The term lower urinary tract symptoms (LUTS) was introduced almost 20 years ago, and covers of storage, voiding and post-micturition symptoms. These symptoms and their defining characteristics are described below:

It is important to remember that these symptoms are defined from the individual patient’s perspective; and so if not volunteered directly by the patient, sample questions to elicit a direct response are also suggested.

Individuals with LUTS often experience urinary incontinence or overactive bladder symptoms. Overactive bladder is a subset of storage LUTS currently defined by the International Continence Society as urgency, with or without urgency urinary incontinence, usually with frequency and nocturia.

There are a number of risk factors for LUTS including¹: 

increased serum dihydrotestosterone levels; obesity; elevated fasting glucose; diabetes; fat and red meat intake; and 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.²

LUTS are common, with prevalence rates estimated to be > 60% in individuals > 40 years of age; with women reporting storage symptoms more frequently than men, but men describing voiding and post-micturition symptoms more frequently than women.³

A great degree of these symptoms in men are attributed to benign prostatic hyperplasia (BPH). Prevalence of BPH is as high as 40% in men in their fifth decade and 90% in men in their ninth decade.⁴

Although the enlarged prostate can contribute to the onset of LUTS in men over 40, it is important to consider other causes or co-contributors as these are often of equal importance.¹ 

BPH is characterised by smooth muscle proliferation within the prostate; often accompanied by an increase in smooth muscle tone and this can result in bladder outlet obstruction (BOO). BPH is a histological diagnosis, whereas BOO is most frequently made clinically.

Bladder outlet obstruction in turn can lead to a variety of complications including urinary retention, recurrent urinary tract infections, renal impairment and bladder calculi.

Clinical assessment of benign prostatic hyperplasia 

History

Generally speaking, men will present initially complaining of voiding symptoms and storage symptoms. 

Voiding symptoms include: slow stream, interrupted stream, terminal dribbling, hesitancy and haematuria. Storage symptoms include: frequency, urgency and nocturia. 

Indeed, men may also present with symptoms related to complications of BPH and bladder outlet obstruction; such as presenting with supra-pubic pain from retention, or dysuria from a urinary tract infection (UTI). 

Other essential details to ascertain from a patient history include a sexual history (as LUTS have been identified as an independent risk factor for erectile dysfunction) as well as a family history of prostate and breast cancer.

Also, it is important to note that some men remain asymptomatic despite having chronic retention. In such cases it is particularly important to determine the amount of daily fluid intake and note all medications – prescription or otherwise.

Physical examination

Evaluation of BPH in men should include an abdominal examination, especially for an enlarged bladder, along with examining the penis, testes and a digital rectal examination (DRE) to assess the prostate. 

The size of the prostate should be assessed, its consistency (firm/rubbery/boggy/soft), and its contour (smooth, irregular, nodules, craggy). A useful guide to estimating prostate size is that each index-finger breadth that can be swept across the rectal surface of the prostate on DRE roughly equates to 15-20g of prostate tissue. The size is unimportant in determining the need for treatment, according to the Agency for Healthcare Policy and Research BPH treatment guideline.⁵ In fact, it recommends prostate size measurement as optional testing to plan an invasive procedure, and not to be used to determine the need for treatment.

Further assessments

Post-void residual volume (PVR) and urine flow rates should ideally be assessed as a baseline assessment. In the case of BPH these may reveal an obstructed picture, ie. an elevated residual volume and reduced flow rate. 

Urinalysis should be routinely performed to outrule infection as a source of the LUTS, or indeed UTI secondary to bladder outlet obstruction. 

Routine bloods can be sent to check the renal function for comparison with baseline, and if appropriate after patient counselling, the prostate specific antigen (PSA) level. 

PSA should be interpreted with caution in the context of recent infection, recent prostate biopsy or urogenital surgery, where the patient is or has recently been catheterised, following prolonged exercise, or indeed following ejaculation (which may result in elevated PSA for up to 48-72 hours). 

PSA levels can be elevated for a variety of conditions: prostate cancer, BPH, inflammation, infection and retention. PSA levels should only be checked with the consent of the patient as an elevated PSA can result in invasive investigations which some patients find distressing. If a patient has a high PSA or an abnormal DRE, then the option to refer to a urologist should be discussed. 

A urology specialist may offer a patient the option of having a transrectal ultrasound guided (TRUS) biopsy of the prostate to outrule a malignancy in men who have an elevated PSA-for-age, an abnormal DRE or a positive family history for prostate cancer. A TRUS biopsy carries with it a not-insignificant risk of various complications, including haematuria, retention, urinary tract infection and urosepsis.

