What you need to know about LUTS in men
Urology GPSI Dr Jonathan Rees answers Dr Linden Ruckert’s questions on lower urinary tract symptom scores, bladder training and which tests are most useful in primary care
Urology GPSI Dr Jonathan Rees answers Dr Linden Ruckert's questions on lower urinary tract symptom scores, bladder training and which tests are most useful in primary care
1. How reliable are lower urinary tract symptoms (LUTS) as a sign of benign prostatic hyperplasia (BPH)?
• storage symptoms – frequency, urgency, nocturia
• voiding symptoms – poor flow, hesitancy, straining, intermittency
• post-micturition symptoms – dribble.
Strictly speaking, BPH is a histological diagnosis, with microscopic BPH affecting approximately 50% of men in their 50s and 90% of men over 80.
The term BPH is often used to mean ‘symptoms of bladder outflow obstruction secondary to benign prostatic enlargement (BPE)'.
It is important to remember LUTS can be caused by a number of conditions, most commonly:
• overactive bladder
• urethral stricture
• acute conditions such as UTI
• prostatitis or sexually transmitted infection
• medical conditions such as diabetes or heart failure.
So it is vital not to assume – particularly in the older man – that all LUTS represent benign prostatic enlargement and to consider these other conditions.
Overactive bladder syndrome in particular is underdiagnosed in men (see figure 1 overleaf).
2. How does distinguishing between voiding and storage symptoms help in management?
In practical terms, this distinction is most useful for assessing the possibility of an overactive bladder syndrome (OAB) as opposed to bladder outflow obstruction.
Patients with OAB present with storage symptoms: classically frequency, urgency (with or without urge incontinence) and nocturia.
They may also complain of provocative factors that trigger their symptoms, such as cold weather, putting the key in the front door, stress, and so on.
If a patient has few or no voiding symptoms, a diagnosis of OAB should be considered, and if medical treatment is required, the use of an anticholinergic rather than an a-blocker is appropriate.
GPs are often cautious about using anti-cholinergics in men with LUTS for fear of precipitating acute urinary retention. But if the patient does not have severe voiding symptoms, evidence suggests the use of anticholinergics is safe.
3. What are the other possible diagnoses, especially in younger men?
There are a multitude of diagnoses that can present with LUTS. In younger men with acute LUTS always consider an STI, particularly chlamydia.
Many medical conditions can present with, or be complicated by, LUTS. For instance, heart failure patients can have troublesome nocturia from reabsorption of peripheral oedema at night.
As GPs we're particularly well placed to make a holistic assessment of the likely causes of these symptoms.
Diabetes should always be excluded in patients with frequency or nocturia.
4. How do we manage young men with ‘irritable bladder'-type symptoms in whom investigations – including a GUM screen – are negative?
If STIs and UTIs have been reliably excluded, these patients can be managed along standard lines for overactive bladder. A trial of an anticholinergic – for example, oxybutynin, tolterodine or solifenacin should be considered if lifestyle measures are unable to control symptoms (see question 7). These symptoms can be extremely bothersome, so have a low threshold for urological referral if patients do not respond.
5. Is the International Prostate Symptom Score (IPSS) useful in practice? If so, how should GPs use it?
The IPSS is a seven-question symptom score, which asks patients to score the severity of common LUTs. It's available to download here.
It ends with a quality-of-life question: ‘If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about it?' – this is scored on a range from ‘terrible' to ‘delighted'.
The symptom score can be useful in primary care in a number of ways.
First, it enables the GP to see the pattern of symptoms, for example predominantly storage.
Second, you can establish a baseline measure of symptom severity, which can be repeated on treatment to evaluate success. Evidence also shows that patients with high IPSS scores are at higher risk of progression to acute urinary retention or surgery, and are thus candidates for early medical intervention.
Third, and perhaps most importantly, the quality-of-life question has been shown to correlate well with more formal measures of symptom bother and quality of life, and so can be used as a useful pointer to patients who need treatment for what are predominantly quality-of-life based symptoms.
