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lower urinary tract symptom (LUTS, prostatism)

Etiology: - causes of outflow obstruction - benign prostatic hyperplasia - urethral stricture - increased urine flow (polyuria) - diuretics - hyperglycemia - hypercalcemia - polydypsia - detrusor overactivity (overactive bladder) - older age - irritation - urinary tract infection - caffeine, spices, alcohol, carbonation - benign prostatic hypertrophy - bladder stones - urethritis - prostatitis, prostate cancer, bladder cancer - neurogenic bladder - spinal cord injury - Parkinson's disease - obstructive sleep apnea - exacerbation by medications - bronchodilators - antidepressants - diuretics - anticholinergics - antihistamines - nasal decongestants [19] - opioids - surgical procedure that may affect innervation of the bladder or urethral sphincter [19] Epidemiology: - up to 30% of men > 50 years of age - > 50% of men > 60 years of age [19] Physical examination: - prostate exam (digital rectal examination) - assess prostate size, contour, rectal spinchter tone, perineal sensation - lower abdominal exam Clinical manifestations: - irritative symptoms (overactive bladder) - urinary frequency - urinary urgency - nocturia - urge incontinence - obstructive symptoms - urinary hesitancy, difficulty initiating urination - straining - a weak urinary stream, prolonged urination, dribbling - urinary retention - sensation of incomplete bladder emptying - bladder fullness, palpable bladder [17] - overflow incontinence Laboratory: - urinalysis a) pyuria suggests infection b) hematuria may be sign of: infection, malignancy c) glycosuria suggests poorly-controlled diabetes mellitus d) trumps PVR even in the absence signs/symptoms of UTI [17] - ref [17] cites 'active urine sediment' as indicator of postobstructive uropathy - prostate-specific antigen in serum Special laboratory: - International Prostate Symptom Score or AUA symptom index to assess severity - postvoid residual (PVR) in men (prior to discontinuation of medications) [3] - urodynamics & cystoscopy as indicated Differential diagnosis: - chronic pelvic pain syndrome - benign prostatic hyperplasia Management: - see BPH - no treatment for AUA symptom index interpreted as mild disease (< 8) [17] - lifestyle modification* for AUA symptom index < 8 [3] - control urinary urgency with pelvic floor muscle contraction - avoid rushing to rest room - prompted voiding for patients with dementia - sit to void to empty more completely [19] - sleep hygiene [21] - pharmaceutical management - tamsulosin - do not use in combination with prazosin [19] - residual symptoms of urinary urgency & urinary incontinence due to overactive bladder may respond to antimuscarinic agent or mirabegron - fesoterodine (or other parasympatholytic) may be used with tamsulosin [15] - tolterodine is another parasympatholytic for use with tamsulosin [19] - solifenacin use with tamsulosin reduces prostate volume & vascularity [22] - dutasteride or finasteride with delayed effectiveness for large prostate - withdrawal of tamsulosin from combined tamsulosin/dustateride therapy after 12 months does not exacerbate symptoms [16] - tadalafil also used for BPH - antimuscarinic agent or mirabegron preferable add-on to tamsulosin especially if symptoms of overactive bladder [19] - Botox no better than placebo [5] - referral to urology - suspected prostate cancer - hematuria - recurrent urinary tract infections - urinary retention - urethral stricture (history or risk of) - neurogenic bladder - abnormal serum PSA - refractory LUTS * additional suggested lifestyle modifications include: - reduce fluid intake - correct constipation - increase frequency of voiding to empty bladder [3]

