Katelarisurology.com.auPULL OUT & KEEP UPDATE
LOWER URINARY TRACT
SYMPTOMS IN MEN
This Update discusses lower urinary tract symptoms in men, outlines the appropriate investigations and describes the management options. DR PHILLIP KATELARIS FRACS (UROL)
Consultant Urological Surgeon
Conﬂ icts: nothing to declare DR CLAIRE BERMAN MB.BCH 18
UPDATE CLINICAL REVIEW
PROSTATIC bladder neck obstruction (BNO) include frequency, urgency, urge inconti- with signifi cant outfl ow obstruction due or benign prostatic hyperplasia (BPH) rarely nence and nocturia. In fact, nocturia is a to benign prostatic hyperplasia or urethral causes symptoms before the age of 40 years. very early symptom of developing prostatic stricture disease.
However, symptoms occur due to bladder obstruction.
Unlike female cystitis, appropriate anti- neck obstruction in more than half of men in Nocturia, however, has a multiplicity of biotics should be provided for a full three • Prostatic bladder neck obstruction their 60s and up to 90% of men in their 70s.
causes including poorly controlled diabetes, weeks as bacterial infection of the prostate (BNO) or benign prostatic hyperplasia Management of this condition includes sleep apnoea and nocturnal polyuria of the is deep-seated and signifi cant parenchy- (BPH) rarely causes symptoms before issues relating to exclusion of prostate can- elderly. It is frequently the irritative symp- mal antibiotic penetration is necessary. the age of 40 years.
cer, timing of intervention and type of inter- toms that adversely aff ect the quality of life Short-course antibiotics often cause aseptic • All men who have suffered urinary tract vention most suitable for the individual for aff ected men. For example, the need to rebound. End-stage bladder neck obstruc- infection should be urodynamical y patient and the severity of his symptoms.
urinate four to fi ve times per night causes tion results in acute urinary retention which investigated for underlying obstructive chronic tiredness and lethargy.
is very painful. Slow onset chronic urinary bladder disorder.
SYMPTOMS AND COMPLICATIONS OF AN
Men with bladder neck obstruction are at retention is in fact bladder muscle failure. • Surgical intervention is for the man- OBSTRUCTED LOWER URINARY TRACT
increased risk of urinary tract infection. All Chronic large residual volumes exist within agement of bladder neck obstruction.
Symptoms of bladder neck obstruction are men who have suff ered urinary tract infec- the bladder resulting in urinary tract infec- best considered as either obstructive or tion should be urodynamically investigated tion, and ultimately in upper tract dilata-irritative. Obstructive symptoms include a for underlying obstructive bladder disor- tion resulting in hydroureteronephrosis. impairment. Chronic outfl ow obstruction poor pressure fl ow, hesitancy and a sense of der; lower urinary tract infections in men The obstructive uropathy must be managed may also result in the formation of bladder incomplete emptying. Irritative symptoms over the age of 50 are usually associated promptly in order to prevent long-term renal stones, sometimes of a considerable size. Diagnosis of lower urinary tract symptoms
Accurate diagnosis is critical prior to a poorly controlled chronic diabetes.
of obstruction does not correlate to prostate in the modern age is low due to modern management strategy being implemented. A urodynamic study is a half-hour size, the decision to treat therefore should bipolar diathermy and holmium laser Scored cross culturally validated patient computerised study that involves the pas- not be based on the size of the prostate surgical techniques.