But it's important to remember that the first seven IPSS questions ask about frequency of symptoms, not the bother associated with them.
Also, there are no questions relating to the impact of their symptoms on sexual function or continence, the effect on their partner or concerns regarding prostate cancer.
6. Is measuring flow rates useful in men with LUTS? What other tests might GPs consider?
Urinary flow rates aim to provide an objective measure of bladder outflow obstruction. They are usually combined with ultrasound assessment of post-void residual urine volume, which is really an assessment of detrusor function.
There is little evidence to support their use at primary care level, where treatment can usually be based on a thorough history and physical examination. They have more of a role in patients who have failed to respond to first-line treatments.
A simple bladder diary or frequency volume chart is probably the most useful primary care test.
The patient is asked to record the time and volume of voids – using a simple plastic measuring jug – over three to five days.
This allows an assessment of voided volume, which may indicate that urinary frequency is due to excess intake, frequency of voids, severity of nocturia and voided volume overnight. Look out for nocturnal polyuria – more than a third of total urine output passed at night.
7. How helpful are lifestyle measures and bladder training?
Extremely helpful, and should be always considered before medical therapy.
Simple measures such as decreasing the intake of fluids in the evening and caffeinated, alcoholic or carbonated drinks can make an enormous difference to symptoms – converting a bothered patient requiring medical intervention into one who requires no treatment.
The frequency volume chart can be a useful tool in assessing those patients who need to consider these measures, particularly if the patient is also asked to record his daily fluid intake – volume and type – on the chart.
Bladder training involves techniques such as delayed voiding, double voiding and urethral milking, often in combination with pelvic floor exercises. A patient leaflet is available at pulsetoday.co.uk/downloads or by clicking on the link (right).
But although these techniques can be taught by verbal advice and written information, they are at their most effective when provided by a trained professional such as a continence adviser.
8. If a patient does not respond to alpha-blockers after three weeks, is there any point in continuing? In those who do respond should we try a trial of withdrawal after an interval? Who are most likely to derive benefit?
Alpha-blockers have a relatively rapid onset of action and can be expected to have had some impact on LUTS within a month.
They are most effective at quickly improving urinary flow and nocturia, whereas frequency and urgency can take longer to respond.
If there has been no response at all to an a-blocker after three to four weeks, it is unlikely to be effective if continued.
Older a-blockers such as doxazosin are an exception as they require dose titration, so here it can be useful to try increasing the dose as tolerated.
If patients have failed to respond to an alpha-blocker it is worth reconsidering your initial diagnosis:
• Does he have predominant storage symptoms and should he have a trial of an anti-cholinergic, either as an alternative to his a-blocker or in combination (BPH and OAB can often co-exist)?
• Or could he possibly have a stricture – for instance from previous catheterisation, cycling, pelvic injury or STI?
If in doubt, it's reasonable to ask for a urological assessment at this stage.
Remember there's no benefit in adding in a 5-a reductase inhibitor (5-ARI), in terms of short-term symptom control. But if longer-term symptom control is the aim, this may be an option.
Withdrawing an a-blocker for patients with relatively mild symptoms is always an option.
If patients respond, it's worth waiting for at least three to six months before trialling without the medication, allowing for a degree of ‘chemical retraining'.
9. So when should we consider combination therapy with 5-ARIs?
These drugs – finasteride and dutasteride – exert their action by inhibiting the conversion of testosterone to dihydrotestosterone, so limiting prostatic growth.
They are most effective in patients with significantly enlarged prostates, both in terms of symptom control and decreasing the risk of progression to retention or surgery.
This risk of progression is also increased by factors such as advancing age, symptom severity and PSA.
Combination therapy refers to using a 5-ARI alongside an a-blocker. The a-blocker is used for relatively rapid symptom control, with the 5-ARI alongside for its longer term benefits.
The landmark MTOPS study showed that combination therapy is more effective than monotherapy with either agent in terms of reducing progression to retention or surgery.
The 5-ARIs should not be first line therapy in primary care, but should be reserved for those at highest risk of progression.
