see also:

• urinary tract infections (UTIs) / cystitis
• sexually transmitted infections (STDs/STIs)
• benign prostatic hyperplasia (BPH)
• European Assoc. Urology guidelines for LUTS

• 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

• benign prostatic hyperplasia (BPH)
• urinary tract infections (UTIs) / cystitis
• sexually transmitted infections (STDs/STIs)
• 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
  • distal urolithiasis / renal stones / renal calculi
  • bladder cancer
  • urethral stricture
  • foreign body
  • neurogenic bladder (eg. cauda equina syndrome (CES))
• many non-urological conditions also contribute to urinary symptoms, especially nocturia such as congestive cardiac failure, polydipsia, etc ¹⁾

• The International Prostate Symptom Score (IPSS)
• 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

• 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);
      • treat constipation
• alpha adrenergic blockers
  • 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.