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 3.2m men experience LUTS. In general, prevalence and severity of male LUTS increases with age.
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).1
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). 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.
Symptoms vary between patients and there is often no correlation between the symptoms of LUTS and the actual diagnosis.
3. Examination and investigations
Patients with LUTS should have an abdominal examination performed, including a digital rectal examination. NICE recommends undertaking a focused neurological examination to assess general mental status and motor function. Any reversible causes of LUTS should be determined (for example, use of diuretics).
NICE guidance also recommends using validated questionnaires, for example the international prostate symptom score, to assess the degree of a patient's symptoms.3 In addition, a bladder diary is often very useful. This involves patients recording the time and volume of each void and also the volume and time of fluid intake.
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.
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.
Other investigations, including uroflowmetry, post-void residual volume and transabdominal ultrasonography, are not recommended by NICE.
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 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. Anticholinergics should be given to those with symptoms of overactive bladder.
Some patients benefit from a combination of an alpha-blocker and an anticholinergic, especially if their storage symptoms persist after treatment with an alpha-blocker alone. For men with nocturnal polyuria, oral desmopressin may be beneficial if other treatments have not helped and other causes have been excluded.
|WHEN TO REFER
Patients with the following should be referred for specialist assessment:
Although medication can be very effective, some men will require urological referral (see box, above), either early to rule out prostate cancer and other conditions or later after initial medical therapy and lifestyle management have failed.4
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 which 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.
Self-catheterisation or long-term catheterisation may also be considered in some cases.
- Dr Newson is a GP in the West Midlands
1. Gravas S, Melekos MD. Male lower urinary tract symptoms: how do symptoms guide our choice of treatment? Curr Opin Urol 2009; 19(1): 49-54.
2. Mongiu AK, McVary KT. Lower urinary tract symptoms, benign prostatic hyperplasia, and obesity. Curr Urol Rep 2009; 10(4): 247-53.
3. NICE. The management of lower urinary tract symptoms in men. CG97. NICE, London, 2010. www.nice.org.uk/nicemedia/live/12984/48554/48554.pdf
4. Roehrborn CG. Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). Med Clin North Am 2011; 95(1): 87-100.