It is important to remember that 5-ARIs take around six months to produce symptom relief, and that the PSA level in a patient established on a 5-ARI is roughly halved by the action of the drug.
10. Who should progress to surgery and what advances have there been recently?
Advances in medical management mean that surgical intervention for benign prostate disease – which was once common – is now used much less.
Most patients having surgery now either have acute or chronic urinary retention, or severe symptoms unresponsive to medical therapy.
Trans-urethral resection of the prostate (TURP) remains the gold standard against which other interventions must compete.
A vast number of techniques have been tried, all of which aim to destroy prostatic tissue using heat, microwave or laser.
To add to the confusion there's a huge array of acronyms – TUNA, TUMT, TUVP, HoLEP, KTP.
A recent systematic review has concluded that in general, men undergoing endoscopic prostatectomy using more modern technology have similar short-term outcomes to TURP, are less likely to require a blood transfusion and more likely to go home sooner. But the quality of evidence is poor and TURP remains the standard approach.
The review also concludes that Holmium laser enucleation of the prostate (HoLEP) shows the most promise of the newer alternative ablation techniques.
11. Many patients presenting with LUTS routinely have a PSA test. Is this reasonable given the known pitfalls of PSA testing and the fact that prostate cancer itself rarely causes LUTS, but is a coincidental finding?
PSA testing continues to be controversial, and its use as a case-finding tool for prostate cancer in males with LUTS – as you suggest – could be considered illogical. But despite this uncertainty there are a number of reasons for considering a PSA test in men presenting with LUTS.
First, patients often expect a PSA test, and research shows that men – and their partners – presenting with LUTS are worried about prostate cancer, even after being reassured that their symptoms are not suggestive of this diagnosis. A PSA may be needed for reassurance. But remember that if the patient is subsequently diagnosed with prostate cancer, they shouldn't be left feeling ‘if only I had a PSA test when I first told my GP about these symptoms'.
Second, we should not forget that prostate cancer is a major killer of men and a nihilistic attitude towards PSA testing denies men access to one of the few tools available that could diagnose it at a treatable stage.
Finally, PSA is a useful tool in assessing prostate disease, in its role as a surrogate marker of prostatic volume and the risk of progression to retention or surgery.
The patient with a PSA of 0.5 is likely to have a small prostate and even if they are symptomatic their condition is unlikely to progress. But the man with a high normal age-specific PSA is at significantly higher risk. The PSA result can therefore alter medical management, with the Primary Care Guidelines of the British Association of Urological Surgeons recommending consideration of a 5-ARI in patients with LUTS and a PSA greater than 1.4.
As a caveat, given the implications of PSA testing, all men who have this test performed should receive some counselling (verbal or written) on the pros and cons of testing before the test is performed.
Dr Jonathan Rees is a GPSI in urology at Backwell and Nailsea Medical Group, Bristol
Competing interests: None declared
What I will do now What I will do now
Dr Ruckert considers the responses to her questions
It's good to be reminded of the discriminating points in the history, including provocative factors, to assess for overactive bladder and I'll probably make that diagnosis more often.
It's reassuring that – in the absence of severe voiding symptoms – anticholinergics are safe and I think I'll feel more confident using them.
I also think it's helpful to be reminded about nocturia and heart failure – an explanation sometimes makes such symptoms slightly more tolerable.
Using the IPSS to screen for those at high risk of retention and therefore earlier referral for surgery is a useful tip. It is also good to be reminded that PSA may be used as a surrogate marker of prostatic volume.
I'll consider bladder diaries and be more consistent about lifestyle advice; I often refer women to continence advisers but I will consider referring more men for bladder training and pelvic floor exercises.
The idea of withdrawing alpha-blockers after three to six months of ‘chemical retraining' is useful.
Dr Linden Ruckert is a GP in north London
thps Bladder training leaflet Bladder training leaflet TURPs remains the gold standard surgical option despite advances such as lasers TURPs remains the gold standard surgical option despite advances such as lasers