#318 LUTS, BPH, and Urinary Incontinence Triple Distilled

January 26, 2022 | By Matthew Watto, MD

Video

Master urinary tract symptoms! Paul and Matt recap, review, and update past episodes on BPH and urinary incontinence so you’ll be able to confidently manage lower urinary tract symptoms (LUTS) in primary care. Topics: categorizing urinary incontinence, lifestyle modifications for LUTS, nonpharmacologic & pharmacologic therapies for urinary incontinence and BPH, plus when to refer to surgery. 

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Credits

• Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Infographic by: Matthew Watto MD, FACP
• Cover Art: Matthew Watto MD, FACP
• Executive Producer: Beth Garbitelli
• Showrunner: Matthew Watto MD, FACP
• Editor: Clair Morgan of nodderly.com

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Defining ED
• Additional history, exam, and labs
• How to talk about ED
• Addressing ED for transgender and nonbinary patients
• Treatment of ED
• Advanced therapies and referral
• Take Home Points; Outro; Bonus clip

Episode #53 Urinary Incontinence

Featuring Molly Heublein and production and graphics by Matt Watto

The History

• Prevalence: Varies widely by source for women with stress urinary incontinence (SUI) ~50%, urge urinary incontinence (UUI) ~17%, and mixed UI 34%. About 3-11% of men mostly urge incontinence (Nitti, 2001).
• Ask the 3IQ or just ask, “do you have bothersome leakage of urine?”. 
• Ask, “in what situations did you leak urine?”.
• Ask about intimate partner violence in women with urinary tract symptoms (Boyd, 2020).
• Functional incontinence can occur in folks with the inability to ambulate or difficulty using the restroom alone (e.g., dementia).
• Think about neurologic conditions that might impair bladder function
• Review med list (diuretics, sedatives, hypnotics, antidepressants, and muscle relaxants –source Dynamed)
• Stress urinary incontinence (SUI): Leakage with coughing, sneezing, physical activity.
• Overactive bladder (OAB) and urge incontinence (UUI): OAB can be “dry” meaning urgency without incontinence, or “wet” if leakage occurs. 
• Mixed: Has features of both SUI and UUI.

Diagnostics

• Evaluate for vaginal atrophy, organ prolapse. Perform a neurologic exam.
• Urinalysis (looking for UTI, proteinuria, hematuria), metabolic panel (Cr, calcium), and hemoglobin A1C. 
• No need to perform the q-tip or cough test in primary care (expert opinion).
• Determine the type of incontinence by history and exam.

Management Pearls

• Lifestyle and behavior interventions: Recommend losing 5% body weight if obese. Avoid constipation! Alter fluid intake to avoid over or under hydration. Trial of diet modifications (see list of irritants below). Regularly scheduled voiding if elderly/limited mobility/cognitive impairment to avoid overly full bladder.
• Bladder irritants*: Caffeine, alcohol, chocolate, foods that are spicy, or acidic. Very concentrated urine (usually dark yellow/brown). *Weak evidence to support claim
• Stress incontinence: pelvic floor muscle training (PFMT), avoiding full bladder (timed voiding), weight loss (5% or more). A pessary or OTC bladder supports can be tried. Surgical consultation for those who fail to respond. 
• OAB/UUI: Our approach – Treat with PFMT, bladder training, lifestyle, and behavioral interventions. Second line = anticholinergic agents. Third line = beta-3 agonist. Consider next line therapies like percutaneous tibial nerve stimulation, botox injections of the bladder if initial therapy fails.
• Trial medications in OAB/UI to determine if benefits outweigh cost and side effects.

Updates

• Ask about intimate partner violence in women with urinary tract symptoms (Boyd, 2020).
• Electromyographic biofeedback plus PFMT did not improve self-reported UI symptoms or pelvic floor muscle strength at 24 months vs. PFMT alone (Hagen, 2020).
• Women who underwent surgery for mixed UI or SUI experienced improved sexual function (less fear, avoidance of sexual intercourse) (Glass Clark 2020). No placebo or non-operative comparator group.

Episode #148 BPH

Featuring Adam C. Reese and production by Paul Williams

Background

Some points of clarity:

• BPH occurs due to hyperplasia (cell proliferation), not hypertrophy (cell size enlargement).
• BPH can be present with or without lower urinary tract symptoms.

