Lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) refer to a group of medical symptoms, that affect approximately 40% of older men. LUTS is a recent term for what used to be known as prostatism.

Symptoms and signs

Symptoms can be categorised into:

Filling or irritative symptoms

• Increased frequency of urination
• Increased urgency of urination
• Painful urination
• Excessive passage of urine at night

Voiding or obstructive symptoms

• Poor stream
• Hesitancy
• Terminal dribbling
• Incomplete voiding
• Overflow incontinence (occurs in chronic retention)

As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer. Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis.

Causes

• Benign prostatic hyperplasia (BPH) with obstruction
• Detrusor muscle weakness and/or instability
• Urinary Tract Infection (UTI)
• Chronic prostatitis
• Urinary stone
• Malignancy: prostate or bladder
• Neurological disease, e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome

Diagnosis

The International Prostate Symptom Score (IPSS) can be used to gauge the symptoms, along with physician examination. Other primary and secondary tests are often carried out, such as a PSA (Prostate-specific antigen) test, urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy and/or cystoscopy.

Placement of a temporary prostatic stent as a differential diagnosis test can help identify whether LUTS symptoms are directly related to obstruction of the prostate or to other factors worth investigation.

ICD 9 CM

• 600.00 Hypertrophy (benign) of prostate w/o urinary obstruction and other lower urinary tract symptoms (LUTS)
• 600.01 Hypertrophy (benign) of prostate with urinary obstruction and other LUTS
• 600.20 Benign localized hyperplasia of prostate w/o urinary obstruction and other LUTS
• 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other LUTS
• 600.90 Hyperplasia of prostate, unspecified, w/o urinary obstruction and other LUTS
• 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other LUTS

Treatment

A number of techniques to destroy part or all of the prostate have been developed. First line of treatment is medical, which includes alpha-1 blockade and antiandrogens. If the medical treatment fails, surgical techniques are done. Techniques include:

• The best nowadays is TURP: trans-urethral removal of the prostate.
• Transurethral microwave thermotherapy
• Thermal ablation
• High intensity focused ultrasonography
• Transurethral needle ablation
• Laser prostatectomy.
• Intraurethral prostatic stenting and balloon dilatation of the prostate.

Other treatments include lifestyle advice , for example sitting down while urinating. A meta-analysis found that, for elderly males with LUTS:

• the post void residual volume (PVR, ml) was significantly decreased
• the maximum urinary flow (Qmax, ml/s) was increased, comparable with pharmacological intervention
• the voiding time (VT, s) was decreased

This urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.

Epidemiology

• Prevalence increases with age. The prevalence of nocturia in older men is about 78%. Older men have a higher incidence of LUTS than older women.

• Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.

• Once symptoms arise, their progress is variable and unpredictable with about one third of patients improving, one third remaining stable and one third deteriorating.

• It is estimated that the lifetime risk of developing microscopic prostate cancer is about 30%, developing clinical disease 10%, and dying from prostate cancer 3%.

References

• Speakman MJ, Kirby RS, Joyce A, Abrams P, Pocock R (May 2004). "Guideline for the primary care management of male lower urinary tract symptoms". BJU Int. 93 (7): 985–90. doi:10.1111/j.1464-410X.2004.04765.x. PMID 15142148.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Juliao AA, Plata M, Kazzazi A, Bostanci Y, Djavan B (January 2012). "American Urological Association and European Association of Urology guidelines in the management of benign prostatic hypertrophy: revisited". Current Opinion in Urology. 22 (1): 34–9. doi:10.1097/MOU.0b013e32834d8e87. PMID 22123290.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• NHS; Cancer Screening Programmes. Prostate Cancer Risk Management.