Recently, PSA and its role in screening for prostate cancer has received much media attention. The Irish Society of Urology, in line with the American Urological Association, recommends that PSA testing should be a shared decision-making process between patient and physician where decisions are made on an individual basis. If PSA monitoring is the decided course of action, an interval of two years between measurements may be appropriate.⁶

The International Prostate Symptom Score (IPSS) is a short, validated and easy to perform questionnaire that assesses the storage (frequency, urgency and nocturia) and voiding (weak stream, intermittency, straining and the feeling of incomplete emptying) symptoms and their effect on quality of life. The patient grades the severity of each of these seven symptoms from 0-5. The maximum score is 35, scores between 0-7 are mildly symptomatic, 8-19 are moderately symptomatic and scores over 20 are severely symptomatic. IPSS is also a valuable tool for assessing a patient’s response to treatments over time. 

Treatment options

Conservative management options

There are a variety of treatment options available for men with LUTS. Where complications are absent and when men who do not feel that their LUTS are affecting their quality of life, a conservative approach can be taken. 

Conservative treatment options include lifestyle modifications accompanied by regular medical assessments with interval IPSS scores to ensure that the LUTS are not progressing. Such lifestyle modifications include engaging in regular moderate intensity exercise, reducing alcohol and caffeine intake, diet modifications, reducing fluid intake before going to bed and using a double-voiding technique when micturating.

Medical intervention

There are two main groups of medications used for the management of BPH, these are: alpha-blockers and  5-alpha reductase inhibitors. 

The alpha-blockers are alpha-adrenergic receptor antagonists. The bladder neck and proximal urethra have high concentrations of alpha1-adrenergic receptors. Overstimulation of the post-synaptic alpha1-adrenergic receptors results in the smooth muscle of the prostate to contract, along with contractions of the bladder neck and proximal urethra, thus, reducing the lumen and causing LUTS. The use of alpha-blockers inhibits this contraction. 

Common alpha-blockers include alfuzosin, tamsulosin and the newer silodosin which is highly selective in its alpha1-adrenoceptor antagonism.

Alpha-blockers can reduce the IPSS score by up to 30% and increase the urinary flow rate by up to 25%, although they will not reduce the size of a prostate.⁷ Side-effects of these medications vary but include orthostatic hypotension, retrograde ejaculation and also intraoperative floppy iris syndrome in patients undergoing cataract operations. As such, it is not advised to start an alpha-blocker for patients awaiting cataract surgery. Alpha-blockers result in an improvement in symptoms within four weeks.

5-alpha reductase inhibitors such as dutasteride and finasteride inhibit the conversion of testosterone to its active metabolite, dihydrotestosterone. Unlike alpha-blockers, the 5-alpha reductase inhibitors take much longer to take effect as they have apoptotic effects on prostate tissue and therefore reduce the size of the prostate. It can take at least three months until there is an improvement in symptoms. 

These medications can reduce the IPSS by up to 30%, reduce the size of the prostate by 25% and increase the flow rate.⁸ 5-alpha reductase inhibitors can also reduce the PSA level by up to 50%. This should be taken into account when interpreting a PSA test in this context; after six months of therapy with an 5-alpha reductase inhibitor, the result should be doubled to estimate the ‘true’ PSA. 

In the case of dutasteride, it is recommended DRE as well as other appropriate evaluations for prostate cancer must be performed on patients prior to initiating therapy, and then periodically therafter. The summary of product characteristics further recommends that patients should have a new PSA baseline established after six months of treatment with dutasteride. Any confirmed increase from lowest PSA level while on a 5-alpha reductase inhibitor may suggest either the presence of prostate cancer (particularly high-grade cancer) or non-compliance to therapy. Regardless of which, such an event should be carefully evaluated, even if those values are still within the normal range for men not taking a 5-alpha reductase inhibitor. 

Treatment with a 5-alpha reductase inhibitor does not interfere with the use of PSA as a tool to assist in the diagnosis of prostate cancer after a new baseline has been established. It is also important to note that total serum PSA levels return to baseline within six months of discontinuing treatment. 

5-alpha reductase inhibitors, but not alpha-blockers, can reduce the risk of acute urinary retention over time, and also reduce the risk of progression of BPH to a stage that would warrant surgical intervention.

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial and subsequently the CombAT (combination of Avodart and Tamsulosin) study, found that combination therapy with an alpha-blocker and a 5-alpha reductase inhibitor is more effective than using either drug alone to relieve symptoms and prevent BPH progression.^9,10

The two-drug regimen reduced the risk of BPH progression by 67%, compared with 39% for the alpha-blocker alone and 34% for the 5-alpha reductase inhibitor alone.⁹ It is important to remember that the same caveats with regard to PSA and prostate cancer monitoring must be adhered to when prescribing combination therapy as mono-5-alpha reductase inhibitor therapy.

