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Experience-sharing interview: Managing a complicated case of lower urinary tract symptoms

Professor Choosak Pripatnanont
President, Thai Urological Association
Professor of Urology, Department of Surgery
Prince of Songkla University
Chang Wat Songkhla, Thailand
3 months ago
Patient presentation
  • A 60-year-old male raised the issue of frequent visits to the bathroom disrupting his work
  • He struggled to achieve uninterrupted sleep as he generally woke up 2–3 times to urinate, had a slow urine stream, and a feeling that his bladder had not emptied completely. He also experienced urgency
  • His clinical history was unremarkable and included normal blood sugar levels and mild hypertension that was not extensive enough to require treatment
  • He had no comorbidities and exercised daily
How did you diagnose the patient and which tests did you conduct?

Given his symptoms at presentation, the patient was suspected of having lower urinary tract symptoms (LUTS). He had an International Prostate Symptom Score (IPSS) of 20, which indicated severe symptoms, with storage symptoms predominant, but further tests were administered to ensure that this diagnosis was correct.

A prostate-specific antigen (PSA) test was performed for two diagnostic benefits:
  • Screening for prostate cancer; and
  • Providing a volumetric assessment of the mass of the prostate gland.
Uroflowmetry was also administered as a non-invasive urodynamic measure of voiding. The test results indicated a PSA score of 1.1 and a uroflowmetry Q­max score of 11 cc/sec, with a volume of 180 cc voided.

How was the patient treated?

Extended-release doxazosin (doxazosin XL; 4 mg), an α-blocker that has been shown to be well tolerated in patients with LUTS,1 was administered to the patient as a first-line treatment based on data indicating that doxazosin XL offers a greater improvement in IPSS score, faster than tamsulosin (Figure 1).2 After 1 week of treatment the patient showed both an improved IPSS, which decreased from 20 to 18, and a uroflowmetry score that increased from 11 to 12 (cc/sec). However, the patient still suffered from episodes of urgency.

HK-PFR-496a1i-fig1_MY

In an effort to combat urgency, the patient was administered tolterodine (2 mg twice daily), an antimuscarinic with relatively few side effects that is effective in addressing the symptoms of urgency in patients with overactive bladder (Figure 2).3,4 The patient reported a vast improvement in his urgency symptoms within 2 months of initiating combined doxazosin XL/tolterodine treatment. Specifically, his IPSS urgency domain score decreased from 5 to 3.

HK-PFR-496a1i-fig2_MY

What were the patient’s long term treatment outcomes?

As per standard clinical practice, the patient’s health status was re-evaluated every 3 months. Uroflowmetry testing was carried out to ensure the treatment was still effective and well tolerated.

The patient reported that combined doxazosin XL/tolterodine therapy enabled him to achieve a better quality of life (QoL) because he was able to sleep well and was more comfortable socializing because his frequency of urination and episodes of urgency had decreased. This is consistent with the expected decrease in nocturia in patients treated with doxazosin XL (Figure 3).2

HK-PFR-496a1i-fig3_MY

What are the challenges in accurately diagnosing LUTS in male patients?

To accurately diagnose a patient with LUTS, a patient history should be recorded and the patient’s IPSS calculated. Analyzing domain scores within the IPSS is necessary to uncover whether the patient suffers from predominantly voiding or storage symptoms. Further tests are required to assess whether a patient with LUTS has benign prostate hyperplasia (BPH) and an objective evaluation may be required given that LUTS and BPH frequently coexist.5

What are some of the challenges in managing patients with LUTS?

Patients with LUTS often see several doctors, all with unique specialities, which can compound the effect of an inaccurate diagnosis. If a patient sees a general practitioner or a cardiovascular specialist they will commonly focus on prostate enlargement or pain; however, in a select group of patients prostate enlargement or pain is not the primary concern. A urologist is more likely to correctly diagnose a complex case of LUTS and identify the most appropriate treatment option. In particular, urologists consider QoL to be the most important measure of long-term outcomes in patients with LUTS.

Do you have any advice or insights you can give to other physicians managing patients with LUTS?

Effective management of LUTS depends on correctly diagnosing whether the condition is storage-symptom or voiding-symptom predominant. Patients with voiding-symptom predominant LUTS related to an enlarged prostate who are administered 5α-reductase inhibitors may experience some sexual dysfunction, such as reduced libido and impotence.6 Moreover, many Asian patients are reluctant to talk to their doctor about sexual dysfunction, so an α-blocker, possibly in combination with antimuscarinic therapy, may be the most appropriate treatment approach for these patients. It has previously been shown that administering tolterodine to men with LUTS, who continue to have urgency symptoms after initiating classical α-blocker therapy, is a reasonable method of treatment.7,8

Doctors should also aim to establish a rapport with their patients that facilitates extensive communication so that treatment can be tailored to meet individual needs, particularly when combination therapies are required to manage the symptoms of LUTS as well as treating BPH.

References
1.    Pfizer Malaysia Cardura XL Prescribing information. 23 March 2015.
2.    Chung MS, et al. Int J Clin Pract 2011;65:1193-1199.
3.    Freeman R, et al. Obstet Gynecol 2003;102:605-611.
4.    Pfizer Malaysia Detrusitol SR Prescribing information. 10 October 2012.
5.    Novara G, et al. BJU Int 2014;115:802-814.
6.    Dimitropoulos K, Gravas S. Res Rep Urol 2016;8:51-59.
7.    Eapen RS, Radomski SB. Rep Res Urol 2016;8:71-76.
8.    Kaplan SA, et al. J Urol 2008;179(5 Suppl):S82-S85.

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