Lower Urinary Tract

Symptoms (LUTS)
Presented by: Saad al-saad,
Osamah al-sewilim, faisal al-sheban

Supervised by: Dr- Al Traifi

Objectives

Discuss the Lower Urinary Tract Symptoms

Causes of LUTS
Work up
Treatment of BPH and other causes LUTS

Definition:
LUTS, or lower urinary tract symptoms , is a

common term used to describe the range of

urinary symptoms as frequency, urgencyetc ,
which was previously called prostatism but this
has been replaced by LUTS because the
prostate is most often not the cause.

LUTS had been categorized into:

1. Storage (irritative ) symptoms

2. Voiding( obstructive) symptoms

3. Post voiding symptoms

Storage symptoms:
Daytime frequency
Urgency: sudden desire for urination that is

difficult to postponed.
Nocturia : urinary urgency that awakens the
pt. from sleep.
Urge incontinence
Enuresis: incontinence during sleep.

Voiding symptoms
hesitancy: delay in starting micturation.
Intermittent folw
Weak stream: diminished force and caliber with

prolonged voiding time.

Double voiding
Straining to void
Terminal dribbling

Post void symptoms

Post void dribbling
Feeling of incomplete emptying

Causes of LUTS:
In males:

Outflow obstruction
BPH
Meatal stenosis

Impaired detrusor function

NM dysfunction
Detrusor instability
Impaired detrusor contractility
Psychogenic voiding dysfunction

CONT

Infection

Cystitis, prostatitis, prostatic abcess and

urethral diverticulum.

neoplastic

Prostatic cancer, bladder cancer

Others:

Bladder diverticulum, stone and

interstitial cystitis.

In females :
Mostly storage symptoms

UTI
Pregnancy
Anxiety
Overactive bladder
Interstitial cystitis
Postmenopausal urogenital atrophy
Bladder tumor or stone
Genital prolapses or pelvic mass

Mostly voiding symptoms

Age related detrusor muscle weakness

Obstruction (urethral stricture, urethral wall divertivulum, periurethral fibrosis)
Urethritis
Drugs ( diuretics, alcohol, lithium, anticholinergics)

In taking history we should enquire about

other UT symptoms like:

Haematuria
Fever
Loin & pelvic pain
PMH of renal colic, UTI
Sexual/erectile difficulties
Medications
Bone pain
DM, HTN

In female:
Dyspareunia , vaginal dryness, genitourinary prolapses(low back
pain, heaviness, dragging sensation)

On examination:
General condition and vital signs
Sign of uremia and enlarged lymph node
Abdominal exam. For:
Palpable kidney
Palpable bladder
Renal & bladder tenderness
Ext. genitalia
Perineal sensation
Rectal exam. (prostate: size, tenderness, nodule)

Investigation
*Laboratory tests:
Urinalysis, urine culture.

CBC,serum creatnine, blood urea nitrogen

Blood sugar and serum electrolytes
(PSA) prostate-specific antigene for male pt over age 50

Voiding Dairy

Cont.

Investigation

*Assessment ot upper tract:

Only for pt with hematuria , recurrent UTI

or history of urinary stones is present.
# U/S of the kidneys and bladder
#CT urography
# (IVU) intravenous urogram

US

Ascending Urethrogram

Cont.

Investigation

2- voiding cystourethrogram(VCUG):
Is performed by filling the bladder with radiographic
contrast agent through a urethral catheter or suprapubic
tube
. The process is monitoring by fluoroscopy .static film are
obtained with the bladder full, during micturation and
after voiding.
. VCUG is excellent method of diagnosing vesical neck
obstruction and vesicoureteral reflux.

Cont.

Investigation

*Uroflowmetry:

an electronic flowmeter can provide a recording of urinary

flow rate

*Cystourethroscopy

Endoscopy permits direct visualization of the entire urinary

tract .

* Cystometry:

is continuous recording of bladder pressure during

gradual filling and during contraction .indication in any
neuralgic disease is suspect

Cont.

Investigation

*Assessment of lower
tract:
1- Ascending retrograde
urethrogram:
-RUG is most useful in visualizing
lesion of the ant. Uretha

-stricture
- diverticula

TREATMENT
*Obstructive ureter:
- Suprapubic cystostomy
- Ureteric catheter drainage

- Uretheral catheter drainage

Cont

TREATMENT

A. Distal urethra:

*Urethral strictures:
-Dilation
- - Visual urethrotomy
transurethral balloon dilation catheter
- Urethroplasty
*Meatal stenosis:
-Dilation
-surgical meatotomy

BENIGN PROSTATE
HYPERTROPHY

Benign prostatic hypertrophy

Excess cells replication.
It is noncancerous growth of prostate gland.
It is most common noncancerous form growth in men.

Pathophysiology
The mechanism of prostate hypertrophy is unknown
But there are multiple theories:
-Male hormones(testerone,DHT,granular epithelium of
prostate,BPH)

-Estrogen( with aging testerone drop, estrogen raise )

-Late activation of cell growth of certain section of
gland signaling other prostate cells to be more sensitive
growth stimulating hormone
-Defective

cell death (apoptosis will stimulate new

cells proliferation )

Symptoms of bladder outlet obstruction

caused by BPH include:
Hesitancy
Weakness of urinary stream
Intermittent urinary stream
A feeling of incomplete bladder emptying and
need for repeat voiding
Bladder irritability, as manifested by urinary
frequency, nocturia, and urinary urgency

Potential Complications of BPH

- Urinary retention
- Renal impairment
- Urinary tract infection
- Gross hematuria
- Bladder stones
- Bladder decompensation
- Overflow incontinence as
a result of retention

Risk factors
-Age : at late 40s only 3.5% of men
at 80s it raise to 35%
-Ethnic

groups: African American at high risk

Asian at low risk

-Family history
-Medical condition :
Obesity
Heart and circulatory disease
Type 2 DM

The initial evaluation of all patient presenting

with LUTS suggestive of BPH should include:
-Medical history
-Digital rectal exam DRE
-Neurological exam
-Urinalysis

The DRE :
-A benign prostate:
Feels smooth
Symmetric
-Prostate cancer
Palpable nodule
Feel hard
Asymmetric gland

Treatment
-Watchful waiting :
A- IPSS score 0 to 7
B- 30% improvement
C- 1-5% symptom progression

-Pharmacological therapy:
A- alpha-1 adrenergic blocker (terazosin, doxazosin, prazosin)
B-finasteroide (reduce prostate size 20%)
C-phytotherapy

-Thermotherapy catheter (>45 C for 30 min )

-Laser prostatectomy
-Open prostatectomy:
Suprapubic prostatectomy
Retropubic prostatectomy
Simple perineal prostatectomy

-Catheters:

Intermittent self catheterization

Indwelling cath
Suprapubic cath