Lower urinary tract symptoms (LUTS) are a common problem in older men.
Standard treatment starts with watchful waiting and moves on to medication and surgery, depending on symptom severity.
Self-management interventions are recommended by the European and American Associations of Urology as the first step for men with uncomplicated LUTS.
They are widely used for LUTS in both primary and secondary care, but the efficacy of self-management had not been investigated until recently.
As well as the day-to-day management of their own care, the patients use problem-solving strategies to help control their symptoms (see box).
Self-management interventions have been shown to be effective for chronic diseases such as arthritis or diabetes.
Since LUTS is a chronic disease with both physical and social aspects, a self-management approach should be effective.
EVIDENCE IN LUTS
The first randomised controlled trial assessing self-management in LUTS has reported. In this study, men assigned to self-management attended a three-session, small-group self- management programme run by a nurse facilitator.
Treatment failure at three, six and 12 months was assessed. This was defined as an increase of three or more points on the international prostate symptom score, use of medication or surgery to control symptoms, or urinary retention.
At three months, treatment failure occurred in 10 per cent of the self-management group, compared with 42 per cent of the standard care group.
The benefits of self-management were seen early and sustained at 12 months.
The most commonly prescribed medical therapies for LUTS are alpha-blockers and 5-alpha-reductase inhibitors.
Anticholinergics are increasingly used since a significant cause of LUTS in men is the overactive bladder, whether as a primary event or secondary to benign prostatic hyperplasia (BPH).
Trials have shown that medical therapy is more effective than placebo in reducing LUTS, improving quality of life and increasing flow rates.
Also, 5-alpha-reductase inhibitors reduce prostate size and risk of urinary retention more than placebo.
Combination therapy works well and has been shown in large-scale studies to have benefits over mono-therapy. However, medication is not always effective, with up to a third of men experiencing no symptomatic improvement at all with alpha-blockers.
Many men with LUTS do not want to take medication, and in some the side-effects of treatment are worse than the original symptoms.
Patient compliance is also a problem. One study has shown that up to 26 per cent of patients prescribed either alpha-blockers or 5-alpha-reductase inhibitors discontinue prior to the next session.
Discontinuation rates can be as high as 64 per cent after three years.
Self-management is at least as effective as usual care for men with uncomplicated LUTS. Implementing a structured self-management programme for LUTS can improve patient outcomes and reduce the economic burden of LUTS treatment by replacing or augmenting the drug therapy.
ELEMENTS OF A LUTS SELF-MANAGEMENT
Education and reassurance
- Discuss causes of LUTS including normal prostate and bladder function.
- Discuss the natural history of BPH and LUTS, including possible future symptoms.
- Reassure that no evidence of a detectable prostate cancer has been found.
Fluid management advice
- Daily fluid intake of 1,500-2,000ml (minor adjustments made for climate and activity).
- Avoid inadequate or excessive intake on the basis of a frequency/volume chart.
- Restrict fluid intake when symptoms are most inconvenient.
- Evening fluid restriction for nocturia.
- Adjust timing of medication to improve symptoms, such as for long journeys.
- Substitute diuretics with suitable alternatives that have less urinary effect.
Caffeine and alcohol
- Patient should avoid caffeine.
- Substitute large- for small-volume alcoholic drinks, such as a pint of beer for a short.
Bladder re-training advice
- Advise double-voiding and urethral milking for men with post micturition dribble.
- Patients should increase minimum time between voids to three hours (daytime) or the minimum voided volume to 200-400ml (daytime) using mind exercises, perineal pressure or pelvic floor exercises.
- Suppress the urge to void for one minute, then five minutes, then 10 minutes, increasing on a weekly basis. Use frequency/volume charts to monitor progress.