questionnaires such as the International sage of a small pressure sensitive device as determined by digital rectal examina-Prostate Symptom Score (I-PSS) are useful. through the urethra into the bladder. In tion, it should be based on the urodynamic EXCLUDING PROSTATE CANCER
Video urodynamics is a very useful clinical order to allow the calculation of subcon- fi ndings of outfl ow obstruction. Similarly, Many men present clinically concerned tool for objectively determining the degree tracted cystometry a pressure sensitive cystoscopy should not be used as the deter- that their symptoms of benign prostatic of outfl ow obstruction and whether or not device is also placed per rectum. Both fi ll- minant of the need for prostate surgery in obstruction may be indicative of early pros- irritating urinary symptoms are due to ing and voiding profi les are studied with the majority of men. The relevance of pros- tate cancer. They should be reassured that primary overactive bladder activity or sec- voided urinary fl ow correlated to bladder tatic size is to determine whether a patient early prostate cancer does not cause symp- ondary to outfl ow obstruction. It is also a pressure as measured in centimetres of is suitable for transurethral resection of the toms of bladder dysfunction. The decision useful way of assessing the lower urinary water pressure units.
prostate or alternatively if an open or supra- to investigate and treat should be based on tract for neurogenic bladder dysfunction Bladder neck obstruction is best pubic prostatectomy approach needs to the inconvenience of symptoms or bother which may be due to spinal cord disease or assessed by a dynamic assessment means be used for the management of his benign rather than the fear that prostate cancer autonomic neuropathy, as may occur with such as urodynamic testing. As the degree disease. The need for open prostatectomy may be present.
BENIGN PROSTATIC HYPERPLASIA
CLINICAL REVIEW UPDATE
Each man who presents with symp- signifi cantly decrease the need for a pros- toms of bladder neck obstruction should be tate biopsy in men with PSA elevation.
evaluated individually for prostate cancer
by means of a digital rectal examination WHEN TO REFER
and PSA determination. Total PSA meas-
Men with bothersome symptoms of blad- urements with free to total ratio specifi ca- der neck obstruction should be referred. A tion should be ordered, a free to total ratio trial of alpha blocker medication is appro-of over 20% is suggestive that the total PSA priate in the fi rst instance. Referral is rec- elevation is due to benign prostatic hyper- ommended when conservative means of plasia rather than to prostate cancer. The management fail or where complications T2 weighted image
free to total ratio has only been validated such as urinary tract infection, bladder prostatic hyperplasia in
for total PSA levels greater than 4.0ng/ml.
stone formation or upper tract dilatation the central gland.
Multiparametric MRI scanning of the occur. All men with an elevated PSA or (From ‘Multiparametric
Prostatic MRI', Update,
prostate gland is an innovative diagnos- abnormal digital rectal examination should 15 August 2014.)
tic technology in this fi eld and should be referred for urological evaluation.
Watchful waiting and medical management
Finasteride is a 5-alpha-reductase inhib- Duodart — a trademark medication — is the absolute increase in fl ow rate — that Men with non-bothersome early symptoms itor introduced many years ago in the belief a combination medication containing an is relief of obstruction — is actually quite of bladder neck obstruction may be man- that decreasing benign prostatic hyper- alpha blocker, tamsulosin and a 5-alpha- modest. Flow rates may increase for aged expectantly. Mild symptoms do not plasia volume would relieve lower urinary reductase inhibitor, dutasteride. The aim example from 7ml per second to 9ml per need intervention and occasionally improve tract symptoms. It works by inhibiting of the combination pill is to allow the second, whereas with defi nitive surgery or at least fl uctuate over time. However, the production of the male hormone dihy- 5-alpha-reductase medication to relieve fl ow rates may increase from 7ml per sec- many men live with disruptive urinary drotestosterone, the hormone implicated lower urinary tract symptoms in the ond to 25ml per second.
symptoms as they are fearful of treatments at least partially in prostatic enlargement. short-term while relying on the benign Approximately 10% of men report they do not completely understand. It is nec- It was found to be of limited therapeutic prostate hyperplasia volume reduc- suppressed libido while taking 5-alpha- essary to strike a balance between over and benefi t in prostate glands less than 60g, tion in the long-term to be eff ective in reductase medication.
under treating lower urinary tract symp- however, in glands over 60g it did seem symptom relief.
