Lower Urinary Tract Symptoms In Men: Management
This guideline covers managing lower urinary tract symptoms in men over 18. It aims to improve the quality of life for men with LUTS by recommending which assessments they should receive, and when conservative management, drug treatment and surgery can help.
In, we reviewed the evidence for phosophodiesterase-5 inhibitors, and added recommendation 1.4.10 on when to use them. We also added a recommendation for research on the clinical and cost effectiveness of phosophodiesterase-5 inhibitors in men who do not have erectile dysfunction.
Health Effects Of Luts
LUTS can be a significant source of bother for some people. LUTS might make you reluctant to leave your house or socialise because of the inconvenience of needing to go to the toilet often or in a hurry.
LUTS can make you anxious and depressed and impact your personal relationships.
Urinary retention can be painful and can lead to urinary tract infections and damage to the bladder or kidneys.
LUTS can be a sign of a serious underlying condition, so itâs really important to see your doctor if you have any urinary symptoms.
Prevalence Burden And Treatment Of Lower Urinary Tract Symptoms In Men Aged 50 And Older: A Systematic Review Of The Literature
- John E. Morley and more…Encyclopedia of Health & Aging
- Encyclopedia of Cancer and Society2007
- The SAGE Encyclopedia of Psychology and Gender2017
- Handbook on Communicating and Disseminating Behavioral Science2007
- The SAGE Encyclopedia of Cancer and Society2015
- The SAGE Encyclopedia of Cancer and Society2015
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Background And Objectives For The Systematic Review
Benign Prostatic Hyperplasia is a “histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.”1 Men are likely to develop BPH as they age. Half of men ages 51 60 years old and 80 percent of men over 80 years old have BPH according to autopsy data.2
About half of men with BPH develop an enlarged prostate gland, called benign prostatic enlargement , and among these, about half develop bladder outlet obstruction .3 BOO and/or changes in smooth muscle tone and resistance that can accompany BPH often result in lower urinary tract symptoms .1 LUTS are storage disturbances, such as daytime urinary urgency and nocturia, and/or voiding disturbances, such as urinary hesitancy, weak stream, straining, and prolonged voiding.2 LUTS affect an estimated three percent of men ages 4549 years old and 30 percent of men over 85 years old.2 Urinary hesitancy, weak stream, and nocturia are the most commonly reported LUTS.4 BPH/LUTS negatively impact quality of life2,3 and cost the United States over $1 billion annually.3
Monotherapy with 5-ARI agents finasteride and dutasteride is another option for LUTS/BPH and BPE.7 Systematic reviews demonstrate that 5-ARIs are safe and effective13,14 and may be better than ABs in preventing disease progression .14
Applicability Of Uroflowmetry In Children With Cerebral Palsy
Until now, the use of invasive urodynamics with use of catheters is still the gold standard for lower urinary tract evaluation in subjects with CP. This suggests a psychological and physical impact of invasive urodynamics in subjects with CP and further demonstrates the need to avoid standard use of invasive urodynamics in children and adults with CP.The current study will evaluate usefulness of uroflowmetry, correlation between uroflowmetry parameters and different lower urinary tract symptom …
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Box : Reasons Why Interpreting Psa Results Can Be Difficult7
- An increased serum PSA level can be present with:
- prostate enlargement
PSA=prostate-specific antigen CKS=clinical knowledge summary
© NICE 2019. LUTS in men: what investigations should I arrange for a man presenting with lower urinary tract symptoms? Available from: cks.nice.org.uk/topics/luts-in-men/diagnosis/investigations All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
Prevalence Of Urinary Symptoms
At least one of the three symptoms was reported by 536 respondents. The distribution of each reported symptom in the cohort is shown in Table 1. The prevalence rate increased significantly from 20% in the 4049 year olds, to 28% in the 7080 year olds . Post-micturition dribbling was the most frequent urinary symptom, with 21% of the men reporting this condition. This symptom occurred at a fairly constant rate across the different age groups. Urgency was reported 15 times more often in the 7080 age range than in the 4049 range . In the 536 men with urinary symptoms, 433 reported one symptom, 80 reported two symptoms and 23 reported all three symptoms. The mean age in men with one, two or three symptoms was 56, 61 and 67 years, respectively. The percentage of individuals who reported two or three symptoms was 1.6, 4, 7.6 and 9.5%, respectively, in the four age groups 4049, 5059, 6069 and 7080 years.
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Box : Causes Of Voiding Luts3
- Benign prostatic hyperplasia or benign prostatic enlargementthe most common cause of voiding symptoms
- Drugs with an antimuscarinic action
- Diabetic autonomic neuropathy and neurogenic bladder
- Urethral stricture and phimosis
- Cancer of the prostate, bladder, or rectum.
© NICE 2019. LUTS in men: what causes it? Available from: cks.nice.org.uk/topics/luts-in-men/background-information/causes-of-luts All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.
