What sort of patient might be suitable to invite to participate in UPSTREAM?

Below are clinic letters (anonymised) from various urologists, which were used in identifying potential recruits for UPSTREAM. They raise a range of scenarios and issues;

• Men with voiding LUTS
• Men who also have storage LUTS or nocturia

All the men described are suitable to approach, since surgery could be an option in the eyes of some urologists at this point- the subsequent tests would be done to finalise the treatment recommendation. At this stage, some men were not aware that surgery could end up being a treatment option; we simply asked the urologist to let the patient know there’s a range of possible treatments, including surgery, and that further tests aim to help finalise treatment recommendations. 

PATIENT 1, Man aged 58 [Suitable for UPSTREAM. He has voiding LUTS, low level storage LUTS, has been on medication, and remains bothered. Spinal trauma is not a contraindication; spinal cord injury would be!]

Thank you for referring this pleasant 58 year old gentleman, who I reviewed on behalf of Mr K- today in the one stop clinic.  He has a history of lower urinary tract symptoms, of suprapubic pain with flow straining, incomplete voiding and double voiding.  He also has frequency, occasional urgency, and he also complained of erectile dysfunction. 

His past medical history includes hypertension, right femur trauma and spinal trauma which is causing him a lot of pain, and he has recently been diagnosed with depression.  His medications include Amitriptyline, Simvastatin, Ibuprofen and Lisinopril Tamsulosin and Finasteride.  No known drug allergies.  No past family history of urological disease.  Ex-smoker of 2 ½ years ago. Has previous smoked for 30 years. Has retired from working in the Army and the railway.  He lives with his wife.

On examination his abdomen was soft and non-tender. Examination of the genitalia:- his right testicle was smaller than the left, otherwise NAD.  DRE. 20 gram benign prostate.  He has been on Tamsulosin and Finasteride for more than a year now, and his symptoms have become worse.  I will arrange for him to have flow studies, and have discussed with him about taking part in clinical trials ‘unblock/upstream’, as I think he would be a good candidate for either trials.  Our research team will be in contact with Mr --- to arrange further discussion about this.

PATIENT 2, Man aged 75 [Suitable for UPSTREAM. He has voiding LUTS but also nocturia; this situation is very important for UPSTREAM, since nocturia is so common in this age group]

I saw Mr --- today in the one stop clinic on behalf of Mr H-.  He has a long history of lower urinary tract symptoms, mainly hesitancy, reduced flow and nocturia.  He thinks that his symptoms have been improved after he started taking Tamsulosin and Finasteride one year ago.  He denies any frequency or urgency during the day, but he still experiences 3-5 episodes of nocturia.  I explained to him that this condition could not be contributed only to urological causes.  I advised that he try to modify some lifestyle habits such as excessive fluid intake before bedtime, and especially alcohol, coffee or tea during the evening.  We performed a flow test today, which was obstructive and he had 350 mls of residual urine in his bladder.  His renal function is normal, and his prostate on examination was enlarged, but smooth.

We discussed treatment options, including TURP, long term urethral catheter or suprapubic catheter, and internal catheterisation.  The benefits and risks of each option, and have provided him with relevant information leaflets.  Mr --- would like to think about these options, so I have arranged to see him again in order to discuss his future management. 

Dictated but not scrutinised 

PATIENT 3, Age 62 [This man has voiding LUTS, but also storage LUTS which appear to be worse than the patient above. He is suitable, since surgery could be an option for his voiding LUTS. The influence of bothersome storage LUTS (symptoms vs urodynamics) in treatment decision making is a really important insight that UPSTREAM may achieve, so this man would be very interesting. The doctor has already recommended urodynamics, so when approached, this patient will need careful explanation about the uncertain place of urodynamics. Note that the doctor has not specifically mentioned surgery at this stage; instead he uses the phrase “proceeding further”. This meets the inclusion criteria for the study, as the patient has LUTS for which a doctor might recommend surgery. However, before being approached for the study, the patient should be told that surgery is one of the treatment possibilities being considered]

Thank you for asking me to see this 62 year old gentleman with ongoing problematic storage LUTS.  At present he is up anything between 1-3-4 times at night.   He voids on average 3-5 times a day, but it can be considerably more.  There is no hesitancy.  He does have some urge, but no urge incontinence.  He has tried Oxybutynin, Trospium Solifenacin Tamsulosin, but all with no effect.  He is a non-smoker.  He drinks two cups of tea a day.

On examination his abdomen was soft and non-tender.  He has a reducible left inguinal hernia.  Genitalia was unremarkable.  DRE confirmed a moderately enlarged benign feeling prostate.  PSA from 2011 was 0.8. Flow rates today showed a Q max of 9 with a voided volume of 160 mls and a post void residual of 150 ml.  The trace looked obstructed.

