostate enlarged microscopically since theage of 40.Half of all men over the age of 60 willdevelop an enlarged prostate
By the time men reach their 70s and 80s, 80% willexperience urinary symptoms
But only 25% of men aged 80 will be receiving BPHtreatment
BPH
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Top 10 Diagnosed Diseasesin Men Age 50 Years
Rank Disease
1-year prevalence (%)
(n = 963,452 person-
years)
1Coronary Artery
Disease/Hyperlipidemia
51.3
2 Hypertension 45.2
3 Diabetes Mellitus Type 2 17.5
4 Enlarged Prostate 13.5
5 Osteoarthritis 13.3
6 Arrhythmias 8.87 Cataract 8.6
8 Gastroesophogeal reflux disease 8.4
9 Bursitis 8.0
10 Prostate Cancer 7.8
Issa MM et al. Am J Manag Care. 2006;12(suppl):S83S89.
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Anatomy of BPHNormal BPH
Hypertrophieddetrusormuscle
Obstructedurinary flow
PROSTATE
BLADDER
URETHRA
Roehrborn CG, McConnell JD. In: Walsh PC et al, eds. Campbells Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:1297-1336.
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Clinical Presentation of BPHObstructive
Symptoms
Incomplete emptying Intermittency Weak stream Hesitancy
Irritative Symptoms
Nocturia Frequency
Urgency
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Prevalence of BPH
Source: J Urol 1984;132:474
Around 25% inmen aged 40-49yearsAround 50% in
men aged 70 andolder
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Risk factors
-Age: at late 40s only 3.5% of menat 80s it raise to 35%
-Ethnic groups: African American at high riskAsian at low risk
-Family history
-Medical condition :Obesity
Heart and circulatory disease
Type 2 DM
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The initial evaluation of all patient presentingwith 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
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Protocol for the management ofBPH
Severe
IPSS > 20
Flow rate < 10 mls/s
Resid vol > 200 mls
Moderate
IPSS 7-20
Flow rate < 15mls/sResid vol
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Treatment Modalities for BPH
Watchful waiting Medical therapy
Phytotherapy
-adrenergic blockers
5-reductase inhibitors Combination therapy
Office-based treatment TUMT
TUNA
WIT
Surgicenter/Hospital-basedtreatment
TURP (gold standard)
TUIP
Open surgery (prostatectomy) TUVP
ILC
VLAP
Prostatic stents
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.
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Drugs for Medical ManagementAlpha Blockers:Alfuzosin
DoxazosinTamsulosinTerazosin
Hormonal: Finasteride
Dutasteride
Combination: Alfuzosin/finasterideDoxazosin/finasteride
Terazosin/finasteride
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Cumulative Incidence of Progression of Benign Prostatic Hyperplasia
McConnell, J. et al. N Engl J Med 2003;349:2387-2398
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Combination Therapy: AUnique Approach
Alpha blockers 5-Alpha reductase inhibitors
Improve symptomsand increase urinaryflow rate by relaxingprostatic and bladder-
neck smooth musclethrough sympatheticactivity blockade
Improve symptoms,increase urinary flow rate,and prevent BPH outcomesby reducing prostate
enlargement throughhormonal mechanisms
Source: Roehrborn CG Curr Opin Urol2001;11:17-25
National Cancer Institute. NIH Publication No. 99-4303, 1999.
Combination Activates Two Distinct and Complementary Mechanisms of Action
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ibution of 1-Adrenergic Receptors
li ti f Ad i
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ocalization of 1-Adrenergiceceptors (1-ARs)
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TURP
Gold Standardof care for BPH
Uses an electrical knife to surgically cutand remove excess prostate tissue
Effective in relieving symptoms and
restoring urine flow
(transurethral resection of the prostate)
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Transurethral Microwave Therapy
Microwave energycauses tissue necrosis
Cooling channels in
catheter cool urethra
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Trans-Urethral Resection ofProstate
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