Urology- LUTS in men

Question 1

What are lower urinary tract symptoms (LUTS) in men?

Answer 1

Lower urinary tract symptoms (LUTS) can be grouped into storage, voiding, and post-micturition symptoms.

Question 2

What are storage symptoms?

Answer 2

• urgency (overactivity)
• urge incontinence (overactivity)
• Frequency
• Nocturia (night time frequency)

Question 3

What are voiding symptoms?

Answer 3

• hesitancy
• poor stream
• straining
• terminal dribble

Question 4

What are post-micturition symptoms?

Answer 4

• post-micturition dribble
• sensation of incomplete emptying

Question 5

Which common conditions in men cause LUTS?

Answer 5

• Benign prostatic hyperplasia (BPH) or Benign prostatic enlargement (BPE) - predominant voiding symptoms
• Overactive bladder- storage symptoms

Question 6

What are the possible causes of voiding LUTS?

Answer 6

• BPH/BPE - most common
• antimuscarinic drugs (TCAs, sedating antihistamines)
• Diabetic autonomic neuropathy
• urethral stricture, phimosis
• cancer of prostate, bladder, rectum

Question 7

What age do LUTS usually start?

Answer 7

testosterone causes the prostate to start enlarging in the 30s, which then continues throughout the man’s life. Symptoms usually start in their 60s.

However you can have a big prostate and no symptoms.
Symptoms in 30s should be investigated with cystoscopy.

Symptoms in 40s and 50s - try meds then refer if no better.

Question 8

What is the prognosis for men with LUTs?

Answer 8

• BPH and LUTS are common and increase with age
• Chance of needing any surgery is low (5%)
• 50% of men only need lifestyle changes. Some may resolve spontaneously
• A PSA (if done) of >1.4 indicates that BPH and LUTS symptoms will likely get worse.
• Complications: infection, acute retention, stones, renal impairment - uncommon
• Men with LUTS not at increased risk of advanced or fatal prostate Ca compared to men without LUTS

Question 9

How should I assess a man presenting with LUTS in primary care?

Answer 9

• History - storage and voiding symptoms. Use IPSS to establish LUTS severity (can be used to monitor symptoms)
• Examination - palpable bladder, DRE. Check size and consistency. Size should be a walnut. If ping pong ball = enlarged. Check consistency - should be firm (feel like tip of your nose), if soft (like your lips) - inflammation/abscess. If hard (like your forehead) - likely prostate cancer.

if prostate enlarged, normal consistency + LUTS = backs up diagnosis of BPH

• Always do urine dip - checking for blood (not normal in BPH), glucose, protein.
• Ask them to complete urinary frequency-volume chart for 3 days

Question 10

What do the IPSS scores indicate?

Answer 10

• Score 20–35: severely symptomatic. (usually need early surgery)
• Score 8–19: moderately symptomatic. (lifestyle/medication)
• Score 0–7: mildly symptomatic. (lifestyle mx)

Question 11

When should U&Es be done in men with LUTS?

Answer 11

• palpable bladder or enuresis - signs of chronic urinary retention
• recurrent UTIs
• hx of renal stones
• hx of renal disease

Question 12

When should PSA be done?

Answer 12

• if prostate feels abnormal on DRE
• If man is concerned re cancer
• to guide BPH treatment (if >1.4 - likely to get worse) - but only once man is counselled.

Question 13

What lifestyle advice should be given to men with LUTS?

Answer 13

• urethral milking (if dampness after putting penis in pants - massage behing scrotum towards tip - urine still in U-bend)
• Reducing caffeine should reduce storage symptoms (bladder spasm). Reduce alcohol.
• Reduce fluid intake in evening (not drinking after 6pm)
• Avoid constipation
• pelvic floor muscle training
• Bladder drill - for frequency e.g put it off when need a wee. Try to last 30 mins then increase to an hour. Or go by the clock (if going every hour, try to go every 2 hours instead)
• containment products - sheath, pads. can refer continence service.

Question 14

Which medications should be offered in men with LUTs, and in what order?

Answer 14

1. alpha blocker e.g tamsulosin- relax SM in bladder neck and urethra. Effect within hours, but long term stop working as well. (avoid if postural drop)
2. Add in 5-Alpha reductase inhibitors (5-ARIs) e.g. finasteride.
3. Add in anti-cholinergic e.g oxybutynin. If storage symptoms. Avoid in frail elderly - risk of confusion - can use mirabegron instead
4. PDE-5 inhibitors for men with LUTs and ED.

review 4-6 weeks after starting treatment then every 6-12 monhts once stable. Repeat IPSS questionnaire

Question 15

When should men with LUTs be referred to urology?

Answer 15

• medications tried but still bothered or getting worse
• recurrent UTIs
• Haematuria
• Bladder pain (may have stones and need operative intervention)
  *

Question 16

What are the contraindications and cautions for anti-cholinergics (anti-muscarinics)?

Answer 16

• Gastrointestinal obstruction or intestinal atony.
• Myasthenia gravis.
• Pyloric stenosis.
• Severe ulcerative colitis.
• Significant bladder outflow obstruction or urinary retention.
• Severe hepatic impairment — manufacturer advises caution for oxybutynin; flavoxate can be used.

Question 17

What are the adverse effects of antimuscarinics?

Answer 17

• confusion (in elderly)
• constipation
• dry mouth
• flushing
• palpitations
• vision disorders, dry eyes, mydriasis (dilated pupils)

Question 18

What should patients be informed about PSA testing?

Answer 18

• no screening for prostate cancer in the UK
• the test is unreliable, lots of false positives (3 in 4)
• 1 in 7 are false-negatives (falsely reassured)
• if positive, the GP has to refer to urology
• this can cause anxiety and unnecessary testing (MRI +/- biopsy)
• PSA can pick up aggresive but also slow growing prostate Ca. This can be slow-growing and never cause symptoms, or shorten life. May receive unecesary treatment

Question 19

What can cause the PSA to rise before a test ?

Answer 19

• PSA is raised until 6 weeks after a UTI or prostatitis, or prostate biopsy.
• self catheterisation
• ejaculation in last 48 hours
• heavy exercise in last 48 hours
• having BPH