lower urinary tract symptoms (LUTS) are common in men and more prevalent as they become older and can impair quality of life
they fall into three main categories:
storage symptoms
voiding symptoms
post-micturition symptoms
traditionally, these have been called “prostatism” due to most being related to bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH), however, in many cases there are unrelated causes (see aetiology below)
NB. there is NO definite link between LUTS and prostate cancer or with upper renal tract malignancy
detrusor overactivity (DO) is a urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked
detrusor underactivity/underactive bladder
overactive bladder syndrome is characterised by urinary urgency, with or without urgency urinary incontinence, usually with increased daytime frequency and nocturia, if there is no proven infection or other obvious pathology
other structural or functional abnormalities of the urinary tract and its surrounding tissues
The International Consultation on Incontinence Questionnaire (ICIQ-MLUTS)
Danish Prostate Symptom Score (DAN-PSS)
Frequency volume charts (FVC) and bladder diaries
Use a bladder diary over at least 3 days to assess male LUTS with a prominent storage component or nocturia
the PR exam
Digital-rectal examination (DRE) is the simplest way to assess prostate volume, but the correlation to prostate volume is poor (transrectal USS is more accurate)
urinalysis
the value of urinary dipstick/microscopy for diagnosing UTI in men with LUTS without acute frequency and dysuria has recently been questioned
renal function
U&E to assess eGFR
hydronephrosis, renal insufficiency or urinary retention are more prevalent in patients with signs or symptoms of BPO
PSA
PSA has a good predictive value for assessing prostate volume - PSA threshold value of 1.5 ng/mL could best predict a prostate volume of > 30 mL, with a positive predictive value (PPV) of 78%
PSA is a stronger predictor of prostate growth than prostate volume and in patients with BPE is a highly significant predictor of clinical progression and risk or subsequent urinary retention or need for BPE-related surgery
Measure PSA if a diagnosis of prostate cancer will change management or if it assists in the treatment and/or decision making process.
NB. the potential benefits and harms of using serum PSA testing to diagnose prostate cancer in men with LUTS should be discussed with the patient
Post-void residual urine
Post-void residual is not necessarily associated with BOO, since high PVR volumes can be a consequence of obstruction and/or poor detrusor function (detrusor underactivity)
a PVR > 50mL has a PPV of 63% and a negative predictive value (NPV) of 52% for the prediction of BOO
a high baseline PVR is associated with an increased risk of symptom progression
monitoring of changes in PVR over time may allow for identification of patients at risk of AUR, especially if being treated with anti-muscarinic medications
Uroflowmetry
should be considered prior to medical or invasive treatment
transabdominal prostatic USS
assesses prostate size, PVR,
should be performed prior to surgical decisions - and a transrectal USS may assist in decisions for those being considered for minimally invasive treatments as presence of a median lobe may guide treatment choice
Urethrocystoscopy
indicated in those with a history of microscopic or gross haematuria, urethral stricture, or bladder cancer, who present with LUTS
urodynamics
not generally indicated
Mx in men over 40yrs age
Many men with LUTS are not troubled enough by their symptoms to need drug treatment or surgical intervention.
All men with LUTS should be formally assessed prior to any allocation of treatment in order to establish symptom severity and to differentiate between men with uncomplicated (the majority) and complicated LUTS
Watchful waiting is a viable option for many men with non-bothersome LUTS as few will progress to AUR and complications:
behavioural modifications:
education
reassurance it is not due to cancer
periodic monitoring
lifestyle changes:
reduction of fluid intake at specific times which are inconvenient
reduce diuretics such as caffeine and alcohol
use of relaxed and double-voiding techniques
urethral milking to prevent post-micturition dribble;
distraction techniques such as penile squeeze, breathing exercises, perineal pressure, and mental tricks to take the mind off the bladder and toilet, to help control storage symptoms
bladder retraining that encourages men to hold on when they have sensory urgency to increase their bladder capacity and the time between voids;
reviewing the medication and optimising the time of administration or substituting drugs for others that have fewer urinary effects (these recommendations apply especially to diuretics);
offer α1-blockers such as tamsulosin to men with moderate-to-severe LUTS
5α-reductase inhibitors
Use 5α-reductase inhibitors in men who have moderate-to-severe LUTS and an increased risk of disease progression (e.g. prostate volume > 40 mL) but warn that the benefits will take 3-6 months
Muscarinic receptor antagonists
Use muscarinic receptor antagonists in men with moderate-to-severe LUTS who mainly have bladder storage symptoms, but avoid in those with PVR > 150mL
Phosphodiesterase 5 inhibitors
reduce smooth muscle tone of the detrusor, prostate and urethra
use phosphodiesterase type 5 inhibitors (eg. tadalafil 5 mg once daily) in men with moderate-to-severe LUTS with or without erectile dysfunction
contraindicated in patients using nitrates, the potassium channel opener nicorandil, or the α1-blockers doxazosin and terazosin
may cause flushing, GOR, nasal congestion, headaches, back pains
Beta-3 agonists
Mirabegron 50 mg
consider use in men with moderate-to-severe LUTS who mainly have bladder storage symptoms although weak evidence.
surgical treatment
TURP is the current standard surgical procedure for men with prostate sizes of 30-80 mL and bothersome moderate-to-severe LUTS secondary of BPO
Transurethral incision of the prostate shows similar efficacy and safety to TURP for treating moderate-to-severe LUTS secondary to BPO in men with prostates < 30 mL who do not have a median lobe
consider plasma bipolar transurethral vaporisation of the prostate as an alternative to TURP to surgically treat moderate-to-severe LUTS in men with prostate size of 30-80 mL.