In Australia, tamsulosin (Flomaxtra) is toms in men.
to decrease the incidence of acute urinary While the improvement in the Inter- not funded by the Pharmaceutical Bene- retention in the long term.
national Prostate Symptom Score ques- fi ts Scheme whereas Duodart is funded by MEDICAL MANAGEMENT OF LOWER
The use of 5-alpha-reductase medica- tionnaire and the fl ow rate in particular the scheme after the initial prescription URINARY TRACT SYMPTOMS
tion has been associated with controversy; is statistically signifi cant in clinical trials, has been arranged by a urologist.
Non-selective alpha blockers such as prazo- a large clinical trial suggested that these sin were used for many years for the manage- agents decrease the incidence of low-grade ment of mild obstructive urinary symptoms. prostate cancer while possibly increas- Selective alpha blockade using medications ing the incidence of potentially signifi cant such as tamsulosin are preferable. Selective high-grade prostate cancer. Argument con-alpha blockers partially relieve symptoms in tinues with respect to whether this fi nding over 50% of men; the symptom relief is often was an artefact of the trial or a valid conclu- not durable as the pathological process pro- sion. Those arguing in favour of 5-alpha- gresses over time. reductase medication not increasing the Side eff ects of even selective alpha block- risk of high-grade prostate cancer interpret ade include postural hypotension, nasal the results to signify that the decrease in congestion and retrograde ejaculation due volume of benign prostate hyperplasia to relaxation of the bladder neck sphincter. increases the diagnostic accuracy of pros-Alpha blockers should be ceased well before tate cancer investigations.
cataract surgery as they can cause ‘fl oppy PSA levels increasing in men taking lens syndrome'. The ophthalmologist should 5-alpha-reductase medication is an abso- always be informed that the patient is taking lute indication for urological referral as the an alpha blocker. Many men are not accept- likelihood of prostate cancer being present ing of long-term alpha blockade as manage- is signifi cant. Over a six-month period on ment for their symptoms. Men are frequently 5-alpha-reductase medication PSA levels forgetful or generally poorly compliant with may halve due to the reduction of benign such medication and frequently request a prostate hyperplasia volume. An increase is more defi nitive and durable approach to therefore suspicious for the development of their symptom complex relief.
complementary products; this represents a placebo response to the product and Alternative therapies for bladder neck also the natural history of bladder neck
obstruction have been widely marketed, obstruction where symptoms will fl uctuate
and as a consequence of this marketing over time.
widely utilised within the population of
the Western world. Chief among these ALTERNATIVE TECHNOLOGIES
products is saw palmetto. In the urological Many alternative technologies have been
community, saw palmetto is not accepted developed and marketed during the last
as an agent that performs any better than 25 years for benign prostatic hyperplasia.
placebo in multiple randomised controlled These include transurethral needle ablation
trials. Furthermore, there is a marked vari-
of the prostate, prostatic alcohol injection, ability dosage of saw palmetto between prostatic thermotherapy and a multitude of manufacturers and even between individ- prostatic laser therapies. With the exception ual lots from the same manufacturer.
of certain laser therapies, the alternative Patients often report symptomatic technologies have not gained wide spread Whole saw palmetto.
relief in the initial early stage of taking acceptance due to a lack of effi cacy.
American Urological Associa- tion Guideline: Management of Benign Prostatic Hyperplasia CLINICAL REVIEW UPDATE
THE INDEPENDENT FLOW STUDY
with voiding pressures and this limits its distended with fl uid, sensation to fi lling disorder or it may indicate, depending on An independent fl ow study involves a diagnostic utility.
is recorded along with an assessment of the fi lling profi le, neurogenic bladder dys- man voiding freely into a computerised bladder compliance and fi lling pressures function which may occur in conditions fl ow meter which records the urinary fl ow URODYNAMIC EVALUATION
at total bladder capacity. According to the such as spinal cord injury, Parkinson's dis- measured in millilitres per second and the A urodynamic study involves a small pres- International Continence Society defi ni- ease and MS .
