LUTS in men

Lower urinary tract symptoms ( LUTS ) in men- storage , voiding and post-micturition symptoms

LUTS can happen due to many causes such as
abnormalities or abnormal function of 

◘ prostate eg prostatitis , cancer
◘ urethra- stricture , foreign body, stone
◘ sphincters -detrusor muscle weakness or overactivity

UTIs and neurological diseases eg neurogenic bladder dysfunction
Foreign body in bladder or urethra
Meatal stenosis or phimosis
Calculus in bladder , distal ureter or urethra
Bladder tumour

Benign Prostatic Enlargement ( BPE ) is the commonest cause


Voiding or 
Obstructive symptoms-Weak or intermittent urinary stream , hesitancy , terminal dribbling and incomplete emptying

Storage
( Overactive bladder )-Urgency , frequency , urgency incontinence and nocturia

storage symptoms may indicate an underlying medical condition ( eg diabetes , htension, OSA )

Post-
micturition-Post- micturition dribbling and feeling of incomplete emptying.Prevalence increases with age
○ 30 % of men over 50 suffer from moderate to severe LUTS
○ bothersome LUTS can happen in upto 30 % of men > 65 yrs Symptoms increase 9.8 % per decade LUTS are independent risk factor for sexual dysfunction in men over the age of 50

Initial assessment-general medical hx current medications
including herbal medications , otc meds physical examination based on symptoms eg
○ abdomen and external genitalia -check for meatal stenosis , phimosis or hypospadias
○ digital rectal examination – prostate volume and surface consistency
 NICE advice asking patients to fill in a urinary frequency volume chart- available here
https://www.bladdermatters.co.uk
/downloads/85923fchart.pdf

These charts can give an objective assessment of bladder performance
Minimum 3 days
 Dipstick -check for blood , glucose ,protein , leucocytes and nitrates PSA – discuss the test / offer advice particularly if
○ BPE suspected
○ abnormal DRE
○ patient is concerned about prostate cancer Us and Es and GFR ( if renal impairment suspected ) Consider an assessment of baseline symptoms using a validated questionnaire for eg
○ International Prostate Scoring system ( IPSS ) 
○ American Urological Association symptom index Do not routinely offer imaging of the upper urinary tract to men with uncomplicated LUTS at initial assessment

conservative management-Weight reduction – can lead to improvement Caffeine – bladder stimulant consider ↓↓ Smoking – ↑↑ ed risk of incontinence Ensure help with emotional and physical conditions Relevant physical ,psychological , sexual and social issues Men with storage LUTS -provide containment products at point of need and advice about relevant support groups Men with overactive bladder
○ offer supervised bladder training
○ adv on fluid intake
○ lifestyle advice Micturition dribble- perform urethral milking

Drug treatment-Only if conservative management fails or are not appropriate Take into account co-morbidities and current treatment Offer an alpha blocker
○ alfuzocin
○ doxazocin
○ tamsulocin
○ terazocin

for moderate to severe LUTS ( IPSS 8 or more )

Alpha blockade of adrenoceptors in the bladder neck and prostate -> relax smooth muscles leading to imrovement in urine flow/rate and reduction in LUTS symptoms
 Offer an anti-cholinergic to manage OAB symptoms Offer a 5-alpha reductase if
○ prostates > 30 g
○ PSA level > 1.4 ng/ml and considered to be high risk progression Consider a combination ie alpha Bl + 5 A Red
moderate to severe LUTS and prostates estimated to be > 30 g Consider offering an anticholinergic + alpha blocker if storage symptoms persist after treatment with an alpha blocker Consider a late afternoon loop diuretic for nocturnal polyuria Consider desmopressin for nocturnal polyuria if
○ other medical cause excluded
○ no benefit from other Rx
○ measure Na level 3 days after the 1st dose and stop Rx if level below the normal range Do not offer phosphodiesterase 5-inhibitors solely for the purpose of treating LUTS symptoms except as a part of randomised controlled trial

Predominantly obstructive symptoms –Exclude and manage cause if identifiable Active surveillance ( lifestyle + regular f/u ) Lifestyle adv ( as on left ). Moderate to severe voiding symptoms-Alpha blocker Review at 4-6 weeks and then every 6-12 months. Enlarged prostate and high risk of progression-5-alpha reductase Review at 3-6 months and then every 6-12 months.Bothersome moderate to severe voiding symptoms and prostatic enlargement-Alpha bocker
 + 5-alpha reductase. Mixed picture storage + voiding and symptoms persist after alpha-Bl Rx-Add an antimuscarinic Review every 4-6 weeks until symptoms stable and then every 6-12 months

Overactive bladder –Offer an antimuscarinic ( anti-cholinergic ) First line Older frail men avoid immediate release oxybutynin Review every 4-6 wks until symptoms stable , then
every 6-12 months Offer Mirabegron if
○ antimuscarinic contraindicated , not tolerated or not effective
○ review at 4-6 weeks

Nocturia -Limit late afternoon/evening fluid intake Late afternoon loop diuretic ( eg furosemide 40 mg ) Consider oral desmopressin if no improvement 
( consider seeking specialist urology adv )

stress incontinence-Offer containment products Refer continence specialist service Refer for specialist assessment if not caused by prostatectomy If secondary to prostatectomy
○ refer for supervised pelvic floor muscle training x 3 months
○ consider referral if no improvement after 3 months

Urinary retention-Acute retention – admit Further management will be guided by urology depending on cause

Referral-Bothersome LUTS that has not responded to conservative management LUTS complicate by
○ recurrent or persistent UTI
○ retention
○ renal impairment that is suspected to be caused by lower UrTr dysfunction or suspected urological cancer Stress urinary incontinence Continence nurse – men with obstructive symptoms Suspected urological cancer Renal impairment that might be due to lower urinary tract dysfunction

References


1. Lower urinary tract symptoms in men : management Clinical guideline CG97 NICE May 2010
2. Management of lower urinary tract symptoms: summary of NICE guidance BMJ 2010 ;340:c2354
3. Lower urinary tract symptoms in men by Dr Louise Newson GP Online
4. Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer ? BMJ 2018; 361:k1202
5. CKS NHS- LUTS in men