Lower urinary tract symptoms underdiagnosed in primary care
A retrospective analysis has found that lower urinary tract symptoms (LUTS) in men are underdiagnosed and undertreated.
The study used data from The Health Improvement Network (THIN) database between 2000 and 2006. This holds information on more than one million men aged ? 18 in the UK, including demographics, medical diagnoses and hospital referrals, from a representative sample of 333 UK general practices.
Increasingly, urologists are breaking down LUTS into those suggestive of bladder outflow obstruction (BOO), ie predominantly voiding symptoms, and those suggestive of overactive bladder (OAB), ie storage symptoms.
The data gathered were used to analyse prescribing trends for 5-alpha reductase inhibitors and alpha-blockers for LUTS secondary to BOO and antimuscarinics for OAB.
The study found that only 0.3% of patients had been diagnosed with LUTS/OAB, and 2.2% with LUTS/BOO. Population studies have shown these symptoms to be highly prevalent in the community, with a prevalence of around 55% and 25% for storage symptoms and voiding symptoms respectively.1
Treatment rates were also low – only 25% of men diagnosed with OAB received antimuscarinics, while 39% of men with suspected BOO received alpha-blockers or 5-alpha reductase inhibitors. Alpha blockers were prescribed to around 10% of men with OAB or storage LUTS who did not have any recorded symptoms of BOO.
This study reflects a number of pertinent issues for GPs. First, there remains a fear that prescribing antimuscarinics to men with LUTS can cause urinary retention. GPs need to be aware of the appropriate use of these drugs and the low risk of retention, provided the patient does not have severe voiding symptoms.
Second, GPs need to take histories carefully to distinguish between storage and voiding LUTS, as this has clear implications on medical management. Generic use of alpha-blockers as first-line treatment for all men with LUTS is not good practice but still appears to be a common tactic.
Third, GPs need to be aware that patients presenting with LUTS are the tip of the iceberg in terms of the prevalence of symptoms in the community, and opportunistic questioning may be useful.
Finally, there is a problem with Read code availability to code diagnoses accurately, perhaps reflecting some of the relatively new terminology in this field. For instance, a code for ‘overactive bladder' does not exist on a commonly used primary care IT system.
This may explain, at least in part, the gap between diagnosed LUTS and estimated prevalence in community studies.
Morant SV, Reilly K, Bloomfield GA et al. Diagnosis and treatment of lower urinary tract symptoms suggestive of overactive bladder and bladder outlet obstruction among men in general practice in the UK. Int J Clin Pract 2008 doi:10.1111/j.1742-1241/2008.01737.xReviewer
Dr Jonathan Rees
GPwSI Urology, Bristol