Related

urinary tract

General

sign/symptom

References

  1. Wuerstle MC, Van Den Edden SK, Poon T, et al. Contribution of common medications to lower urinary tract symptoms in men. Arch Intern Med 2011; 171(18):1680-1682 PMID: 21987200
  2. Roehrborn CG. Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). Med Clin North Am. 2011 Jan;95(1):87-100. Review. PMID: 21095413
  3. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Deprecated reference
  5. McVary KT et al. A multicenter, randomized, double-blind, placebo controlled study of onabotulinumtoxinA 200 U to treat lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2014 Jul; 192:150. PMID: 24508634 http://www.jurology.com/article/S0022-5347%2814%2900249-3/abstract
  6. Rees J, Bultitude M, Challacombe B The management of lower urinary tract symptoms in men. BMJ. 2014 Jun 24;348:g3861 PMID: 24963071
  7. Gani J, Perlis N, Radomski SB. Urologic medications and ophthalmologic side effects: a review. Can Urol Assoc J. 2012 Feb;6(1):53-8. PMID: 22396371 Free PMC Article
  8. Silva J, Silva CM, Cruz F. Current medical treatment of lower urinary tract symptoms/BPH: do we have a standard? Curr Opin Urol. 2014 Jan;24(1):21-8. Review. PMID: 24231531
  9. Wang X, Wang X, Li S, Meng Z, Liu T, Zhang X. Comparative effectiveness of oral drug therapies for lower urinary tract symptoms due to benign prostatic hyperplasia: a systematic review and network meta-analysis. PLoS One. 2014 Sep 12;9(9):e107593. PMID: 25216271 Free PMC Article
  10. Jefferies M, Cox A, Bennett A, Kynaston H. Management of lower urinary tract symptoms in men. Br J Hosp Med (Lond). 2013 Sep;74(9):518-22. Review. PMID: 24022553
  11. Radomski SB. Update on medical therapy for male LUTS. Can Urol Assoc J. 2014 Jul;8(7-8 Suppl 5):S148-50. Review. PMID: 25243039 Free PMC Article
  12. Chapple CR. A Comparison of Varying alpha-Blockers and Other Pharmacotherapy Options for Lower Urinary Tract Symptoms. Rev Urol. 2005;7 Suppl 4:S22-30. PMID: 16986051 Free PMC Article
  13. Komninos C, Mitsogiannis I. Obstruction-induced alterations within the urinary bladder and their role in the pathophysiology of lower urinary tract symptomatology. Can Urol Assoc J. 2014 Jul;8(7-8):E524-30. Review. PMID: 25210556 Free PMC Article
  14. Lee SH, Lee JY. Current role of treatment in men with lower urinary tract symptoms combined with overactive bladder. Prostate Int. 2014;2(2):43-9. Review. PMID: 25032191 Free PMC Article
  15. Oelke M, Becher K, Castro-Diaz D, et al. Appropriateness of oral drugs for long-term treatment of lower urinary tract symptoms in older persons: results of a systematic literature review and international consensus validation process (LUTS-FORTA 2014). Age Ageing. 2015;44(5):745-755 PMID: 26104505 Free PMC Article
  16. Matsukawa Y, Takai S, Funahashi Y et al Effects of Withdrawing alpha1-Blocker from Combination Therapy with alpha1-Blocker and 5alpha-Reductase Inhibitor in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: A Prospective and Comparative Trial Using Urodynamics. J Urol. 2017 Oct;198(4):905-912. Epub 2017 May 10. PMID: 28499730
  17. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022.
  18. Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med 2012 Jul 20; 367:248 PMID: 22808960 https://www.nejm.org/doi/full/10.1056/NEJMcp1106637
  19. Lightner DJ, Gomelsky A, Souter L, et al. Diagnosis and treatment of overactive bladder (Non-neurogenic) in adults: AUA/SUFU guideline amendment 2019. J Urol. 2019;202:558-563. PMID: 31039103
  20. Talebraza S et al Geriatrics Evaluation & Management Tools American Geriatrics Society. 2021 https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007/
  21. Drake MJ et al. Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: Cluster randomised controlled trial. BMJ 2023 Nov 15; 383:e075219. PMID: 37967894 PMCID: PMC10646682 Free PMC article https://www.bmj.com/content/383/bmj-2023-075219
  22. Sakalis V, Sfiggas V, Vouros I, et al. Combination of solifenacin with tamsulosin reduces prostate volume and vascularity as opposed to tamsulosin monotherapy in patients with benign prostate enlargement and overactive bladder symptoms: results from a randomized pilot study. Int J Urol. 2018;25(8):737-745 PMID: 30008188 https://onlinelibrary.wiley.com/doi/10.1111/iju.13721
  23. Lerner LB, McVary KT, Barry MJ et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART I - Initial work-up and medical management. J Urol 2021 Oct; 206:806-817. PMID: 34384237 https://www.auajournals.org/doi/10.1097/JU.0000000000002183 - Lerner LB, McVary KT, Barry MJ et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA GUIDELINE PART II - Surgical evaluation and treatment. J Urol 2021 Oct; 206:818 PMID: 34384236 https://www.auajournals.org/doi/10.1097/JU.0000000000002184
  24. Sandhu JS, Bixler BR, Dahm P et al Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol. 2024 Jan;211(1):11-19. PMID: 37706750