LOWER
URINARY TRACT SYMPTOMS (LUTS); PROSTATE
The
lower urinary tract consists of the bladder, prostate, sphincter mechanisms and
urethra. The bladder is an important
organ for storage and voiding of urine.
The urethra runs through the prostate which is also an organ important
for production of semen.
The
commonest lower urinary tract symptom is that of nocturia. Passing urine once
or more at night (preceded and followed
by sleep) is considered nocturia.
Nocturia may or may not disturb sleep.
Women also suffer from nocturia but they do not have a prostate! Nocturnal polyuria occurs when the urine
output at night is more than one third the total output and the treatment is
not urological. The lifestyle strategies
to reduce bothersome nocturia include reducing the amount of fluid taken at
night and taking an afternoon nap or just lying down for an hour such that more
of the fluid accumulated in the lower limbs is returned to the body and
excreted before sleep.
In
a publication by Teh GC et al in
Malaysian Medical Journal 2001; 56: 186-195, it was reported that the frequency
of lower urinary tract symptoms is as follows:
nocturia 56%, urinary frequency 50.4%. This is similar to a report from
Asia published by the British Journal of Urology International 2007; 101:
197-202, whereby nocturia is reported in 64% of patients with LUTS. Frequent toilet visits can affect the quality
of life. Another important LUTS is
urinary urgency which is a strong and sudden urge to void which cannot be
postponed. This may or may not be
associated with urinary urge incontinence.
According to the International Continent Society (ICS), OAB,
overactive bladder is defined as urinary urgency with or without urinary urge
incontinence, usually accompanied by urinary frequency more than 8 micturitions
per day and nocturia more than 1 episode per night. OAB can also be managed by
lifestyle adjustments for bladder care e.g. emptying the bladder before and
after any event, restricting fluid before an event. Two groups of medications may be used to
relax the bladder, namely, the anti-cholinergics (e.g. Tolterodine SR 4 mg,
Solifenacin 5 mg daily) or the beta-adrenergic agonist (e.g. Mirabegron 50 mg
daily).
Another
group of LUTS is that of urinary hesitancy, slow stream, intermittent stream
and terminal dribbling. Eventually the patient may go into urinary
retention.
LUTS
may be documented with the IPSS Questionnaire (International Prostate Symptom Score) which
also has a question on the Quality Of Life score.
LUTS
traditionally does not include haematuria nor dysuria. When there is gross haematuria, one would
need to rule out a tumour of the urinary tract (e.g. bladder, ureter or kidney)
or urinary stones. Urinary stones are
typically associated with pain and urinary tract infection as well. When there
is LUTS with pain and urinary abnormality and a negative bacterial culture, one
will have to think of interstitial cystitis or ketamine cystitis, in the local
context. When the clinical diagnosis is
likely to be that of UTI, urinary tract infection, a suitable antibiotic
(according to the local antibiogram) may be used to clear the symptoms. When
there is LUTS with pain but no urine abnormality, one has to think of the wide
spectrum of chronic pelvic pain syndrome, CPPS.
Therefore,
the underlying pathologies for LUTS includes the following: benign prostatic
enlargement, BPE, benign prostatic enlargement obstruction, BPEO, benign
prostatic obstruction, BPO, bladder outlet obstruction, BOO, overactive
bladder, OAB, underactive bladder, UAB, urinary tract infection, UTI,
interstitial cystitis, IC and various types of neuropathic bladder.
BPH, benign prostatic
hyperplasia
is extremely common, occurring in almost every man above the age of 60.
Nevertheless, taking history and physical examination are needed to find out the
underlying cause for the LUTS. Severe phimosis
is occasionally undetected in elderly men.
A DRE, digital rectal examination is essential to feel the anal tone,
the prostate (size, consistency, lateral lobes, median sulcus, any nodularity),
to feel any other masses and any constipation.
Investigations for LUTS may consist of the
following:
(1)
Urinalysis
is mandatory.
(2)
Ultrasound
of the urinary tract: looking for bladder volume, pre and post micturition, any
intraprostatic protrusion of the prostate (IPP), the prostate volume, bladder
wall thickness and any hydronephrosis.
(3)
In
symptomatic male patient, a PSA, prostatic specific antigen is useful as a
baseline before medical therapy.
(4)
A
uroflowmetry is a cornerstone for the diagnosis of LUTS as well as for
follow-up. The normal maximum flow rate is
more than 15 ml/s provided the voiding volume is more than 150 mls. The pattern of the voiding would also be
indicative of whether it is due to the enlarged prostate, a urethral stricture
or otherwise. Uroflowmetry alone by itself will not be able to confirm the UAB,
underactive bladder. However, underactive bladder tends to have a smooth normal
bladder outline.
