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