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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
Document references
- Abrams P; New words for old: lower urinary tract symptoms for "prostatism". BMJ. 1994 Apr 9;308(6934):929-30.
- Clinical Knowledge Summary; Urological cancer - suspected
- Boyle P, Robertson C, Mazzetta C, et al; The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study. BJU Int. 2003 Sep;92(4):409-14. [abstract]
- Clinical Knowledge Summary; Benign Prostatic Hypertrophy
- NICE Clinical Guideline; Referral Advice (2001)
- British Association of Urological Surgeons; Primary care management of male lower urinary tract symptoms (LUTS). February 2004 (included in Obstetrics, Gynaecology and Urology Section of Eguidelines - requires registration and password).
Internet and further reading
- NICE Clinical Guidance; Referral for suspected cancer. June 2005.
- Bandolier; Benign Prostatic Hyperplasia Site
- NHS; Cancer Screening Programmes. Prostate Cancer Risk Management.
- European Association of Urology Guideline; Benign Prostatic Hypertrophy (2004)
DocID: 2399
Document Version: 20
DocRef: bgp24560
Last Updated: 18 Mar 2008
Review Date: 18 Mar 2010
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