Tag: BPH

This topic seems to crop up fairly regularly as a tutorial request. It’s funny because whenever we go through it I think it actually seems very straightforward. Yet there seems to be this tendency to over think the subject. So I have put together my approach to the male LUTS consultation. My suggested reading for this topic is the hyperlinked BMJ article and the NICE guidance.

A good way to approach male LUTS are to consider the symptoms as storage versus voiding symptoms. Having this in the back of your mind is helpful for data gathering but also gives you information from which to consider the most appropriate management options.

	Storage	Voiding
Symptoms	Frequency Urgency (and urge incontinence) Nocturia	Hesitancy Poor stream Terminal dribbling Double voiding
Causes	Overactive bladder (if isolated)	Benign prostatic hypertrophy Urethral stricture Meatal stenosis Phimosis
Management options	Anticholinergics	Alpha blockers 5-alpha reductase inhibitors

A mixed picture of symptoms would suggest bladder outlet obstruction, most commonly cause by benign prostatic hypertrophy (BPH).

I take a history of the above symptoms in a systematic manner. I go through all the steps of passing urine to clarify what symptoms they have. It is also important to consider the duration of these symptoms. If these symptoms are acute then you should be considering whether this might be a urine infection, or potentially a bladder cancer.

The other important information you need to know are whether they have (or could have) any other medical conditions that may be causing their symptoms. E.g. is this a presentation of diabetes if they have increased frequency of micturition. Also, the medications that they take for other medical conditions could cause side effects that mimic LUTS. So check with them and check their medication list. You also need to consider taking a sexual history if they have any dysuria or penile discharge.

One of the important questions to ask, as with all consultations:

Why is this man presenting now? What are his concerns?

This is the golden question because it is going to guide your management plan. I often see men who wish to discuss their urinary symptoms because they are concerned about the possibility of prostate cancer. But once this is discussed and investigated they don’t feel the need to take medication for their symptoms. So ask them about expectations – it might save an unwanted prescription!

You need to examine your patient:

• Abdominal examination
• Genital examination
• Digital rectal examination (DRE)
• Look for peripheral oedema
• Neurological examination – if there is anything in the history that creates suspicion

A note about DRE and Prostate specific antigen (PSA). You need to undertake a DRE at some point during your assessment of the patient presenting with LUTS. Unless the patient is having their blood test very soon after the DRE it is unlikely to impact upon the PSA results. However, you could undertake the PSA testing, advise them they will need this examination at their follow up consultation and then perform it at the review. That is down to your preference. As long as it is completed in good time.

Investigations:

• Urinalysis – can look for infection, diabetes, or possibility of malignancy.
• An input/output diary – if they have storage symptoms or nocturia. Make sure they note caffeine intake.
• PSA – You need to counsel the patient prior to offering a PSA test. I really like this website for providing a man with information about PSA testing.

It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. The man’s scoring on this questionnaire can direct the management plan put in place.

Management:

First line should be information. About their condition and the lifestyle measures they can make that may improve their symptoms e.g. fluid modification. I really like this patient information leaflet from BAUS

Drug treatments. This is where the IPSS can be helpful.

Mild LUTS (IPSS <8) Enlarged prostate	5 Alpha reductase inhibitor
Moderate – Severe LUTS (IPSS >7) Normal sized prostate	Alpha blocker
Moderate – Severe LUTS (IPSS >7) Enlarged prostate	Alpha blocker + 5 Aplha reductase inhibitor
Overactive bladder (isolated storage symptoms)	Anticholinergics (if fails or not tolerated Beta 3 agonist)

Consider the common side-effects of these medications when explaining them to patients:

• Alpha blockers (e.g. Tamsulosin) – reduced ejaculation, postural hypotension (it is advisable to suggest the patient takes these last thing at night)
• 5 Alpha reductase inhibitors (e.g. Finasteride or Duasteride) – Reduced libido, Erectile dysfunction, gynaecomastia. With this treatment it may take several months for it’s benefit is seen. It is worth explaining this to the patient up front.
• Anticholinergics (e.g. Oxybutynin) – dry eyes, dry mouth, constipation, confusion (in the elderly).
• Beta 3 agonist (e.g. Mirabegron) – Tachycardia

Organise follow-up:

It is useful to review they patient at 4-6 weeks post initiation of treatment. They you can review at 6-12 month intervals. If it is Finasteride only that you have initiated then you may wish to lengthen the first review to around 3-6 months to allow time for it’s effects to have been seen.

Who to refer?

• Failure of medical treatment after a couple of reviews
• Severe LUTS (IPSS 20+)
• DRE suggests malignancy
• Elevated age-specific PSA
• Recurrent UTIs
• Persistent non-visible haematuria or any visible haematuria
• Urinary retention

This is the British Association of Urological Surgeons (BAUS) age adjusted PSA guide:

Age	Maximum PSA (ng/ml)
40-49 years	2.7
50-59 years	3.9
60 – 69 years	5.0
70-79 years	7.2
80-84 years	10
85+ years	20

If your patient has a raised PSA then this is a really nice web page to direct them to or print off to explain what this means and what might happen next.

I really hope this has shown you how straightforward a male LUTS consultation can be. If you have any questions then just as and I will answer as best I can.