Investigations
There is no need to perform routine renal ultrasound in a man presenting with uncomplicated LUTS1
However, in the presence of complicating factors such as loin pain, bladder pain, recurrent UTI or suspected chronic urinary retention, an ultrasound may be useful, particularly to check for renal/ureteric/bladder calculi and signs of chronic retention – for instance, large post-micturition residual volume or hydronephrosis.
Routine measurement of renal function is unnecessary in a man with LUTS unless you suspect renal impairment1
In the history this would be suggested by nocturnal enuresis – potentially due to chronic retention with overflow incontinence – recurrent UTI or previous renal calculi. Finding a palpable or percussable bladder would suggest chronic retention and possible renal involvement.
Measurement of flow rate and assessment of post-micturition residual volume are unnecessary in the initial assessment of the majority of men with LUTS1
Men can be offered therapy based on a clinical assessment of their symptoms, consisting of lifestyle advice, reassurance, monitoring or medical therapy using α-blockers, 5-α reductase inhibitors, anticholinergics and potentially PDE5 inhibitors.
In men with storage symptoms suggestive of an overactive bladder, an anticholinergic can be prescribed without prior assessment of residual volume, provided he does not have significant voiding symptoms suggestive of bladder outflow obstruction by benign prostatic hyperplasia (BPH). If the latter is the case, an α-blocker should be prescribed, but with the option of adding an anticholinergic if bothersome storage symptoms persist.
Do not add PSA testing to a list of investigations without discussion with the patient
PSA tests are often added to a list of investigations without the patient being counselled. A common scenario is to see a borderline or mildly raised PSA result in an elderly man presenting with new-onset back pain. The Prostate Cancer Risk Management Programme explicitly states that PSA testing should not take place without careful explanation and an understanding of the limitations.1 Borderline PSA results can cause great anxiety to patients – it would be far more useful in the scenario above to assess the prostate using a digital rectal examination, as in the absence of palpable disease the likelihood of metastatic prostate cancer is extremely unlikely.
Do not perform PSA testing in an asymptomatic man with estimated life expectancy of less than 10 years
While PSA testing remains as controversial as ever, there is consensus that PSA screening in older asymptomatic men does not improve outcome. It is suggested that a cut-off of 10 years’ estimated life expectancy should be used, so if a man has significant cardiovascular disease and diabetes, the upper age for PSA testing will be far lower than in a healthy man without significant comorbidities. Generally speaking, do not carry out PSA testing on an asymptomatic man over the age of 75, but allow for some flexibility around this age based on estimation of life expectancy.
Do not do a PSA test for a minimum of six weeks after treatment of a UTI
PSA levels are falsely (and significantly) elevated during and for several weeks after a UTI. Inappropriate PSA testing during an episode of urinary infection is a common cause of inappropriate referral to secondary care and can cause great anxiety to patients and their partners.
Do not routinely request urine cytology in haematuria
Using urine cytology for assessment of haematuria in primary care is unnecessary and potentially offers false reassurance with a negative result, because of low sensitivity. Do not routinely request this test – it may be done in the haematuria clinic, but this will be in the context of a full urological investigation.2
Do not routinely screen patients for non-visible haematuria
NVH is prevalent in the general population, with approximately 2.5% of people affected. There is no evidence to support routine screening for NVH, but despite this, many practices continue to perform ‘multistick’ urine dipstick testing for all new patients.3 Routine urine dipstick for blood should only be undertaken for patients with new-onset urinary symptoms (lower or upper tract), newly discovered proteinuria or CKD, in monitoring of multisystem disease with potential renal involvement (for instance, lupus) or in annual assessment of hypertension or diabetes.1
Treatment
Do not recommend phytotherapy for the treatment of LUTS
NICE guidelines advise against the use of phytotherapy for this indication (as well as other complementary therapies such as acupuncture and homeopathy).3 Despite a number of randomised controlled trials, there is no good quality evidence to support the use of these preparations, despite their popularity as an OTC purchase. The most commonly taken phytotherapy in the UK for male LUTS is saw palmetto (Serenoa repens) – a recent Cochrane review of 17 trials concluded that ‘saw palmetto therapy does not improve urinary symptoms or flow rates compared with placebo in men with BPH, even at double or triple the usual dose’.2 But remember that placebo is actually a remarkably effective treatment for LUTS and so many men will report a benefit from use of these products, which are thought to be safe and well tolerated.
Referral
Do not refer a patient aged under 40 with NVH but no other risk factors to a one-stop haematuria clinic
Urological clinics for assessment of NVH are designed to perform flexible cystoscopy and upper tract imaging to exclude bladder tumours, upper tract tumours (both transitional cell and renal) and calculi. However, in patients under the age of 40 with no other strong risk factors (for instance heavy smoking history, occupational exposure, family history, new onset storage LUTS, upper tract symptoms such as loin pain) the risk of finding pathology of this nature is extremely low. Guidelines produced in 2010 state that for patients under the age of 40 with NVH, assessment of renal function using eGFR, urine albumin: creatinine ratio and blood pressure measurement should be performed and monitored annually for as long as the haematuria persists, referring to nephrology (according to the NICE chronic kidney disease guidelines) if this is abnormal or deteriorating.5
Dr Jon Rees is a urology GPSI at Backwell and Nailsea Medical Group, North Somerset
References
