The term 'lower urinary tract symptoms' (LUTS) has replaced 'prostatism' to describe obstructive and irritating voiding disturbances that occur in men as they age.
In the UK, approximately 3.4m men experience LUTS. In general, prevalence and severity of male LUTS increases with age.1 Over one third of men aged 50 years or over have moderate to severe symptoms of LUTS. Most men with LUTS can be effectively managed in primary care.
There are numerous causes of LUTS, the most common being benign prostatic enlargement. However, many studies have shown that not all male LUTS are associated with prostate pathology and that the bladder plays a part in the development of LUTS (especially in storage symptoms).
LUTS is usually caused by abnormalities of the prostate, urethra, bladder or sphincters. Other causes include detrusor muscle weakness/overactivity, prostatitis, UTIs, prostate cancer and neurological diseases (for example, MS).
Drugs such as diuretics, calcium-channel blockers, caffeine, alcohol and also excessive fluid intake can all cause LUTS. There is a higher prevalence of LUTS in men who are obese.2
Symptoms can relate to voiding, storage or post-micturition.
Voiding symptoms are the most common, but storage symptoms are the most bothersome. About 40% of men aged 75 years or over have storage symptoms. Isolated storage symptoms are most commonly due to an overactive bladder.
Symptoms vary between patients and there is often no correlation between the symptoms of LUTS and the actual diagnosis.
Examination and investigations
It is vital to assess how bothersome symptoms are to each individual patient. Some men may have very mild symptoms, which are affecting the quality of their (and often their partner’s) life, whereas others have many symptoms but are not particularly bothered by them.
Patients with LUTS should have an abdominal examination performed, including a digital rectal examination to assess the prostate.
Examination should also include assessment for a palpable or percussable bladder and a genital examination to look for meatal stenosis, phimosis, or hypospadias. Any reversible causes of LUTS should be determined (for example, use of diuretics).
A bladder diary is often very useful. This involves patients recording the time and volume of each void and also the volume, type and time of fluid intake. This should be completed for at least three days.
Urinalysis to detect blood, glucose, protein, leucocytes and nitrites should be performed in all patients. U&Es are not routinely recommended, unless renal impairment is suspected.
NICE recommends that PSA testing should only be offered to men with symptoms suggestive of bladder outflow obstruction secondary to benign prostatic enlargement, if the prostate feels abnormal or if the patient is concerned about prostate cancer.3 It is important that patients are adequately counselled about PSA testing prior to having a test.
Other investigations, including uroflowmetry, post-void residual volume and transabdominal ultrasonography, are not recommended by NICE.
Daytime urinary frequency
Sensation of incomplete emptying
Treatment aims to improve symptoms and quality of life. Ideally it should also reduce disease progression. All men should be given lifestyle advice and those with mild or moderate symptoms should also be reassured.
Non-medical management includes bladder training for men with overactive bladder symptoms. These men should also be advised on fluid intake and lifestyle.
Alcoholic, carbonated and caffeine-containing drinks may all exacerbate storage LUTS. It may be appropriate to advise some men with frequency and nocturia to reduce their fluid intake after 4pm.
Medication is offered to men who have bothersome symptoms that have not improved with conservative treatment. NICE recommends alpha blockers (alfuzosin, doxazosin, tamsulosin or terazosin) for men with moderate to severe LUTS.
Alpha-blockers are the preferred treatment; these work by relaxing smooth muscle at the bladder neck and within the prostate. Both storage and voiding symptoms improve with alpha-blockers. Symptoms typically improve after a few weeks.
Antimuscarinics should be given to those with symptoms of overactive bladder. If antimuscarinics fail or are not tolerated, new beta-3 adrenoceptor agonists (for example, mirabegron) are a possible second-line treatment.
The 5-alpha reductase inhibitors (finasteride and dutasteride) inhibit conversion of testosterone to dihydrotestosterone in the prostate. These drugs take at least six months to have an effect.
There is evidence that a combination of finasteride plus doxazosin is more effective at than either drug alone. A combination is usually used for those men whose symptoms do not improve or for those men at high risk of clinical progression.
There is increasing evidence that phosphodiesterase inhibitors improve LUTS.
Although medication can be very effective, some men will require urological referral (see box), either early to rule out prostate cancer and other conditions or later after initial medical therapy and lifestyle management have failed.4
|When to refer|
Patients with the following should be referred for specialist assessment:
Around one-third of patients fail to achieve sufficient symptom improvement with medication, lifestyle adjustment and fluid management, and may require more invasive or surgical treatment.
Patients with detrusor overactivity may be offered bladder wall injection with botulinum toxin or a cystoplasty. Those with stress urinary incontinence that has not responded to medication may be considered for implantation of an artificial sphincter.
If an enlarged prostate is causing voiding symptoms, transurethral resection of the prostate, monopolar transurethral vaporisation of the prostate or holmium laser enucleation of the prostate may be performed. For some men, the newer technique of prostatic urethral lift may be considered.5
Self-catheterisation or long-term catheterisation may also be considered in some cases.
- Dr Newson is a GP in the West Midlands
- Rees J, Bultitude M, Challacombe B. The management of lower urinary tract symptoms in men. BMJ 2014; 348: g3861.
- Yelsel K, Alma E, Eken A, Gülüm M, Erçil H, Ayyildiz A. Effect of obesity on International Prostate Symptom Score and prostate volume. Urol Ann 2015; 7(3): 371-4.
- NICE. The management of lower urinary tract symptoms in men. CG97. NICE, London, 2010. Available atwww.nice.org.uk/nicemedia/live/12984/48554/48554.pdf
- Oelke M, Bachmann A, Descazeaud A et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013; 64: 118-40.
- Garcia C, Chin P, Rashid P, Woo H. Prostatic urethral lift: A minimally invasive treatment for benign prostatic hyperplasia. Prostate Int 2015; 3(1): 1-5.