Navigation towards the optimal management of

men with LUTS

Matthias Oelke

VSO/14/0028/EUa June 2014

This symposium is supported by Astellas Pharma Europe Ltd., including speaker honoraria and production of materials – the slides are the speakers’ own.

Hannover, Germany

Disclosures

Consultant / Speaker / Clinical studies sponsored by / research grants from: • Allergan• Apogepha• Astellas• Bayer• Ferring• GSK• Lilly• Mundipharma• Pfizer • Pohl-Boskamp• Recordati• Sophiris

Prevalence of Male LUTS

Irwin DE et al. Eur Urol 2006;50:1306-15

% o

f p

ati

en

ts

• EPIC: Cross-sectional survey in 19,165 individuals ≥18 years in Canada, Germany, Italy, Sweden and UK

0

10

20

30

40

50

60

70

80

Nocturia Urgency Increaseddaytime

frequency

Urinaryincontinence

Intermittency Slow stream Straining Feeling ofincomplete

bladderemptying

18-39 years 40-59 years >60 years

Correlation between symptom prevalence and age

In line with other prevalence studies

Seen a physician Not seen a physician

Help seeking behaviour of men with LUTS

Nørby B et al. Eur Urol. 2005; 47: 817 - 23; Speakman M et al. BJU Int. 2014; doi: 10.1111/bju.12745

Mild symptoms Moderate symptoms Severe symptoms

4%19%

44%

Men should be encouraged to seek medical advice

LUTS should not be accepted as part of ageing

Survey in 8,700 Danish men aged >50 years

In line with other prevalence studies

27%

4%

5545%

%All patients receiving monotherapy(antimuscarinic OR α1-AR antagonist) (N=1,940)

14

16%

25

30%

43%

0 10 20 30 40 50

Indicator of inadequate control

Bothered by symptoms

Inadequate change in condition over last 3 months

Low improvement in daily life

Less than satisfied with current drug

May not continue current drug

1 or more indicator(s) of inadequate control

No indicators of inadequate control

%

%

Adapted from MacMillan L et al. Presented at the EAU 2014 congress; abstract 776.

Men with Storage and Voiding LUTS Report Inadequate Control with Monotherapy

%

• Cross-sectional survey among 481 physicians, completed records of 3,977 European men with LUTS/BPH

Compliance to Guidelines and Patient’s LUTS Profiling before Surgical Intervention

Urologists following (AUA) BPH-guidelines: • Less likely to perform surgery for BPH 1

Many patients receive medication after prostatic surgery 2:• Persisting storage LUTS 3

• Detrusor overactivity 3

• Sexual and urinary complications possible 4

1) Strope SA et al. Urology 2012;80:84-9;

2) Lukacs B et al. Eur Urol. 2013;64:493-501;

3) Seaman EK et al. J Urol. 1994;152:935-7;

4) Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

-91% prostate operations

10,9

9,1

6,24,6

2,4

0

2

4

6

8

10

12

% r

eceiv

ing

surg

ical

inte

rvention

Guideline compliance

Urologists following AUA guidelines: • Less likely to perform surgery for BPH 1

Many patients receive medication after prostatic surgery 2:

• Persisting storage LUTS 3

• Detrusor overactivity 3

• Sexual and urinary complications possible 4

Thorough assessment is key to success

2nd line pharmacological therapy if symptoms persist

1) Strope SA et al. Urology 2012;80:84-9;

2) Lukacs B et al. Eur Urol. 2013;64:493-501;

3) Seaman EK et al. J Urol. 1994;152:935-7;

4) Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

Compliance to Guidelines and Patient’s LUTS Profiling before Surgical Intervention

How to Manage Men with LUTS Adequately?

