LUTS Flashcards
Causes
Men:
BPH
Chronic prostatitis
Both:
UTI
Urological malignancy
Detrusor muscle weakness or instability
Urethral stricture
External compression e.g. pelvic tumour, faecal impaction
Neurological disease e.g. multiple sclerosis, spinal cord injury
Women:
Menopause
Lifestyle factors, including drinking fluids late at night, excess alcohol intake, and excess caffeine intake can exacerbate LUTS. Additionally, polyuria (for example secondary to diabetes mellitus, excessive fluid intake, diuretics) can exacerbate or mimic LUTS.
Types/symptoms
-Storage symptoms occur when the bladder should otherwise be storing urine, symptoms being urgency, frequency, nocturia, and urgency incontinence.
Increased urinary frequency
Nocturia
Increased sense of urgency to urinate
Urge incontinence
-Voiding symptoms occur usually due to bladder outlet obstruction making it more difficult to pass urine, therefore symptoms being hesitancy, intermittency, straining, terminal dribbling and incomplete emptying.
Hesitancy in micturition
Poor flow (<10mL/s)
Terminal dribble
Feeling of incomplete emptying
Ask about associated symptoms, such as visible haematuria, suprapubic discomfort, or colicky pain, and their medication history, as certain medication, including anticholinergics, antihistamines and bronchodilators, are known to exacerbate LUTS
Investigations
A digital rectal examination and / or examination of the external genitalia may be helpful, depending on the presentation.
The International Prostate Symptom Score can be a useful tool for assessing and monitoring the impact of LUTS on quality of life in men, both initially and throughout any treatment course
Post-void bladder scanning and flow rate can help distinguish between causes of LUTS(For example, in overactive bladder there will be a low post-void residual, whereas in BPH there will may be high post-void residual with a flow rate low), and help to quantify the severity of the condition in those presenting with voiding symptoms. A urinary frequency and volume chart is often useful in highlighting patterns of behaviour which may be contributing to symptoms.
Urinalysis assessing for signs of UTI predominantly, however also haematuria (e.g. bladder stones) or glycosuria (e.g. diabetes mellitus) may also aid in initial investigations. Urine culture should be sent to further investigate infection if relevant.
Routine blood tests, including FBC and U&Es, are useful as part of a baseline assessment, particularly if there is clinical suspicion of renal impairment or infection. Prostate-Specific Antigen (PSA) may be useful (after appropriate counselling) if there is clinical suspicion of prostatic pathology.
Specialist Investigations
Urodynamic studies can be used to assess flow rate, detrusor pressure, and storage capacity if indicated (for example, in patients where neurogenic bladder dysfunction is a differential). (flow rate and cysto-meterogram pressures)
Cystoscopy is the gold standard investigation for assessing the lower urinary tract and may be offered if clinically indicated, such as a history of recurrent infection or the presence of haematuria.
Upper urinary tract imaging, such as via ultrasound or CT scanning, may be useful if there is a history of chronic retention, history of recurrent infection, or the presence of haematuria.
Management
Initial management is usually treatment of the underlying pathology. However, there are a number of conservative measures that may be useful in the initial management of LUTS in some patients whilst investigation of the underlying cause is ongoing.
Regulating fluid intake, such as timing and volume of drinks consumed and reducing caffeinated and alcoholic beverages in evenings, is important for all patients.
Individuals suffering from voiding symptoms may benefit from urethral milking techniques* (manually emptying the bulbar urethra of residual urine) or double voiding (passing urine and then remaining for a short time before passing urine again)
Pelvic floor exercises to strengthen the pelvic floor are useful in cases of stress incontinence or post-micturition dribble.
Bladder training techniques, which aim to increase the duration between the urge to void and micturition, when done properly (under supervision) these may be useful in overactive bladder.
Anticholinergics (e.g. oxybutynin, tolterodine) for overactive bladder, helping to relax bladder muscle by opposing parasympathetic cholinergic control of contraction
Mirabegron, a β3 adrenergic agonist, may also be useful in managing overactive symptoms
Alpha blockers (e.g. alfuzosin, tamsulosin) and / or 5α-reductase inhibitors (e.g. finasteride) for BPH can help in reducing prostate size by relaxing prostatic muscle
Loop diuretics (e.g. furosemide, bumetanide), though unlicensed, may be taken mid-afternoon to prevent nocturia
Desmopressin is also unlicensed but has been shown to aid in reducing nocturia
Complications
Left untreated, progressive LUTS may increase the risk of infection and formation of renal and bladder calculi due to stagnation of urine.
Chronic obstruction may lead to bladder wall muscle hypertrophy or distention which can lead to overflow incontinence. Renal complications include renal failure and bilateral hydronephrosis.
Acute urinary retention may also occur in patients with progressive BPH.
Key points
LUTS in men are most commonly due to benign prostatic enlargement, whereas in women they are most commonly caused by urinary tract infection
The International Prostate Symptom Score is a useful tool for assessing and monitoring the impact of LUTS on quality of life in men, both initially and throughout any treatment course
Ruling out non-urological pathology that may mimic LUTS, such as polyuria secondary to diabetes mellitus, is important