volume voided. These results are plotted sure sensitive device being inserted per tion, an adult bladder should comfortably During the voiding phase the patient on nomogram graphs to indicate whether urethrum into the bladder and also per accommodate at pressures of less than is tilted to the upright position, often on or not the fl ow rate is in the obstructed anum. This allows for subcontracted pres- 10cm of water 500ml volume. When the a fl uoroscopy table. The voided stream or non-obstructed range.
sure evaluation; the ambient intra-abdom- pressure exceeds 10cm of water the patient in millilitres per second is correlated The independent fl ow study may inal pressure is subtracted from the total is diagnosed as having detrusor overactiv- with the subtracted cystometry that is be used as a screening test for assess- bladder pressure to give the true detrusor ity. The overactivity may refl ect overactiv- the true voiding detrusor pressure. Once ment of lower urinary tract function, pressure responsible for voiding.
ity secondary to outfl ow obstruction, it again nomograms give an indication as to however it does not correlate fl ow rates During the fi lling phase the bladder is may indicate primary overactive bladder whether or not a patient is obstructed. Surgical intervention for the management of bladder neck obstruction
BLADDER NECK INCISION
side eff ects of chronic drug therapy. procedure is a highly eff ective operation Small tight prostates and men with bladder Its signifi cant advantage is that retro- with minimal morbidity.
MORE ONLINE FROM
neck dyssynergia (a condition of failure of grade ejaculation has not been reported The patient is admitted for a 24—48 hour bladder neck relaxation during voiding) in treated men which is preferable for cer- period and the procedure performed under are often will managed with bladder neck tain men who wish to maintain anti-grade general spinal anaesthesia. Return to sed-incisional surgery. The prostate is incised ejaculation.
entary work within fi ve days is feasible.
rather than resect it or ablated.
The traditional resection technology GUIDE TO GUIDELINES
Under a general anaesthetic, cystos- GREENLIGHT LASER ABLATION
was monopolar diathermy. This requires our online col ection of clinical guidelines copy is performed and thereafter — uti- GreenLight laser ablation of the prostate irrigation with an isotonic fl uid such as lising a Collins knife diathermy cutting has been widely marketed in recent years. glycine. Glycine and/or water intoxication device — the trigone, bladder neck and It is a tissue ablation technique that oper- syndromes can occur where excessive irri- easy to search and quick to download prostate gland is incised deeply in the ates by absorption of light in the green gating fl uid is systemically absorbed. With midline to the level of the verumonta- light spectrum. The procedure is done the signifi cant technological improvement num. This relieves the obstructive eff ect under general anaesthesia utilising a mod- in the surgery and the much improved normal saline. Absorption of the normal of the small tight prostate and dyssyner- ifi ed cystoscope.
training of endoscopic surgeons this saline does not cause the so-called TURP gic bladder neck. It is a minimally inva- Anaesthetic times are generally longer occurrence is now very uncommon.
syndrome. The bipolar technology has sive procedure with good long-term relief than for conventional transurethral resec- Bipolar diathermy technology has now facilitated excellent haemostasis, and of symptoms for well selected patients. It tion surgery, as it is an ablation technique been introduced, allowing for irrigation the ability to resect very large glands in a is not suitable in men with large prostate and tissue is not obtained for histological during the operation with physiological timely manner.
glands or in men with prominent sub trig- examination. It is therefore necessary to one or middle lobes.
carefully screen men prior to laser abla- Younger men with bladder neck dys- tion for the possibility of prostate cancer Endoscopic prostate
synergia may elect to watchfully wait or in the transition zone of the prostate. Ret- utilise a trial of alpha blockade medication rograde ejaculation occurs with green light in the fi rst instance. Should symptoms laser ablation as it does with transurethral
become suffi ciently bothersome, bladder prostatectomy.
neck incisional surgery is appropriate.
