Lower Urinary Tract Symptoms (LUTS) in Men

Lower urinary tract symptoms (LUTS) are a common problem affecting older men. Symptoms can be categorised into filling symptoms (previously called irritative) and voiding symptoms (previously called obstructive). Symptoms are non-specific and large studies of patients have failed to show any correlation between lower urinary tract symptoms and a specific diagnosis.¹ LUTS are common and not necessarily a reason for suspecting prostate cancer.²

• Prevalence increases with age. The prevalence of nocturia in older men is about 78%. Older men have a higher incidence of LUTS than older women.³
• Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.⁴
• Once symptoms arise, their progress is variable and unpredictable with about one third of patients improving, one third remaining stable and one third deteriorating.
• It is estimated that the lifetime risk of developing microscopic prostate cancer is about 30%, developing clinical disease 10%, and dying from prostate cancer 3%.

See separate article in order to determine the International Prostate Symptom Score (IPSS).

• Filling symptoms: frequency, urgency, dysuria, nocturia.
• Voiding symptoms (previously 'obstructive'): poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence (occurs in chronic retention).
• Also enquire about: haematuria, fever, loin and pelvic pain, past history of renal calculi, past history of urinary tract infections, sexual/erectile difficulties, constipation, medications and bone pain.
• Signs: palpable bladder, rectal examination (prostate: size, tenderness, nodules), check for loin pain and/or renal masses, perineal sensation.
• Lower urinary tract symptoms include frequency, urgency, hesitancy, dysuria, haematuria, reduced flow, dribbling, nocturia, incontinence and pelvic pain.
• Some patients develop acute retention.
• Others develop chronic retention with overflow incontinence and, on rare occasions, renal failure.

• Examination: look particularly for signs of uraemia, enlargement of the bladder, kidneys and the prostate, and palpable nodes.
• Check blood pressure (avoid using alpha blockers in people prone to postural hypotension).
• Initial assessment in primary care should include measurement of plasma creatinine, urinalysis, MSU and rectal examination.
• A PSA test should be considered and discussed with the patient.
• Further investigations in secondary care to establish or confirm the diagnosis include ultrasound and urinary flow studies, imaging, prostate biopsy and/or cystoscopy.

• Benign prostatic hyperplasia (BPH) with obstruction
• Detrusor muscle weakness and/or instability
• Urinary Tract Infection (UTI)
• Chronic prostatitis
• Calculi
• Malignancy: prostate or bladder
• Neurological disease, e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome

• Immediate referral (seen within 1 day):
  • Acute retention or acute renal failure
• Urgent referral (according to local definitions of maximum waiting times but maximum time of 2 weeks):
  • Visible haematuria
  • There is a suspicion of prostate cancer based on the finding of a nodular or firm prostate, and/or a raised PSA
  • Culture negative dysuria
  • Chronic urinary retention with overflow or night-time incontinence
• To be seen soon (according to local definitions of maximum waiting times but maximum time of 2 weeks):
  • Recurrent UTIs
  • Microscopic haematuria
  • Symptoms have failed to respond to treatment in primary care and are severe enough to affect quality of life (best assessed by using International Prostate Symptom Score
  • Evidence of chronic renal failure or renal damage

• Men with LUTS and small or moderate sized prostates will improve appreciably with lifestyle advice and alpha blocker therapy.
• Men with LUTS and large prostates are at significant risk of disease progression particularly if they have additional risk factors such as age >70 years or flow rate less than 12 ml/s. These men will benefit from treatment with lifestyle advice and 5-alpha reductase inhibitors (5-ARIs).
• 5-ARIs reduce the risk of acute urinary retention and the likelihood of prostatectomy by 50-60% compared with placebo.
• An alpha blocker alone could be substituted in a man with bothersome symptoms, without additional risk factors, if he preferred rapid symptom relief.
• The combination of 5-ARI and alpha blocker is more effective in delaying the clinical progression of the disease and in improving LUTS and maximal urinary flow rate, than either drug alone.
• After six months of treatment with a 5-ARI, PSA levels will be reduced by 50%. Therefore PSA values for patients on long-term therapy should be doubled to allow appropriate interpretation and avoid masking the early detection of localised prostate cancer.
• Surgical treatment is generally reserved for men who have failed or are unable to tolerate drug treatment, or for those who have developed complications.³