In May 2010, NICE published a clinical guideline on the management of lower urinary tract symptoms in men, which provides healthcare professionals with an overview of the best practice techniques for diagnosis and treatment.
However, as is the inherent nature of such guidelines, the diagnostic recommendations are necessarily generic in order to take into account the regional differences in the infrastructure of healthcare delivery or the variation in the skills of the professionals delivering the care.
Benign prostatic hyperplasia
There has been a paradigm shift in the management of benign prostatic hyperplasia (BPH) from the early 1980s to the present; the default setting in the 1980s used to be surgical intervention for symptoms of enlarged prostate (mostly transurethral resection of the prostate), whereas the current situation is that a significant proportion of these patients can be managed with medication, as well as pads and collecting devices. Early identification, before symptoms have progressed, may be best accomplished in the primary care setting.
In the UK, approximately 3.2 million men - that is, over one third of those aged 50 years or over - suffer from the symptoms of BPH. The troublesome and unpleasant urinary symptoms associated with BPH do not just impair the quality of life of the patients, but they have serious impact on the patients' partners, who suffer from 'second-hand prostatism', which mars their quality of life and relationships.
This is an area that has been repeatedly, and justifiably, addressed in the NICE guideline. The risk of serious and expensive long-term complications such as acute urinary retention, hospitalisation and surgery are by no means inconsequential either.
This article summarises the salient points of the NICE recommendations with an emphasis and elaboration on the relevant aspects, which are particularly applicable to primary care physicians, including GPSIs.
Definition and terminology
The term prostatism has traditionally been used to describe a constellation of obstructive and irritative voiding disturbances that occur in men as they age. However, this suggests that these symptoms are specific to the prostate whereas we now appreciate that they may also be caused by other organs in the lower urinary tract. Therefore, the term lower urinary tract symptoms (LUTS) has replaced prostatism to describe this symptom complex.
Clinicians have adopted BPH to describe a clinical syndrome comprising three components: LUTS, benign prostatic enlargement (BPE) and bladder outlet obstruction. A fourth term, benign prostatic obstruction (BPO), describes the concurrent occurrence of bladder outlet obstruction and BPH.
Voiding (obstructive) symptoms include weak or poor flow, intermittency, straining and a sense of incomplete evacuation. Storage (irritative) symptoms include frequency, urgency and nocturia and are proposed to be a result of obstruction (they improve with relief of obstruction). The major post-micturition symptom is terminal or post-micturition dribble.
It is clear that BPH is a disease identified by its symptoms. A patient could have a large prostate and no symptoms, or a small gland and have severe symptoms. Nevertheless, it is the symptoms that bring the problem to the attention of the patient and GP. The NICE guideline suggests the use of validated questionnaires, for example the international prostate symptom score (IPSS), to assess the degree of symptoms.
Patients seem most concerned by symptoms centred on nocturia and flow. A logical approach may be to address these two points.
- Nocturia questions are fairly straightforward, such as "Do you get up at night to urinate and does this bother you?"
- Similarly, most men will have a good perception of their flow and can answer the question: 'Is it a comfortable arc, or a dribble?' However simple this enquiry may sound, the question of 'writing your name in the snow in Braille or script' is readily understood by most patients and this quick enquiry may put them at ease with their GP.
An affirmative response to nocturia and flow may lead one to start thinking about BPH. However, it is important to ask about symptoms that may indicate other diseases and diagnoses.
Pay particular attention to storage (irritative) symptoms rather than voiding (obstructive) symptoms as a reason for referral. However, pay attention to voiding symptoms when considering reasons for progression.
Evaluation of patients with LUTS
At all times, GPs should look for significant findings that may warrant immediate referral to a specialist. It is equally important to uncover possible reversible causes of LUTS (such as renal pathology or diuretics) and to identify comorbidities that could potentially complicate treatment.
The physical examination can focus on a few key elements:
- An abdominal examination is important to evaluate tenderness, masses or bladder distension.
- A focused neurological examination is needed to assess general mental status and motor function.
- A digital rectal examination is invaluable in the evaluation of rectal tone and prostate size, consistency, nodules or pain.
Abnormal findings on physical examination should be fully investigated.
The laboratory tests required are minimal and most will have been carried out during the routine or yearly examination of the patient. Assessment of renal function by measurement of serum creatinine is not uniformly recommended. A urinalysis is essential to check for blood or infection. Haematuria warrants an immediate referral for evaluation of urological malignancy.
Offer PSA testing if LUTS are suggestive of BCO secondary to BPE, the prostate feels abnormal or if the patient is concerned about prostate cancer.
Uroflowmetry, post-void residual volume and transabdominal ultrasonography are not recommended by NICE in the initial work up of patients with LUTS.
It is important to identify the factors that may place the patient at risk for BPH progression.
The aims of therapy are to improve LUTS and quality of life, and to reduce disease progression. The choice of treatment belongs to the patient after a complete explanation by the care provider. A patient who is educated on the disease state is likely to stay more involved and compliant with whatever modality is chosen.
There is evidence to show that although alpha-blockers provide durable symptom relief, they do not impact the long-term risks of acute urinary retention and surgery. In those men with severe symptoms, and/or a prostate volume >30g (a PSA of >1.4ng/ml), there is a significant risk of treatment failure.
- Dr Majumdar is a GP principal & GPSI in urology in Greater Manchester
NICE Lower urinary tract symptoms. CG97. London, NICE, 2010.