Assessing lower urinary tract symptoms in men
Jane Coe, nurse practitioner in men's health, talks to Dr Linden Ruckert about streamlining prostate services
What impact has the presence of a nurse specialist had on the urology clinic for men who present with lower urinary tract symptoms?
Patients who previously could have waited up to four months are now being seen within a four-week period. Those patients with lower urinary tract symptoms referred by their GPs are now booked into a prostate assessment clinic which I run in conjunction with the lead clinician.
This clinic focuses specifically on the investigation and management of lower urinary tract symptoms.
We hope to allow GPs to book appointments directly with the clinic in the near future to improve access for patients.
What do you do as an initial assessment?
A medical history is taken along with urinalysis, blood pressure, abdominal and genital examination, digital rectal examination, flow rate and post-micturition residual volume.
Ideally the patient will have had a baseline serum creatinine and PSA done by their GP which helps us to complete a full assessment more quickly.
In addition patients are asked to complete an International Prostate Symptom Score (IPSS) and a four-day frequency volume chart before attending. This provides us with a useful indicator of their current symptoms and fluid intake.
These investigations enable us to identify patients who have complicated lower urinary tract symptoms that may pose a threat to life expectancy and who require specialist intervention.
Complicated lower urinary tract symptoms will include patients with an abnormal digital rectal examination or raised PSA indicating a possible prostate cancer, or patients with a large urine residual volume and renal impairment which can occur as a result of outflow obstruction.
Findings such as these are discussed with the consultant and further investigation or treatment is instigated.
The advantage for patients is that the shorter waiting time for assessment and management may help to reduce the impact their lower urinary tract symptoms may have on their quality of life and, of course, that of their partner.
How useful is the IPSS?
The IPSS helps to assess the severity of symptoms. Each time a patient visits they complete a further IPSS, which is a useful indicator of symptom progression or deterioration.
The IPSS can be difficult for some patients to understand. Often I will help them fill it in by adapting the wording. We also have the IPSS in other languages besides English. Occasionally I am forced to abandon the questionnaire entirely.
What do you say about PSA?
All patients referred to the prostate assessment clinic are sent an information sheet on the PSA test which explains what the test is and the pros and cons.
This also provides patients with my contact number if they want further information or have any questions. Furthermore patients are given the opportunity to decline the test.
The sheet was compiled by a British Association of Urological Surgeons working party1 and contains all the information needed to obtain informed consent in clear and simple language. Counselling the patient during a clinic consultation before obtaining the test is time-consuming and the amount of information required for informed consent can often overwhelm the patient.
There is an interesting study by Chan and Sulmasy2 which identified the facts about PSA screening that physicians and patients believed should be disclosed for obtaining informed consent. A multidisciplinary group then reviewed this data and reached a consensus on which facts ideally should be given.
They state that some facts should be given as an absolute basic minimum, others should be disclosed during the conversation and others should be provided in the form of a patient information leaflet.
Is lifestyle advice useful?
Providing patients with advice that puts them in control in terms of self-management may be very useful. It is empowering for patients and may possibly reduce the need for medical intervention.
Lifestyle advice such as fluid management, avoiding caffeine, reducing alcohol intake, retraining the bladder and avoiding constipation is provided by many doctors and nurses but the content of such advice can be variable, and identifying which areas need to be addressed for lifestyle modification is extremely time-consuming. Furthermore no one knows for sure if such advice will improve the patient's symptoms.
Our lead clinician, Mr Mark Emberton, has initiated a research programme in conjunction with the Royal College of Surgeons, examining the efficacy of lifestyle advice on patients' lower urinary tract symptoms.
Should, say, a-blockers ever be stopped once started? What about the use of saw palmetto?
Lower urinary tract symptoms wax and wane. Studies have shown that many patients' symptoms will remain stable or even improve without any intervention. Not everyone's symptoms will deteriorate.
It is reasonable for patients on
a-blockers to consider a trial off therapy if they wish, when their symptoms have settled, for example at six months. Symptom relief with a-blockers is usually fairly rapid so it is easy to start them again if symptoms worsen.
Some patients have used their
a-blockers in this way and have felt it was beneficial. One of my patients uses his
a-blockers on an 'as required' basis at work when his symptoms are most bothersome, although we would not recommend this method.
Many patients ask about saw palmetto and whether we would recommend it for benign prostatic hyperplasia. Our advice is that no one knows for sure whether it is truly beneficial in reducing benign prostatic hyperplasia symptoms, since the published studies show conflicting results.
But it is accepted that there may be a placebo effect for the patient and if they are keen to try it this is their choice and we would support them in it. Interestingly, in Germany and other parts of Europe saw palmetto is widely used for the treatment of benign prostatic hyperplasia.
Do you offer post-operative support?
Many patients feel vulnerable on discharge home. Knowing that there is someone to contact if problems arise may make the difference between coping with the situation and not coping. The urology unit here routinely provides all patients with a contact number before leaving hospital. The urology nurse practitioners and urology nurse specialists will also give the patients a contact number should any problems arise.
Before their discharge home all patients will be given specific advice and information leaflets where necessary. Patients often phone with concerns and we can help them to identify whether something they are noticing is a normal part of their recovery or if it's something that needs further intervention. We are more than happy to be contacted by GPs or community nurses for further advice.
Many patients with benign prostatic hyperplasia who undergo transurethral resection of the prostate may find that their lower urinary tract symptoms persist for a while after their surgery, which can cause distress.
If a urine infection or urine retention has been excluded, patients should be reassured that sometimes it takes up to three months for symptoms to improve. Some of these continued symptoms may be explained by the changes that have occurred in the bladder over time as a result of the outflow obstruction found in benign prostatic hyperplasia.
In benign prostatic hyperplasia the bladder wall hypertrophies in order to generate more forceful contractions in response to increased outflow resistance. There is also a loss of compliance and some decrease in the capacity of the bladder.
These changes give rise to the symptoms of urgency and frequency, which may persist for a while after the outflow obstruction is relieved. These continued strong detrusor contractions may also cause symptoms of bladder pain or discomfort, which should improve with time but occasionally anticholinergics may be useful in easing this symptom.
It is the practice on our unit to start those patients who have had episodes of retention, post-operatively or in the community, on a
48-hour course of a-blockers before catheter removal. This has been shown to improve the success rate of the trial of void.
Post micturition dribble is common in older men because the muscles that normally help the urethra expel the urine at the end of a void may be less efficient. This may lead to pooling of urine in the bulbar urethra.
It can also occur in younger men they should be reassured that this is common and a simple remedy is pressing behind the scrotum which lifts that part of the urethra and empties it.