AssessmentTreatment

Routine Assessment of Male LUTS

Adapted from Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

Male LUTS

patient

History (+ Sexual Function)

UrinalysisPSA

Symptom Score Questionnaire

Measurement PVR

Physical Examination

Routine Assessment of Male LUTS: EAU Guideline Recommendations

LE GR

A medical history must always be taken from men with LUTS 4 A

A valid symptom score questionnaire with QoL question(s) should be used for the routine assessment of male LUTS in all pts. and should be applied for re-evaluation of LUTS during treatment

3 B

Physical examination including DRE should be a routine part of the assessment of male LUTS

3 B

Urinalysis (dipstick/urinary sediment) must be used in the assessment of male LUTS

3 A

PSA measurement should be performed only if a diagnosis of PCa will change the management or if PSA can assist in decision-making in pts. at risk of progression of BPE

1b A

Measurement of PVR in male LUTS should be a routine part of the assessment

3 B

Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

In Case of Complicated LUTS• History (+ sexual function)• Symptom Score Questionnaire• Physical Examination• Urinalysis• PSA (if diagnosis of PCa will change the

management – discuss with patient)• Measurement of PVR

• Abnormal DRE • Suspicion of neurological disease• High PSA• Hematuria, nitrites, pyuria, glucose

Evaluate according to relevant guidelines or clinical standard

Treat underlying condition(if any, otherwise return to initial

assessment)

Complicated LUTS

Adapted from Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

In Case of Bothersome Symptoms or Significant PVR

• History (+ sexual function)• Symptom Score Questionnaire• Physical Examination• Urinalysis• PSA (if diagnosis of PCa will change the

management – discuss with patient)• Measurement of PVR

• Abnormal DRE • Suspicion of neurological disease• High PSA• Hematuria, nitrites, pyuria, glucose

Evaluate according to relevant guidelines or clinical standard

Treat underlying condition(if any, otherwise return to initial

assessment)

Significant PVR

• US of kidneys +/- renal function assessment

• FVC with predominant storage LUTS/nocturia

• US assessment of prostate• Uroflowmetry

Benign Conditions of Bladder and/or Prostate with baseline values

Plan Treatment

Medical Treatment according to Treatment

Algorithm

• Endoscopy (if test alters the choice of surgical modality)

• Pressure Flow Studies

Surgical Treatmentaccording to Treatment Algorithm

Bothersome SymptomsComplicated

LUTS

Adapted from Gravas S et al. EAU Guidelines 2014, available at www.uroweb.org.

What are the Pharmacological Treatment Options for Men with Bothersome LUTS?

Adapted from Oelke M et al. Eur Urol. 2013; 64: 118 – 40.

+

Nocturiapredominant?

-

Storagesymptoms

predominant?-

+

-

+

Prostatevolume>40 ml?

Long-termtreatment?

-

Edu/lifestyle +/- 5-ARI +/-

α1-AR antagonist or PDE5-I

Bothersomesymptoms?

Edu/lifestyle +/-

α1-AR antagonist or PDE5-I

What are the Pharmacological Treatment Options for Men with Predominant Storage Symptoms?

+

Nocturiapredominant?

-

Storagesymptoms

predominant?+

Edu/lifestyle +/-Muscarinic receptor

antagonist

Bothersomesymptoms?

Adapted from Oelke M et al. Eur Urol. 2013; 64: 118 – 40.

1-AR antagonist Monotherapy is NOT Always Sufficient – what if Storage Symptoms Persist?

+

Nocturiapredominant?

-

Storagesymptoms

predominant?-

Prostatevolume>40 ml?

-

Residual storage symptoms

+ Muscarinic receptorantagonist

+ continue with Edu/Lifestyle

Bothersomesymptoms?

Edu/lifestyle +/-

α1-AR antagonist or PDE5-I

Adapted from Oelke M et al. Eur Urol. 2013; 64: 118 – 40.

A Symptom-Oriented Approach to Choose the Right Treatment for the Right Patient

- +

Nocturiapredominant?

- +

Storagesymptoms

predominant?- +

+

-

+

Prostatevolume>40 ml?

Long-termtreatment?

-

Residual storage symptoms

+ Muscarinic receptorantagonist

+ continue with Edu/Lifestyle

Watchful waiting +/-Edu/lifestyle

Edu/lifestyle +/- 5-ARI +/-

α1-AR antagonist or PDE5-I

Edu/lifestyle +/-Muscarinic receptor

antagonist

Edu/lifestyle +/-Vasopressin

analogue

Bothersomesymptoms?

Edu/lifestyle +/-

α1-AR antagonist or PDE5-I

Adapted from Oelke M et al. Eur Urol. 2013; 64: 118 – 40.

Conclusions

EAU guidelines on managing a man with LUTS adequately:

Thorough assessmentMatching treatment

to patient’s symptoms

Conclusions

EAU guidelines on managing a man with LUTS adequately:

Matching treatment to patient’s symptoms

Thorough assessment