In the case of more significant BOO/BPH, surgical intervention may be considered.

Surgical intervention

Surgical options for the treatment of BPH include: 

• Transurethral resection of the prostate (TURP) 
• Laser photoselective vaporisation of the prostate (PVP)  
• Open prostatectomy. 

TURP has the ability to improve LUTS by up to 70%.¹¹ Generally, men are admitted for up to three days and anticoagulants such as clopidogrel, warfarin and direct thrombin inhibitors must be stopped prior to surgery. Complications of this procedure include: haematuria, failed trial without catheter, UTIs, bladder neck stenosis, urethral stricture, retrograde ejaculation, TURP syndrome (hyponatraemia) and incontinence. 

Laser PVP can be performed as a day-case procedure with most patients having a successful trial without catheter on the next day of surgery. Laser PVP has similar complications to TURP; however, an advantage is that oral anticoagulants do not need to be stopped pre-operatively.¹² Another advantage is the cost; this procedure can be performed as a day-case and can also reduce inpatient stay, potentially saving the health service considerable costs. A disadvantage of this mode of treatment is that there is no tissue for histological analysis, thus, PSA and DRE should be performed and a TRUS biopsy may need to be performed if indicated prior to this procedure.

For men with very large prostates, an open prostatectomy is perhaps more appropriate. The development of the open prostatectomy procedure was pioneered by two Irish urologists, Sir Peter Freyer (1851-1921) and Mr Terence Millin (1903-1980). Freyer removed the prostate through an incision in the bladder, while Millin incised the prostate capsule and removed the prostate via blunt dissection with his fingers, a procedure still in clinical use 60 years later.

When to refer?

Refer men to specialist assessment if they have:

• Bothersome LUTS 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
• Visible (frank) haematuria and culture-negative dysuria

Summary

Lower urinary tract symptoms can have a significant negative effect on a man’s quality of life. The ‘triple assessment’ of LUTS in the primary care setting should include: 

• A careful history and physical examination; which in itself can suggest BOO and BPH as a possible cause.
• Urine analysis 
• Use of the IPSS questionnaire. 

Further optional investigations maybe performed if indicated, or the patient referred for specialist management. The IPSS is a valuable tool for monitoring a patient’s response to conservative, medical or surgical treatments over time. 

Referral to a urologist should be made for those men who fail initial management for BPH or prompt referral to a rapid access prostate assessment clinic should be made for those men with features suggestive of prostate carcinoma. 

References

1. Oelke M, Bachmann A, Descazeaud A, et al. Guidelines on the management of male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). In EAU Guidelines 2012, edition presented at the 27th EAU Annual Congress, Paris
2. Parsons JK. Benign prostatic hyperplasia and male lower urinary tract symptoms: epidemiology and risk factors. Current bladder dysfunction reports, 2012; 5(4): 212-218
3. Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. European urology, 2006; 50(6): 1306-1315
4. Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. The Journal of urology, 1984; 132(3): 474-479
5. McConnell JD, Barry MJ, Bruskewitz RC, et al. Clinical Practice Guideline Number 8: Benign Prostatic Hyperplasia: Diagnosis and Treatment. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1994. AHCPR publication 94-0582
6. Carter HB, Albertsen PC, Barry MJ, et al. Early Detection of Prostate Cancer: AUA Guideline. The Journal of urology, 2013
7. Van Kerrebroeck P, Jardin A, Van Cangh P, Laval KU. Long-term safety and efficacy of a once-daily formulation of alfuzosin 10 mg in patients with symptomatic benign prostatic hyperplasia: open-label extension study. European urology, 2002; 41(1): 54-61
8. Roehrborn CG, Boyle P, Nickel JC, Hoefner K, Andriole G. Efficacy and safety of a dual inhibitor of 5-alpha-reductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia. Urology, 2002; 60(3): 434-441
9. McConnell JD, Roehrborn CG, Bautista OM, et al. Medical Therapy of Prostatic Symptoms (MTOPS) Research Group. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med, 2003; 349(25): 2387-2398
10. Roehrborn CG, Siami P, Barkin J, et al. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. European urology, 2012; 57(1): 123-131
11. Madersbacher S, Marberger M. Is transurethral resection of the prostate still justified. BJU int, 1999; 83(3): 227-237
12. Sohn JH, Choi YS, Kim SJ, et al. Effectiveness and safety of photoselective vaporization of the prostate with the 120 W HPS greenlight laser in benign prostatic hyperplasia patients taking oral anticoagulants. Korean journal of urology, 2011; 52(3): 178-183
13. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub‐committee of the International Continence Society. Neurourology and urodynamics, 2002; 21(2): 167-178