I have explained to Mr --- that it is not clear whether we are dealing with detrusor instability or overactive bladder type symptoms.  If we are dealing with primary detrusor instability or perhaps instability secondary to bladder outflow obstruction.  It is important that we determine this before proceeding any further.  In view of this I have recommended performing urodynamics.  I have put this to him today and also encouraged him to complete a bladder diary before his attendance at urodynamics.

Dictated but not scrutinised 

PATIENT 4, Aged 67 [Men with an indwelling catheter are excluded from UPSTREAM, but this man is going to be taught ISC as an insurance against going into full blown retention, and that is not a problem for the study. The doctor originally planned to bring him back to clinic in 4 months, but we changed this to get him to the UPSTREAM clinic earlier than that. The patient is currently keen to avoid surgery; this does not exclude him, since a urologist clearly might recommend surgery]

Thank you for referring this 67 year old fit gentleman who I saw on behalf of Mr Q-.  He is normally fit and well.  His main complaints are increase in LUTS despite dual therapy.  He is up 3-4 times at night.  He voids 3-4 times during the day.  There is some hesitancy and also associated poor flow.  I note his PSA on Finasteride was 3.8.  Interestingly he is only taking half a dose of Finasteride at present, as he is concerned about side effects.  I have explained that he should increase his finasteride to 5 mgs per day.  Mr --- wanted to discuss further treatment in the form of a TURP.

On examination his abdomen was soft and non-tender, his genitalia was unremarkable.  DRE confirmed an enlarged benign feeling prostate.  Flow rates today were somewhat small as he was only able to void 80 mls.  His post-void residual was 60 mls.

I strongly suggest he has LUTS secondary to bladder outflow obstruction, and he is most likely heading for bladder outflow obstruction surgery at some point. However in the first instance I am arranging for him to have a repeat flow rate for an optimal void.  If he is unable to produce this we will arrange urodynamics.

Mr --- has on occasions had difficulty initiating his stream, and he is worried about developing full blown retention.  In view of this I am going to arrange for him to be taught intermittent self-catheterisation, as a ‘get out of gaol’ card.  He is keen to avoid an operation for the time being.  However he would like to see how he progresses with self-catheterisation and increasing his Finasteride dose.  I will arrange to see him in four months time, at which time we will do a repeat flow, and will discuss adding him to our waiting list for a TURP.

Dictated but not scrutinised 

PATIENT 5, Aged 80 [The doctor has recommended a flexible cystoscopy, but this is not really logical since it is recognised to be inadequate as a test for obstruction. He’s suitable for UPSTREAM, as distinction between obstruction and underactive bladder is core to the questions being assessed].

I had the pleasure of seeing this 80 year old gentleman, accompanied by his wife, in the one stop clinic today.  He complains of an episode of urinary retention in September 2014, for which a catheter was inserted.  The trial without a catheter was afterwards successful, even though he had a post-void residual of about 100-200 mls of urine.  Since then he has experienced recurring episodes of urinary tract infections three times.  The last episode occurred at the beginning of this month, therefore he has been commenced on a two-week course of Trimethoprim.  Currently the urinalysis is normal and the patient is free of symptoms even though he still complains of chronic lower urinary tract symptoms which involve a weak stream, nocturia x 2.  He has been on Tamsulosin for a long time and the PSA recently done was satisfactory.  On digital examination I could palpate a flat surface of the prostate with no clear nodules palpable.  I discussed with the patient the possible options for him now which involve medical treatment, which might include Finasteride +/- long term of antibiotic, or a TURP.  I explained the pros and cons of each of these treatment options, but I would prefer beforehand, that he has a flexible cystoscopy to better define what is going on, and how obstructing is the prostate, as I suspect there is a certain amount of bladder impairment for which the patient might not necessarily benefit from any treatment option.  I am requesting a flexible cystoscopy to be done in a second appointment as there is not a slot available today, and at that time we can also discuss his treatment options.

Dictated but not scrutinised 

PATIENT 6 [Perfect for UPSTREAM]Presenting problems 1.     LUTS, 2.     Erectile Dysfunction

Thank you for asking us to see this pleasant gentleman who has been troubled by benign prostatic enlargement for some time. He has done reasonably well on Alfuzosin, but is now finding that his flow is diminishing, and he is having to strain to pass urine.  He also has erectile dysfunction.  He has a normal PSA.  Today on DRE he had a benign feeling prostate gland of moderate size.

I organised flows today, which showed that he had a reduced flow with a Q max of 4.6 ml per sec. and a post void residual of more than 136 mls. I discussed some of our research studies today, as he is quite keen to have laser treatment for his enlarged prostate, and I have given his details to our research team who will be in contact with him.  As far as his erections are concerned I have given him a trial of Cialis 20 mgs. To see whether this helps the situation generally.  I am going to see him back in clinic in around six weeks, and will keep you up-dated.

Dictated but not scrutinised