Bladder neck incisional surgery involves HOLMIUM LASER ENUCLEATION
a 25% occurrence of retrograde ejacula-
OF THE PROSTATE (HOLEP)
tion on a permanent basis and hence Holmium laser enucleation of the prostate subfertility.
is a well-established form of transition Bladder neck incisional surgery should zone enucleation. Unlike GreenLight laser not be performed on a man who wishes to ablation signifi cant prostatomegaly does retain fertility. Notwithstanding apparent not represent a major challenge. The diffi -retrograde ejaculation, emission of sperm culty of laser enucleation is that the tissue may still occur and therefore retrograde is delivered into the bladder and needs to ejaculation cannot be relied upon as a con- be removed by a process of morcellation traceptive procedure, concurrent bilateral which can at times be technically diffi cult. vasectomy would be necessary in this The removed tissue can be pathologically regard.
analysed. This technique also causes ret-rograde ejaculation.
THE UROLIFT DEVICE
The UroLift device has recently been intro-
duced into Australia and is approved by OF THE PROSTATE
the Therapeutic Goods Administration.
Transurethral resection of the prostate This procedure involves the placement gland has long been considered the gold of sets of intraprostatic sutures anchored standard therapy for symptomatic benign from within and from without by titanium prostatic hyperplasia. The term, con- bolsters. This pulling apart of the prostatic temporary transurethral resection of the urethra results in the formation of an ante- prostate, refers to the operation being per- rior channel and the relief of obstructive formed by well-trained specialist urologi-urinary symptoms.
cal surgeons using continuous fl ow resect It is not suitable for men with signifi - escapes and three chip digital cameras. In cant middle lobe enlargement. It does not earlier years the procedure was plagued preclude defi nitive transurethral resection by poor visualisation due to substand- surgery at a later date should that become ard optics. Signifi cant bleeding was also necessary.
caused by poor diathermy technology The UroLift device is a suitable replace- and non-specialist urological surgeons ment for men who do not wish to take long- performing the technique. The modern term drug therapy and certainly avoids the transurethral resection of the prostate 24
UPDATE CLINICAL REVIEW
Suprapubic or open prostatectomy
MORE IN OUR ONLINE UPDATE ARCHIVE
Very large benign prostates causing sig- supra-pubic prostatectomy does not carry medobs.com.au & search the title
nifi cant symptoms may need to be enucle- this risk. Retrograde ejaculation will occur ated via an open supra-pubic approach. An after supra-pubic prostatectomy.
assessment is made cystoscopically with There are a number of eff ective surgical respect to the size of the transition zone. interventions as listed above for the man- Multi-parametric prostatic MRI imaging –
When it is estimated that an endoscopic agement of benign prostatic hyperplasia a new way of looking at the prostate gland
resection would involve the removal of resulting in bladder neck obstruction and 80—100g or more of tissue and open pro- lower urinary tract symptoms. It is a mat- cedure is best considered. Open or supra- ter of surgical judgement and training with Female urinary incontinence
pubic prostatectomy is the enucleation of respect to which technology is applied to the transition zone via a lower abdominal the individual patient, all of the above transverse skin incision. Current blad- techniques when performed by well- Nocturnal enuresis
der stones can be conveniently removed. trained surgeons on well selected patients Patients are usually discharged on day have the potential for producing excellent The neurogenic bladder
three postoperatively with an indwelling outcomes.
catheter for a further seven days.
It is to be noted that following the relief Supra-pubic prostatectomy should not of bladder neck obstruction it is usual for be confused with radical retropubic pros- ongoing irritative symptoms such as fre- reverses within a 12 month period. Should beyond 12 months, and be resistant to tatectomy which is total removal of the quency, urgency, urge incontinence and bothersome irritating symptoms occur anticholinergic medication, consideration prostate and not enucleation of the transi- nocturia to persist for 3— 9 months. For the postoperatively, anticholinergic medica- could be given to the use of intravesical tion zone. Whereas radical prostatectomy majority of men poorly compliant overac- tion can be utilised in the form of oral Botox injection therapy or alternatively can damage the neurovascular bundles tive bladder activity that has developed medication or trans-dermal oxybutynin. sacral-neuro modulation by means of the bilaterally responsible for erectile function over decades secondary to obstruction Should overactive bladder activity persist implanted sacral nerve electrodes.