(5)
UDS,
urodynamics study is occasionally useful in LUTS eg confirming an underactive
detrusor muscle.
There are 2 types of
medications for slow urination due to BPH.
The first is to relax the prostate smooth muscle, namely, an alpha
adrenergic blocker e.g. Terazosin , Doxazosin. The main side effect of these alpha adrenergic blockers is that of
postural hypotension and therefore, the dosage may have to be titrated. More uro-selective alpha blockers include
Tamsulosin or Alfuzosin. These uro-selective alpha blockers have less postural
hypotension but they have more incidence of reduced ejaculation. The second
group of medications for the prostate are the 5-alpha reductase inhibitors, namely, Finasteride or
Dutasteride. These work by blocking the
conversion of testosterone into dihydrotestosterone in the prostate cell.
However, the prostate takes time to shrink, often more than 6
months. The improvement of uroflowmetry from medical therapy is usually about 2-
3 ml/s but this is often sufficient to give the patient symptomatic relief.
Medical therapy also reduces the risk of acute urinary retention and drastically reducing the need for prostate
surgery in the last two decades.
BPEO,
benign prostatic enlargement obstruction is occasionally complicated by urinary
tract infection, bladder stones, hydronephrosis and obstructive uropathy (about
1% of BPEO patients). These
complications are usually an indication for catheterisation for a few weeks
before the patient undergoes surgical treatment. The goal standard surgical
treatment for BPEO, benign prostatic enlargement obstruction is TURP,
transurethral resection of the prostate.
The complication of TURP is that of prostatic bleeding. A long term complication of TURP is that of
retrograde ejaculation.
Prostate cancer
is probably
the commonest cancer in men. “It is a
cancer which every man will get if they live old enough”. Most prostate cancers are slow growing and
men tend to die with the cancer rather
than from the cancer. However, if the prostate cancer is
aggressive, the symptoms could consist of local effects (e.g. urinary retention)
and from metastatic disease to the spine (backache) or the regional lymph nodes
(with hydronephrosis and lower limb swelling).
Screening
of prostate cancer is currently discouraged unless there is a strong family
history of young family members with prostate or breast cancer. The diagnosis of prostate cancer is usually
with transrectal ultrasound guided systemic and targeted biopsies. The main
complication of transrectal ultrasound
prostate biopsy is that of sepsis and if the patient has a fever of 38°C after the biopsy (up to 5%
of them), urgent intravenous antibiotic is needed: a suitable regime is that of
IV Meropenem 1 gm 3 times a day for 5 days. Transperineal prostate biopsy
(template and targeted) is an option with almost no septic complication,
coupled with the ability to target the anterior and apical parts of the
prostate gland. However, such a percutaneous
approach is painful and requires a general anaesthetic.
The
prostate biopsy is useful to confirm that it is indeed an adenocarcinoma, to
confirm the tumour grade (Gleason 3 – 5), the location of the tumour and
percentage of the tumour.
If
the prostate cancer is diagnosed to be of low grade, low stage and a PSA of
<10 b="" cores="" disease="" low="" style="mso-bidi-font-weight: normal;" volume="">active surveillance
of the prostate cancer may be an
option. This would consist of 3 to 6
monthly testing of PSA and repeat prostate biopsy every few years. If the cancer
is localised to the prostate, a good treatment option is that of RARP, robot assisted radical prostatectomy. The main complication of RARP is that of
sexual dysfunction and about 5% of these patients is incontinent at 1 year.
For
locally advanced and metastatic prostate cancer, the mainstay treatment is that
of anti-androgen therapy. This may be a
surgical orchidectomy or medical orchidectomy, starting with oral medication,
e.g. Bicalutamide 50 mg, three tablets a day. The testosterone from the testes
can also be suppressed with injection LHRH analog (e.g. Leuprolide) or LHRH
antagonist (e.g. Degarelix). After a few
years, the prostate cancer will become castrate resistant, i.e. CRCP cancer
prostate. They will then require secondary anti-androgen therapy, e.g. Abiraterone
or Enzalutamide. For patients who are
fit and with high volume disease, chemotherapy with the Taxotere group of drugs
may be effective.
Lecture By Dr
Clarence Lei Chang Moh, FRCS Urol, FEBU
Consultant
Urologist
Adjunct
Professor, Universiti Malaysia Sarawak
13th
July 2017
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