It is important to ask about red-flag symptoms to exclude diagnoses such as urological cancer .4 Specific questions about haematuria, weight loss, and bone pain are useful, and a digital rectal examination should be performed to assess whether:5
- the prostate is of normal size or enlarged, and whether any enlargement is diffuse, with a palpable median sulcus
- the prostate is hard or irregular with an impalpable sulcus
- there are nodules or tenderness.
Referral For Specialist Assessment
Refer men for specialist assessment if they have:
- Bothersome lower urinary tract symptoms that have not responded to conservative management or drug treatment.
- LUTS complicated by recurrent or persistent UTIs.
- Urinary retention.
- Renal impairment thought to be due to lower urinary tract dysfunction.
- Suspected urological cancer.
- Stress urinary incontinence.
Other indications for referral include immediate referral for acute retention of urine and acute kidney injury and urgent referral for visible haematuria and culture-negative dysuria.
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D Assessment Of Methodological Risk Of Bias Of Individual Studies
Risk of bias of eligible studies will be assessed using instruments specific to RCTs. We will develop an instrument based upon AHRQ guidance.20 Relevant items will include participant selection, method of randomization, attrition, blinding, allocation concealment, and appropriateness of analytic methods.
One investigator will independently assess risk of bias for eligible studies a second investigator will review the risk of bias assessment. Investigators will consult to reconcile any discrepancies in overall risk of bias assessments. Overall summary risk of bias assessments for each study will be classified as low, moderate, or high based upon the collective risk of bias inherent in each domain and confidence that the study results are believable given the study’s limitations.
B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions
We will search Ovid Medline, Ovid PsycInfo, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials for primary health outcomes published and indexed in bibliographic databases. We will attempt to assess long-term or rare harms with nonrandomized controlled trials and large controlled observational studies if RCTs are not available. Our search strategy includes relevant medical subject headings and natural language terms for LUTS/BPH . These concepts were combined with filters to select trials. We will supplement the bibliographic database search with forward and backward citation searching of relevant systematic reviews and other key references. We will update searches while the draft report is under public/peer review.
We will search for grey literature in ClinicalTrials.gov and to identify completed and ongoing studies. We will search for conference abstracts from the past three years to identify ongoing studies. Grey literature search results will be used to identify studies, outcomes, and analyses not reported in the published literature. Information from grey literature will also be used to assess publication and reporting bias and inform future research needs. Additional grey literature will be solicited through a notice posted in the Federal Register and Scientific Information Packets and other information solicited through the AHRQ Effective Health Care Web site.
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Papers Of Particular Interest Published Recently Have Been Highlighted As: Of Major Importance
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003.
de Groat WC, Yoshimura N. Anatomy and physiology of the lower urinary tract. Handb Clin Neurol. 2015.
Andersson KE, Arner A. Urinary bladder contraction and relaxation: physiology and pathophysiology. Physiol Rev. 2004.
Wein AJ, Kavoussi LR, Partin AW, Peters CA. Campbell-Walsh urology 12th edition. Elsevier. 2015 2.
Wein AJ, Kavoussi LR, Partin AW, Peters CA. Campbell-Walsh urology 11th edition. Elsevier. 2015 2.
McAninch JW, Lue TF. Smith & Tanaghos general urology. McGraw-Hill. 2013.
Kelly CE. Evaluation of voiding dysfunction and measurement of bladder volume. Rev Urol. 2004 6:1.
Mangat R, Ho HSS, Kuo TLC. Non-invasive evaluation of lower urinary tract symptoms in men. Asian J Urol. 2018.
Klingler HC, Madersbacher S, Djavan B, Schatzl G, Marberger M, Schmidbauer CP. Morbidity of the evaluation of the lower urinary tract with transurethral multichannel pressure-flow studies. J Urol. 1998 159.
Digesu GA, Gargasole C, Hendricken C, Gore M, Kocjancic E, Khullar V, et al. ICS teaching module: ambulatory urodynamic monitoring. Neurourol Urodyn. 2017 36.
Kocher NJ, Damaser MS, Gill BC. Advances in ambulatory urodynamics. Curr Urol Rep. 2020.
Paduch DA. Viral lower urinary tract infections. Curr Urol Rep. 2007.
Does The Prostate Mediate Luts
Despite the observation that both men and women develop LUTS, the unequivocal effectiveness of transurethral resection of the prostate strongly suggests that the prostate and/or prostatic urethra must play an important role in the pathophysiology of clinical BPH. Schwartz and Lepor14 have also demonstrated that in men with clinically localized prostate cancer and LUTS, radical prostatectomy has the same beneficial effect on symptoms as does TURP. This provides further evidence that the prostate is an important factor in the pathophysiology of LUTS in men.
Lepor and Rigaud15 reported the treatment outcome for 30 men with clinical BPH undergoing TURP. Overall, 87% of the patients experienced marked or moderate improvement in their symptomatology. In this prospective study, the relationship between changes in peak flow rate and changes in obstructive symptom score was not statistically significant . Similarly, changes in peak flow rate versus changes in irritative symptom score were not statistically significantly . Schaeffer has reported that symptom improvement following prostatectomy is equivalent in men with and without pressure flow evidence of bladder outlet obstruction. These studies suggest that TURP relieves LUTS and decreases bladder outlet obstruction via independent mechanisms.
