More mens bits…

LUTS

Hugh Alberti
January 20171
Case studies in 2 groups
Case 1:
Mr G. Land is a 72 year old farmer. He rarely attends. But today he
comes to discuss his waterworks. He is asking if anything can help him
as getting up at night for a pee is making getting up at dawn to sort the
cows out more difficult. Also, he’s fed up having to wipe the toilet clean
(or his wife is) every time he has a wee. Where do you go from here?

Case 2:
Mr I.P.Allott is a 55 year old gentleman, a new patient to the practice.
On his first consultation with you he tells you he has had urinary
problems getting worse over 2 years since he stopped work. His last
doctors couldn’t help him. He has to go all the time, and occasionally
doesn’t make it. He gets up frequently at night. Life is intolerable.

Groups of 4-5, one person roleplay the patient (with the answers) the
others alternate roleplaying the doctor.
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Overview
 How common are the problems?

Increases with age; maybe 30-40% over

the age of 50.

You will not see all of these people

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 What are L.U.T.S.?
Lower urinary tract symptoms is a term of
convenience that encompasses storage,
voiding and post-micturition problems.

It’s a term and not a diagnosis.

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L.U.T.S. consists of -
 Storage problems
 Voiding problems
 Detrusor problems
 Retention
 Incontinence

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Clinical Presentation
 History of problem
 Examination
 Exclude other causes
 Judicious use investigations
 When do we refer?

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How the prostate feels

Walnut
sized

Satsuma Like the

sized gruffalo’s
head

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 N.I.C.E. says
• At initial assessment, offer men with LUTS an assessment
of their general medical history to identify possible
causes of LUTS, and associated co-morbidities. Review
current medication, including herbal and over-the-
counter medicines, to identify drugs that may be
contributing to the problem.
• At initial assessment, offer men with LUTS a physical
examination guided by urological symptoms and other
medical conditions, an examination of the abdomen and
external genitalia, and a digital rectal examination (DRE).
• At initial assessment, ask men with bothersome LUTS to
complete a urinary frequency volume chart.
• Refer men for specialist assessment if they have LUTS
complicated by recurrent or persistent urinary tract
infection, retention, renal impairment that is suspected to
be caused by lower urinary tract dysfunction, or
suspected urological cancer. 8
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 Management
 Why treat?
 How to treat
watchful waiting
life style management
drug therapy
surgery

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Intake advice, retraining and
urethral milking…

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Drug Therapies
Voiding…
 Alpha – 1 selective adrenergic antagonists
 5 alpha – reductase inhibitors
 Combination therapy

Storage…
 Antimuscarinics

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LUTS: Drug treatment
Cause Treatment Review

LUTS Alpha blocker 4-6w then 6mly

OAB Anticholinergic 4-6w then 6mly

LUTS + prostate >30g 5ARI (Finasteride) 3-6m then 12mly

Bothersome LUTS + >30g AB + 5ARI 4-6w then 6mly

Unresponsive LUTS Add anticholinergic 4-6w then 6mly

Plus?
 Remember all drugs only partially
effective
 BPH not a risk factor for Ca, but Ca may
present with LUTS
 Nocturnal polyuria – (>35% output)
– ?Late afternoon diuretic ??desmopressin
 ?Tadalafil for LUTS (“not recommended”)

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Don’t expect miracles though

This would be unlikely

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Surgical Intervention
 Surgery is effective
 N.I.C.E. has advised which are the best
surgical options.
 Be cautious though regarding surgery for
storage symptoms
 A urologist is likely best placed to discuss
some of the options

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Any questions from the cases…

http://www.bmj.com/content/357/bmj.j1493
(10m in consultation LUTS in an older man)

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 References

NICE clinical guideline 9 ‘The management of lower urinary tract symptoms in

men’
Issue date: May 2010
Benign prostatic hyperplasia.Part 1—Diagnosis, Timothy J Wilt, James N’Dow
BMJ 2008;336:146-9. Part 2—Management BMJ 2008;336:206-10
Lower urinary tract symptoms in men. BMJ 2007;334:2
Extracts from “Clinical Evidence” Benign prostatic hyperplasia BMJ
2001;323:1042–6
10minute consultation Prostatic symptoms Andrew Farmer. BMJ 2001;322:1468
Managing urinary incontinence in older people Subashini Thirugnanasothy BMJ
2010;341:c3835

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