LUTS + BPH

Question 1

What is the common cause of LUTS in older men?

Answer 1

Bengin prostatic enlargement (BPE) most commonly due to the histological diagnosis of BPH.

Question 2

What is the most common aetiology of LUTS in women?

Answer 2

Over 40 years old and commonly associated with lower urinary tract infection.

Question 3

What is LUTS?

Answer 3

Term used to describe array of symptoms affecting control and quality of micturition

Question 4

What are the casues for LUTS in men?

Answer 4

BPH 
UTI 
Urological malignancy 
Detrusor muscle weakness or instability 
Chronic prostatitis 
Urethral stricture 
External compression e.g. pelvic tumor, faecal impaction 
Neurological disease e.g. MS, spinal cord injury

Question 5

What are the causes of LUTS in females?

Answer 5

UTI
Menopause
Urological malignancy
Detrusor muscle weakness or instability
Urethral stricture
External compression e.g. pelvic tumor, faecal impaction
Neurological disease e.g. MS, spinal cord injury

Question 6

What lifestyle factors can excerbate LUTS?

Answer 6

Drinking fluids late at night
Excess alcohol intake
Excess caffeine intake

DM and diuretics can both mimic LUTS

Question 7

What are voiding symptoms?

Answer 7

Hesitancy 
Poor flow 
Terminal dribble 
Feeling of incomplete emptying 
Intermittency 
Straining

Question 8

What are storage symptoms?

Answer 8

Urgency
Frequency
Nocturia
Urgency incontinence

Question 9

What assoicated symptoms should be asked about in a history of LUTS?

Answer 9

Visible haematuria
Suprapubic discomfort
Colicky pain
Medication history - anticholinergics, antihistamines and bronchodilators

Question 10

What scoring system may be used for LUTS in men?

Answer 10

International prostate symptom score - IPSS

Question 11

What examinations may be carried out in LUTS?

Answer 11

DRE

External genitalia

Question 12

What initial investigations should be done for LUTS?

Answer 12

Post-void bladder scanning and flow rate

Urinary frequency and volume chart

Urinalysis +/- urine culture

Routine bloods

PSA?

Question 13

What specialist investigations may be ordered for LUTS?

Answer 13

Urodynamic studies

Cystoscopy - GOLD standard for lower urinary tract

Upper urinary tract - ultrasound and CT

Question 14

What does urodynamic studies involve?

Answer 14

Flow rate
Detrusor pressure
Storage capacity

Used in neurogenic bladder dysfunctions suspected

Question 15

When is cystocopy indicated?

Answer 15

Recurrent infection

Presence of haemturia

Question 16

When is ultrasound and CT indicated in LUTs?

Answer 16

Chronic retention
Reccurent infection
Presence of haematuria

Question 17

What is the conservative management of all LUTS other then treating underlying cause?

Answer 17

Regulating fluid intake - timing and volume of drinks consumed and reducing caffine and alcoholic drinks

Question 18

What is the conservative management for voiding symptoms in LUTS?

Answer 18

Voiding symptoms - urethral milking techniques (manually emptying the bulbar urethra of residual volume) or double voiding (passing urine and then remaining for a short time before passing urine again)

Question 19

What is the conservative management for stress incontinence and post-micturition dribble?

Answer 19

Pelvic floor exercises

Question 20

What is the conservative management for overactive bladder?

Answer 20

Bladder training technique

Question 21

What is the pharmacological managment of overactive bladder?

Answer 21

Anticholinergics - oxybutynin and tolterodine - first line

Mirabegron - B3 adrenergic agonist

Question 22

What is the pharmacological managment for BPH?

Answer 22

Alpha blocker - tamsulosin

5 alpha reductase inhibitors - finasteride

Question 23

What is the pharmacological managment of nocturia?

Answer 23

Loop diuretics - taken mid afternoon - unlicensed

Desmopression - unlicensed

Question 24

What are the complications of LUTS in left untreated?

Answer 24

Infection
Renal and bladder calculi
Chronic obstruction leading to overflow incontince
Renal failure and bilateral hydronephrosis

Acute urinary retention in BPH

Question 25

What are the side effects of alpha blockers?

Answer 25

Reterograde ejactulation Postural Hypotension

Question 26

What are the side effects of 5-alpha redcutase?

Answer 26

ED Decreased libido Rash

Question 27

What is TURP syndrome?

Answer 27

Dilutional hyponataremia due to TURP procedure using glycine. This is due to hypoosmolar irrigation during TURP and leads to fluid overload. Presents as confusion, nausea, agitation or visual changes Quite rare due to the use of bipolor energy which uses isotonic irrigation fluid

Question 28

What are the differntial diagnosis for BPH?

Answer 28

Prostate cancer UTI Overactive bladder Bladder cancer

Question 29

What investigations should be requested for in BPH?

Answer 29

Urinary freq and volume chart Urinalysis Post-void bladder scan - chronic urinary retention PSA Ultrasound + urodynamic studies

Question 30

What is the management of BPH?

Answer 30

Symptom diary Medication review an sutible lifestyle advice Alpha-blockers - first line unless contraindicated 5 alpha reductase - decrease prostatic volume - can take upto 6 months to achieve symptomatic benefits

Question 31

What is the surgical management of BPH and when is it offered?

Answer 31

Not responding to medical management or develop significant sequlae of bengin prostatic hyperplasia (e.g. high pressure retention) Transurethral resection of the prostate (TURP)

Question 32

What are the complications of TURP?

Answer 32

Haemorrhage Sexual dysfunction Reterograde ejaculation Urethral stricture

Question 33

What are other techniques other then TURP in BPH management?

Answer 33

Holmium laser enucleation of the prostate (HoLEP) Less commonly prostatectomy - pts with large prostates

Question 34

What is the main complications of BPH?

Answer 34

High-pressure retention Reccurent UTIS or significant haematuria