Prevalence:

• BPH is almost universal in patients with prostates over 45 years.
• For men younger than middle age, particularly if they only have irritative symptoms, bladder issues are more likely (Kaplan, 1996; Nitti, 2002).
• 60% of patients over 60 have BPH, and 80% of patients over 80 (AUA guidelines 2021)

The History

Lower urinary tract symptoms can be divided into:

• Obstructive/voiding symptoms–weak stream, straining to void, hesitancy, intermittency of urinary stream, feeling of incomplete emptying, post-void dribbling.
• Irritative/storage symptoms–urinary frequency, urgency, nocturia.

The history should include current medical problems, prior urologic procedures, sexual history, and use of medications.

• Sometimes modification of diuretics and diabetes medications (SGLT2i) can ease symptoms significantly.
• Assess caffeine intake, alcohol intake, and nighttime fluid consumption.
• Calculate The International Prostate Symptom Score to help determine the need for treatment and track treatment efficacy over time (AUA guidelines 2021).

Diagnostics

Recommendations are based on our discussion with Dr. Reese and recent AUA guidelines.

• Perform a digital rectal exam (DRE) to assess size, nodules, irregularity, and tenderness.
• The American Urological Association recommends urinalysis as part of the work-up to evaluate glucosuria, hematuria, proteinuria, or evidence of infection.
• Post-void residual can be tracked over time. Note: There is no universally accepted definition of clinically significant PVR.
• PSA is an imperfect test and not part of the current AUA guideline for initial work-up. Elevation of the PSA can suggest malignancy, or prostatic inflammation. PSA should be tested before initiation of 5-alpha reductase inhibitors since a) 5-ARIs are not recommended for PSA under 1.5 and b) PSA will decrease by 50% on 5-ARI, so a baseline is warranted (AUA guidelines 2021)!

Management Pearls

• Review/adjust medications (diuretics, SGLT2i, etc.)
• Lifestyle modifications: avoiding caffeine and alcohol, limiting beverages before bedtime, and double-voiding should be attempted.

Alpha-blockers (first-line)

• Selective agents (tamsulosin, silodosin) are less likely to cause orthostasis but more likely to cause ejaculatory dysfunction (anejaculation).
• Nonselective agents (terazosin, doxazosin) can be used to treat comorbid hypertension.
• Benefits are seen in about a week!
• Ophthalmologists should be aware that patients are taking alpha-blockers, given the possibility of floppy iris syndrome (Kumar, 2021).

5-alpha reductase inhibitors (5-ARIs) 

5-ARIs are a treatment option in patients with prostatic enlargement as judged by prostate volume >30cc on imaging, PSA > 1.5 ng/dL, or palpable prostate on DRE (AUA guidelines 2021).

• Usually add-on therapy to alpha-blockers, but can be used as monotherapy. . 
• These agents reduce PSA by about 50%.
• Gynecomastia and sexual side effects (decreased libido, erectile dysfunction) can occur.
• Benefits may take over a month to be seen.

Tadalafil

• Daily tadalafil, a phosphodiesterase inhibitor, is a good choice for patients with mild LUTS and concomitant erectile dysfunction.
• Patients should be reassessed in 4-12 weeks after initiation of therapy

Updates

• “Post finasteride syndrome” was not seen in a large one observational study of (Hagberg, 2016; Unger, 2016) men with BPH or alopecia receiving 5-ARIs. Authors at UpToDate question its existence given recall bias, implausible mechanism, poor trial design, and newer evidence refuting existence.
• Okay to stop alpha-blocker after 1 year of combo therapy (alpha and 5-ARI), but use caution if higher BMI (Matsukawa, 2017)
• 5-ARIs may increase the risk of T2DM similar to that seen with statins (NNH of 100 over 5 years on therapy) —Wei, 2019.

Goal

Listeners will review tops pearls from curbsiders episodes on BPH and urinary incontinence.

Learning objectives

After listening to this episode listeners will…

1. Diagnose and treat BPH in primary care
2. Diagnose and treat urinary incontinence in primary care

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Watto MF. “#318 LUTS, BPH, and Urinary Incontinence Triple Distilled”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date January 26, 2022.