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Appendix A: Search Strategy
Consultation For Voiding Difficulties
Only 96 respondents had sought health care for voiding difficulties in the 12 months prior to the start of the present study. About half of these reported urgency, stress incontinence or dribbling. The percentage of consultations among men with one, two or three symptoms was 6% , 19% and 35% , respectively. Men of 6080 years of age had sought the help of health care providers significantly more often than men of 4059 years of age .
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Uti Causes And Risk Factors
The most common cause of a UTI in the urethra is a sexually transmitted disease. Chlamydia and gonorrhea are two STDs that can cause a UTI. STDs are also the most common cause of UTIs in younger men.
Prostate problems can also cause UTIs. An enlarged prostate is common in older men and can block the flow of urine. This can increase the odds that bacteria will build up and cause a UTI.
Prostatitis, which is an infection of the prostate, shares many of the same symptoms as UTIs.
Diabetes and other medical issues that affect your immune system can also make you more likely to get a UTI.
Prostate Artery Embolization: Single Center Experience
Benign prostatic hyperplasia is an enlarged prostate gland from smooth muscle and glandular hyperplasia seen in the aging population with a prevalence of upto 90% in patients in the ninth decade. Lower urinary tract symptoms and bladder outlet obstruction are the most common presenting symptoms of BPH. Patients are initially evaluated with a complete history and physical exam to rule out other causes of LUTS and assess the severity of LUTS with scoring systems such as the Amer …
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Risk Factors For Lower Urinary Tract Symptoms
Risk factors associated with lower urinary tract symptoms include:
- Increased serum dihydrotestosterone levels.
- Fat and red meat intake.
- Inflammation, which increases the risk.
Vegetables, exercise and non-steroidal anti-inflammatory drugs appear to decrease the risk. Moderate alcohol intake appears to decrease the risk of BPH but increases the risk of developing LUTS.
Read This Article To Learn More About:
Dr Toni Hazell
- common symptoms and causes of lower urinary tract symptoms in men
- investigations for and management of LUTS in primary care
- red flags for referral for suspected bladder or prostate cancer.
Read this article at: GinP.co.uk/455950.article
Lower urinary tract symptoms are common in primary care, and their prevalence increases with age.1 Most elderly men have LUTS to some degree, but symptoms only cause problems in around 30% of men aged over 65 years.1 Many men with LUTS are concerned about prostate cancerit is reassuring, therefore, to know that men who report LUTS are not at increased risk of advanced or fatal prostate cancer compared with men without LUTS, and that few will experience complications such as urinary retention or kidney stones.2
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Box : Nice Criteria For Suspected Prostate Cancer And Bladder Cancer4
- Refer men using a suspected cancer pathway referral for prostate cancer if their prostate feels malignant on digital rectal examination
- Consider a prostate-specific antigen test and digital rectal examination to assess for prostate cancer in men with:
- any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency, or retention, or
- erectile dysfunction, or
- visible haematuria
- Refer people using a suspected cancer pathway referral for bladder cancer if they are:
- aged 45 and have:
- unexplained visible haematuria without urinary tract infection, or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
Study Screening And Data Extraction
The titles and abstracts were screened independently by two authors, and then the full texts of the relevant studies were reviewed later. The reference lists of relevant articles were hand-searched. Two authors independently extracted and cross-checked the following data: first author, publication year, nation, age, study type, sample size, criteria of LUTS severity categories, assessment tools for LUTS and sexual function, and diagnosis criteria of sexual dysfunction. Any disagreements were discussed by the two authors or sought help from the third author.
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Applicability And Response Rates
Two hundred and third three subjects were recruited for pilot psychometric testing of the IPSS HKv2. Five subjects could not complete the questionnaire. 98% of the data was analyzable. Baseline characteristics of study subjects are shown in Table 1. The mean time taken to complete the IPSS HKv2 was 2.40 minutes. The subject recruitment flowchart is shown in Figure 1.
How Are Luts Treated
Treatment options for lower urinary tract symptoms depend on the cause and how the symptoms affect your life.
Your healthcare provider may recommend lifestyle changes such as:
- Adjusting the amount of fluids you drink or the times of day you consume liquids.
- Changing certain medications you take.
- Going to the bathroom at scheduled intervals throughout the day.
- Limiting or eliminating nicotine, caffeineand alcohol.
- Strengthening your pelvic floor muscles with Kegel exercises.
Various medications may be used to treat LUTS, including:
- 5-alpha reductase inhibitors, such as finasteride and dutasteride.
- Antibiotics to treat infections.
- Alpha-blockers that can relax your bladder, such as alfuzosin or tamsulosin.
- Antihypertensives to relax the blood vessels, such as doxazosin and terazosin.
- Bladder antispasmodics, such as oxybutynin and mirabegron.
Other causes of LUTS may be treated surgically. For example, if theres an obstruction, you may need an operation to remove whatevers causing the blockage. If your prostate is enlarged, your healthcare provider might recommend a procedure to remove part of it.
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