Management of prostate problems: Helping men through a difficult process

In the second of his articles on prostate care, Jim Pollard continues his inside track on a male-only disease by looking at how LUTS and prostate cancer should be treated - including the NICE guidance - and how you can help men through what can be a difficult process psychologically as well as physically.

Since 2010, NICE has been providing guidance on the management of lower urinary tract symptoms (LUTS). Research suggests that following the guidance can not only help you manage these patients more effectively but also save money. The amount saved on each individual might be small but given that 40% of men over the age of 50 and 75% of men over the age of 70 have urinary symptoms that may be caused by an enlarged prostate,1 it can add up.

A survey carried out last year by Opinion Health in June 2011 suggested that the guidance had increased confidence among GP practices in handling LUTS conditions and reduced their costs.²

Some 201 GPs were surveyed: 46% of them were following the NICE guidelines, 41% said that they had greater confidence in conducting the necessary diagnostic tests, such as a digital rectal examination. As a result their confidence in knowing when to refer to secondary care had significantly improved.

To help boost uptake of this guideline, NICE has also produced an online education tool3 in collaboration with the BMJ Learning, which can be accessed by practice nurses and takes just an hour to complete, and a LUTS commissioning guide,4 which could save your practice money.

Dr John Rees, a GP with a special interest in urology who was involved in the development of the NICE guideline, said: 'The majority of men with LUTS can be safely assessed and treated in the community and without the need for costly hospital referrals.'

In the last article, we outlined the main types of prostate problems (benign prostatic hyperplasia or BPH, prostatitis and prostate cancer) and looked at why men are reluctant to present with prostate problems and how you can help to overcome this reticence. This article, which is based largely on the NICE guidance, assumes that you have successfully enticed the reluctant male into your clinic.

TYPICAL SYMPTOMS

In most prostate cases, men will initially present with LUTS - storage, voiding and post-micturition symptoms affecting the lower urinary tract. Typical symptoms will include:

• Weak urine flow
• Intermittency - a flow that stops and starts
• Hesitancy - having to wait before you start to go
• Frequency - having to urinate more often than previously
• Urgency - finding it difficult to postpone urination
• Nocturia - having to get up at night to urinate

Research carried out by the European Men's Health Forum via its yourprostate.eu website suggests that nocturia followed by frequency and urgency are the symptoms of most concern to men.⁵

These symptoms alone can be very disruptive and significantly reduce quality of life. What NICE rather euphemistically refer to as 'bothersome LUTS' can occur in 'up to 30% of men older than 65 years'.⁶

INITIAL ASSESSMENT

At the initial assessment, your general medical history to identify possible causes and comorbidities should include a review of all current medication (including herbal and over-the-counter medication). You can evaluate the severity of the LUTS using the International Prostate Symptom Score (IPSS) which is based on seven symptom questions marked on a scale of 0-5 and one quality of life question (see Box 2).

NICE defines mild LUTS as an IPSS of 0-7, moderate LUTS as an IPSS of 8-19 and severe LUTS as an IPSS of 20-35. Of course, these are broad categories offering guidance only - each patient needs to be understood as an individual. What one man can live with may be intolerable to another and the self-evaluation nature of the IPSS will only partially assist you here.

Your practice should also offer a physical examination guided by symptoms and history. This might include an examination of the abdomen, the external genitalia and a digital rectal examination of the prostate (DRE). A urine dip-stick test can be offered to detect blood, glucose, protein, leucocytes and nitrites.

For men whose LUTS are not bothersome, offer advice on lifestyle changes (for example, time and nature of fluid intake). Offer review if symptoms change.

At this stage, it may be appropriate to ask about erectile dysfunction (ED). Few men feel comfortable initiating this subject as a topic of conversation but they will respond, in some cases with considerable relief, if you ask. There is a moderately strong association between LUTS and ED, which most men will be ignorant of or too embarrassed to mention. Ensure the man is aware of the link between ED and not only LUTS but also heart disease. Indeed, pointing out that ED is one of the best early-warning signs of heart disease may prompt a man to get the problem checked out with somewhat more urgency.⁷

Men with bothersome LUTS can also be asked to complete a urinary frequency volume chart.

Watchful waiting

For those with bothersome mild or moderate LUTS, the options are watchful waiting (active surveillance with a repeat appointment and lifestyle advice) or some sort of symptom management, which may include drugs treatment or surgery.

For those considering treatment, discuss their IPSS in more detail. Ensure that they understand that BPH and prostatitis are not necessarily linked to cancer and that, indeed, BPH and cancer tend to involve different parts of the prostate.

NICE suggests that healthcare professionals do not routinely offer any other tests. Offer a PSA test only if the man's LUTS are suggestive of bladder outlet obstruction secondary to prostate enlargement or his DRE suggests an abnormal prostate (hard, irregular) or if the man has genuine concerns - family history, for example - about prostate cancer. Urinary infection should be excluded before PSA testing.

Counselling is suggested before a PSA to explain its limitations. The test is a rough guide only. It lacks precision so may cause needless worry or false reassurance. There's an NHS patient information sheet online at http://www.cancerscreening.nhs.uk/prostate/prostate-patient-info-sheet.pdf

You should offer a serum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation) only if you suspect renal impairment.

