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Top tips on lower urinary tract symptoms

Advice from urology GPSI Dr Jonathan Rees on urinary tract symptoms and what they could indicate.

Advice from urology GPSI Dr Jonathan Rees on urinary tract symptoms and what they could indicate.

1. Lower urinary tract symptoms (LUTS) are under-reported. Studies suggest that about 40% of men over 50 in the UK report LUTS of moderate to severe degree, but clearly a far smaller proportion seek medical help. And recent research suggests a diagnosis is made in only 2% of patients in this age group. LUTS have a significant impact on quality of life of both the patient and their partner, and there is clearly a chance for opportunistic questioning, particularly in men with symptoms that may be related to their LUTS, such as fatigue or depression.

2. LUTS can be divided into storage, voiding and post-micturition symptoms. Storage symptoms include frequency, urgency and nocturia, while voiding symptoms include poor flow, hesitancy and incomplete emptying. The International Prostate Symptom Score (IPSS) is a seven-item questionnaire that can assess the severity of these symptoms and includes a further question assessing the impact of these symptoms on the patient. Obtaining a baseline IPSS score can be particularly useful for judging the effectiveness of subsequent treatment. Download the IPSS here (right).

3. Bladder diaries – frequency volume charts – are underused in primary care. The patient is asked to record the time and volume of each void on a number of days (having passed urine into a standard kitchen measuring jug bought for the purpose!). This will provide information on total daily voided volume, frequency of micturition and nocturia. It can help particularly in identifying patients with excessive fluid output (usually due to excessive input) or those who pass excessive amounts of urine at night (more than one-third of total daily urine output) who may have nocturnal polyuria rather than bladder outflow obstruction. A bladder diary can also be downloaded right.

4. Always examine the external genitalia in men with LUTS. A tight phimosis or meatal stenosis can cause obstructive urinary symptoms. Urologists frequently see patients referred with refractory urinary symptoms who turn out to need a circumcision rather than TURP. A quick examination when patients present with urinary symptoms can save embarrassment later.

5. LUTS can be divided into complicated and uncomplicated. Uncomplicated LUTS are generally of gradual onset, no history of UTI or haematuria, and patients have an impalpable bladder, normal external genitalia and a benign-feeling prostate on examination. These patients should be managed, at least initially, in primary care and only referred if initial medical management fails. Complicated symptoms and signs include pelvic pain, incontinence, haematuria, recurrent UTI or abnormal rectal examination and are likely to result in urological referral. Severe symptoms alone need not require referral, as urologists are unlikely to offer surgical treatment without attempting medical management first.

6. Consider self-management strategies before commencing medical treatment, particularly in patients with mild LUTS. It is worth discussing fluid intake, particularly evening fluid intake for patients with nocturia. Managing excessive fluid intake – especially caffeinated drinks – can be very effective in decreasing the severity of LUTS. Consider referral to a continence nurse for bladder training in patients with overactive bladder symptoms.

7. All alpha-blockers have similar efficacy in improving symptoms and urinary flow rate. The effect is usually maximal within one month of starting treatment. Terazosin and doxazosin require dose titration to minimise adverse effects such as postural hypotension. Tamsulosin and alfuzosin do not require dose titration but there is no convincing evidence that they cause fewer cardiovascular adverse events than other alpha-blockers.

8. Don't forget that LUTS in men may be caused by an overactive bladder (OAB) rather than outflow obstruction by the prostate. Men with storage symptoms of frequency, urgency and nocturia but without significant voiding symptoms such as poor flow and hesitancy may have OAB and would be more likely to benefit from an anti-cholinergic than an ?-blocker. Even if these symptoms are due to outflow obstruction, anti-cholinergics can be very effective and the risk of precipitating urinary retention is very low, particularly if the patient has little in the way of voiding symptoms.

9. The 5-alpha-reductase inhibitors should not be used as first-line therapy in primary care. These drugs – finasteride and dutasteride – work by shrinking the prostate and maximal effect is reached after approximately six months. They have significant side-effects of fatigue, loss of libido and breast tenderness. They can be used alongside symptomatic treatment with an alpha-blocker for patients with severe symptoms or those who are felt to be at high risk of progression to acute retention or surgery. Always remember that PSA levels will be approximately halved by these drugs and this must be taken into account when examining PSA results in patients on these drugs.

10. An afternoon dose of a diuretic can be helpful in managing bothersome nocturia. In patients who have persistent nocturia despite fluid management and an alpha-blocker, taking a small dose of frusemide at 4pm can be helpful. This will cause a significant diuresis during the evening and can decrease the frequency of night-time voiding.

Dr Jonathan Rees is a GPSI in urology at the Backwell and Nailsea Medical Group

Competing interests None declared

IPSS chart IPSS chart Voiding diary Voiding diary Enlarged prostate

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