Lower Urinary Tract Symptoms

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2021-01-18

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Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. Although LUTS is a preferred term for prostatism, and is more commonly applied to men, lower urinary tract symptoms also affect women.

LUTS affect approximately 40% of older men.

Symptoms and signs

Symptoms can be categorised into:

Filling (storage) or irritative symptoms

Increased frequency of urination
Increased urgency of urination
Urge incontinence
Excessive passage of urine at night

Voiding or obstructive symptoms

Poor stream (unimproved by straining)
Hesitancy (worsened if bladder is very full)
Terminal dribbling
Incomplete voiding
Urinary retention
Overflow incontinence (occurs in chronic retention)
Episodes of near retention

As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer. Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis. Also, recently a report of lower urinary tract symptoms even with malignant features in the prostate failed to be associated with prostate cancer after further laboratory investigation of the biopsy.

Causes

Benign prostatic hyperplasia (BPH)
Bladder stone
Cancer of the bladder and prostate
Detrusor muscle weakness and/or instability
Diabetes
Use of ketamine
Neurological conditions; for example multiple sclerosis, spinal cord injury, cauda equina syndrome
Prostatitis, including IgG4-related prostatitis
Urethral stricture
Urinary tract infections (UTIs)

Diagnosis

The International Prostate Symptom Score (IPSS) can be used to gauge the symptoms, along with physician examination. Other primary and secondary tests are often carried out, such as a PSA (Prostate-specific antigen) test, urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy and/or cystoscopy.

Placement of a temporary prostatic stent as a differential diagnosis test can help identify whether LUTS symptoms are directly related to obstruction of the prostate or to other factors worth investigation.

Treatment

Treatment will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given.

With prostatic causes of LUTS; the first line of treatment is medical, which includes alpha-1 blockade and antiandrogens. If medical treatment fails, or is not an option; a number of surgical techniques to destroy part or all of the prostate have been developed.

Surgical treatment

Surgical treatment of LUTS can include:

Ablation procedures - used in treating both bladder tumours and bladder outlet obstruction, such as prostate conditions.
Bladder-neck incision (BNI)
Removal of the prostate - open, robotic, and endoscopic techniques are used.
Stenting of the prostate and urethra.
Transurethral removal of the prostate (TURP)
Transurethral microwave thermotherapy
Urethral dilatation, a common treatment for strictures.

Lifestyle changes

Other treatments include lifestyle advice; for example, avoiding dehydration in recurrent cystitis.

Men with prostatic hypertrophy are advised to sit down whilst urinating. A 2014 meta-analysis found that, for elderly males with LUTS, sitting to urinate meant there was a decrease in post-void residual volume (PVR, ml), increased maximum urinary flow (Qmax, ml/s), which is comparable with pharmacological intervention, and decreased the voiding time (VT, s). The improved urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.

Epidemiology

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.
Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.
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%.