Clarifi cation of the term ‘prostatitis'
Many men with symptoms referable to the generalised symptoms of fever, rigors and and it therefore may not be appropriate A routine urinary tract ultrasound lower urinary tract are labelled as hav- chills. Local symptoms include frequency in somebody who has been to Asia within is helpful and where indicated, a uro- ing ‘prostatitis'. This generally precipi- urgency and dysuria. The man looks ill, the last six months. Following resolution dynamic study should be performed tates protracted treatment with multiple there may be retention of urine, the pros- of the acute toxicity four weeks of oral to exclude signifi cant outfl ow obstruc- courses of antibiotic therapy which may tate may feel boggy to digital rectal exami- trimethoprim is recommended in order to tion that may predispose to bacterial have a short-term placebo eff ect prior to nation and is generally swollen and tender. sterilise the prostatic parenchyma.
Occasionally a fl uctuant mass indicating Managing men with lower urinary tract a prostatic abscess may be present espe- symptoms that are atypical and are asso- cially in the immunosuppressed man.
ciated with perineal discomfort requires Men with acute toxic bacterial pros- ESSENTIAL MEDICAL NEWS – that bacterial infection be excluded, blad- tatitis are best managed in hospital with der neck obstruction be excluded and that parenteral antibiotics. Catheterisation the patient is asked sensitively yet frankly may be necessary if there is incomplete about stressors in his life and an assess- bladder emptying. Blood and urine cul- ment is made with respect to depression tures need to be obtained preferably prior and anxiety.
to initiating antibiotic therapy and there-after empirical initial treatment with intravenous gentamicin and ampicil- Bacterial prostatitis is an acute and poten- lin initiated. The pathogenic is usually a tially serious gram negative infection of gram negative organism such as E. coli or the prostate gland that if untreated may Klebsiella. The routine use of gentamicin lead to gram negative septicaemia.
is now being questioned due to the reali- It is generally an infection of the older sation that chronic vertigo may result male and may be associated with sig- from even short-term use. Parenteral nifi cant bladder neck obstruction with quinolone antibiotic therapy may be sub-incomplete bladder emptying. The patient stituted though there is signifi cant resist-typically presents very unwell with ance to this class of antibiotics in Asia Non-bacterial prostatitis or chronic
pelvic pain syndrome (CPPS)
It is preferable not to use the term prosta- at the tip of the penis and other diffi cult to titis in men without evidence of lower uri- explain symptoms referable to the genital nary tract infection. It tends to lead to the area. Reassurance for these men is very prolonged use of inappropriate oral antibi- otic therapy.
Prostate cancer, prostate infection and This symptom complex is generally bladder neck obstruction should all be associated with men who are stressed, actively excluded and the patient reassured introspective and who may have a signifi - with respect to the results. If signifi cant cant over-performance mentality. It can anxiety depression is suspected the patient also be somatisation of an anxiety/depres- should be referred for appropriate profes- sional help. While there are a number of These symptoms typically involve a somewhat novel treatment propositions for feeling that the man is ‘sitting on a golf chronic pelvic pain syndrome including ball'; there may be spasm of the pelvic fl oor Botox injection and neuromodulation ther- muscles or rectal tenesmus. The latter is apy, the initial approach should be reassur- Medical Observer e-Newsletter
associated with a writhing discomfort cen- ance and regular daily exercise which tred round the anus and perineum. A typi- seems to have a positive physical and psy- To sign up, go to medicalobserver.com.au/member/register
cally associated symptom may include pain chological benefi t for these men. 26
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