TREATMENT

There are a range of useful options and drugs short of surgery that you can offer. But for many men using incontinence pads or having a catheter will feel like an undermining not only of independence but of their masculinity too - handle these discussions with sensitivity. Some discussion of support groups may be appropriate.

For suspected overactive bladder, offer supervised bladder training, lifestyle advice and, if necessary, containment products such as pads or collecting devices (sheath appliances, pubic pressure urinals). Many find the idea of containment products stressful - explain that they're temporary pending diagnosis and fuller treatment.

For men with urinary incontinence after prostatectomy suggest, in the first instance, supervised pelvic floor muscle training. Try this for at least three months before other options are considered.

For voiding symptoms requiring catheterisation, NICE suggests intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation. Explain to men with post micturition dribble how to perform urethral milking. [See Box 3]

For acute urinary retention, NICE again suggests catheterisation (offering an alpha blocker beforehand). The appropriate response to chronic retention (defined by NICE as 'as residual volume greater than 1 litre or presence of a palpable/percussable bladder') will depend on whether kidney function is normal or not (determined by a serum creatinine test and imaging of the upper urinary tract).

Drug options

Drug treatment, taking into account comorbidities and current treatment, should only be offered when more conservative options have been unsuccessful or are not appropriate. NICE advises an alpha blocker for LUTS symptoms, a 5-alpha reductase inhibitor for enlargement and an anticholinergic for overactive bladder or storage symptoms which persist despite an alpha blocker. Full details are in the NICE guidance. NICE does not recommend homoeopathy, herbal remedies, phytotherapy or acupuncture.

Surgery

This should only be considered if drugs and more conservative treatments have been ineffective. Discuss the options frankly as men may not realise quite how many prostate operations there are and how they vary in nature and the degree of intervention involved. The types of surgery for voiding symptoms include monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP).

For a smaller prostate (less than 30g), the much less-invasive transurethral incision of the prostate (TUIP) is an alternative. For larger prostates (over 80g), an open prostatectomy is an alternative offering some visual advantages over the TURP.

TURP is one of the UK's most common and successful surgical procedures. According to the NHS, some 40,000 are performed every year - well over 100 a day.⁹ Research shows that patients sexually active before TURP generally remain so afterwards. It has no negative influence on the quality of erections measured by self-assessment questionnaires although it can lead to 'significant' loss of ejaculatory function, which you should explain.⁸

IMPACT ON EVERYDAY LIFE

LUTS symptoms are not trivial. They can seriously disrupt a man's life, making it difficult to go out or even go to sleep. This can lead to fatigue and depression. Both the symptoms of the condition, and its side effects, such as grumpiness, can have a major impact of relationships. It is very important to try to encourage men to talk about the impact of LUTS on their day-to-day life. Setting it in he context of how things are for another man - a hypothetical husband, father, grandfather or other patient - can normalise the patient's feelings and make it easier for him to talk. You could even ask for advice. 'My father is up all night going to the loo which keeps both him and my mother awake. She's not very happy about it. Got any tips?'

For more on the best approaches to take to encourage men to talk about their prostate concerns, see the first article on this topic in Practice Nurse, 9 March 2012, Vol 42, Issue 4.

Finally, ensure men know about the European Men's Health Forum's yourprostate.eu site. On it, they can ask a question anonymously about anything to do with the prostate or their treatment and get an answer from a urology nurse within 48 hours. It's that easy.

Declaration of interest: Jim Pollard also works for the European Men's Health Forum and has worked on yourprostate.eu. He is the editor of malehealth.co.uk and author of the award-winning User's Guide to the Male Body.

REFERENCES

1. The Prostate Cancer Charity. Enlarged Prostate. Available at: http://www.prostate-cancer.org.uk/information/the-prostate/prostate-problems/bph 2. NICE. Press release: GPs following NICE LUTS guidance. Available at: http://www.nice.org.uk/newsroom/news/GPsFollowingNICELUTSGuidance.jsp 3. BMJ Learning. Lower urinary tract symptoms in men: a guide to management - in association with NICE. Available at: http://learning.bmj.com/learning/search-result.html?moduleId=10016753 4. NICE Commissioning guidance: management of lower urinary tract symptoms in men. Available at: http://www.nice.org.uk/usingguidance/commissioningguides/luts/LUTS.jsp 5. Banks I, Mayor S, Meryn S. Talking prostates. Journal of Men's Health. 2010 Oct; 7(3):221-226 (http://www.jmhjournal.org/article/S1875-6867(10)00064-3/abstract) 6. NICE. Management of lower urinary tract symptoms in men. Quick reference guide to Clinical guideline 97, May 2010. Available at: http://www.nice.org.uk/nicemedia/live/12984/48575/48575.pdf 7. Jackson G et al. Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus. Int J Clin Pract. 2010 Jun;64(7):848-57
8. Muntener M et al. Sexual Function after Transurethral Resection of the Prostate (TURP): Results of an Independent Prospective Multicentre Assessment of Outcome. European Urology. 2007. 52:510-516