Lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. Although LUTS is a preferred term for prostatism,[1] and is more commonly applied to men,[2] lower urinary tract symptoms also affect women.[3]

"LUTS" redirects here. For other uses, see Luts.
Lower urinary tract symptoms
Other namesLUTS, prostatism
SpecialtyUrology

LUTS affect approximately 40% of older men.[4]

Symptoms and signs

Symptoms can be categorised into:

[5]Filling (storage) or irritative symptoms

Voiding or obstructive symptoms
  • Poor stream (unimproved by straining)[5]
  • Hesitancy (worsened if bladder is very full)[5]
  • Terminal dribbling
  • Incomplete voiding
  • Urinary retention
  • Overflow incontinence (occurs in chronic retention)
  • Episodes of near retention

As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer.[1][5] Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis.[6] Also, recently a report of lower urinary tract symptoms even with malignant features in the prostate failed to be associated with prostate cancer after further laboratory investigation of the biopsy.[5]

Causes

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,[5][11] urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy[5] 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.[5]

Treatment

Treatment will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given.[5]

With prostatic causes of LUTS; the first line of treatment is medical, which includes alpha-1 blockade and antiandrogens. If medical treatment fails, or is not an option; a number of surgical techniques to destroy part or all of the prostate have been developed.

Surgical treatment

Surgical treatment of LUTS can include:

Lifestyle changes

Other treatments include lifestyle advice; for example, avoiding dehydration in recurrent cystitis.

Men with prostatic hypertrophy are advised to sit down whilst urinating.[15] A 2014 meta-analysis found that, for elderly males with LUTS, sitting to urinate meant there was a decrease in post-void residual volume (PVR, ml), increased maximum urinary flow (Qmax, ml/s), which is comparable with pharmacological intervention, and decreased the voiding time (VT, s).[16] The improved urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.[16]

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.[17]
  • Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.[18]
  • 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.
  • 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.
  • NHS; Cancer Screening Programmes. Prostate Cancer Risk Management.
  1. Abrams P (April 1994). "New words for old: lower urinary tract symptoms for "prostatism"". BMJ. 308 (6934): 929–30. doi:10.1136/bmj.308.6934.929. PMC 2539789. PMID 8173393.
  2. "Lower Urinary Tract Symptoms in Women | Doctor". patient.info. Retrieved 7 September 2017.
  3. Takahashi, Satoru; Takei, Mineo; Nishizawa, Osamu; Yamaguchi, Osamu; Kato, Kumiko; Gotoh, Momokazu; Yoshimura, Yasukuni; Takeyama, Masami; Ozawa, Hideo; Shimada, Makoto; Yamanishi, Tomonori; Yoshida, Masaki; Tomoe, Hikaru; Yokoyama, Osamu; Koyama, Masayasu (1 January 2016). "Clinical Guideline for Female Lower Urinary Tract Symptoms". LUTS: Lower Urinary Tract Symptoms. 8 (1): 5–29. doi:10.1111/luts.12111. ISSN 1757-5672. PMID 26789539.
  4. RoehrbornCG and McConnell JD: Etiology, pathophusiology, epidemiology, and natural history of benign prostatic hyperplasia. Campell's Urology. WB Saunders Co 2002; chapt 38, p1309.
  5. Eziyi, Amogu K.; Oluogun, Waheed A.; Adedokun, Kamoru A.; Oyeniyi, Ganiyu A. (2020-01-01). "Prostate tuberculosis: A rare complication of pulmonary tuberculosis with malignant features mimicking prostate cancer". Urological Science. 31 (1): 36. doi:10.4103/UROS.UROS_80_19. ISSN 1879-5226.
  6. Clinical Knowledge Summary; Urological cancer — suspected
  7. Winstock, Adam R.; Mitcheson, Luke; Gillatt, David A.; Cottrell, Angela M. (2012). "The prevalence and natural history of urinary symptoms among recreational ketamine users". BJU International. 110 (11): 1762–1766. doi:10.1111/j.1464-410X.2012.11028.x. PMID 22416998.
  8. Rodolfo Montironi; Marina Scarpelli; Liang Cheng; Antonio Lopez-Beltran; Maurizio Burattini; Ziya Kirkali; Francesco Montorsi (December 2013). "Immunoglobulin G4-related disease in genitourinary organs: an emerging fibroinflammatory entity often misdiagnosed preoperatively as cancer". European Urology. 64 (1): 865–872. doi:10.1016/j.eururo.2012.11.056. PMID 23266239.
  9. Yoshimura Y, Takeda S, Ieki Y, Takazakura E, Koizumi H, Takagawa K (1 Sep 2006). "IgG4-associated prostatitis complicating autoimmune pancreatitis". Internal Medicine. 45 (15): 897–901. doi:10.2169/internalmedicine.45.1752. PMID 16946571.
  10. Nishimori I, Kohsaki T, Onishi S, Shuin T, Kohsaki S, Ogawa Y, Matsumoto M, Hiroi M, Hamano H, Kawa S (17 Dec 2007). "IgG4-related autoimmune prostatitis: two cases with or without autoimmune pancreatitis". Internal Medicine. 46 (24): 1983–1989. doi:10.2169/internalmedicine.46.0452. PMID 18084121.
  11. The Prostate-Specific Antigen (PSA) Test: Q & A — National Cancer Institute
  12. Kramer, MW; Wolters, M; Cash, H; Jutzi, S; Imkamp, F; Kuczyk, MA; Merseburger, AS; Herrmann, TR (April 2015). "Current evidence of transurethral Ho:YAG and Tm:YAG treatment of bladder cancer: update 2014". World Journal of Urology. 33 (4): 571–9. doi:10.1007/s00345-014-1337-y. PMID 24935098.
  13. Elshal, AM; Elmansy, HM; Elhilali, MM (March 2013). "Transurethral laser surgery for benign prostate hyperplasia in octogenarians: safety and outcomes". Urology. 81 (3): 634–9. doi:10.1016/j.urology.2012.11.042. PMID 23332997.
  14. Fitzpatrick JM. Non-surgical treatment of BPH. Edinburgh: Churchill Livingstone, 1992.
  15. Y. de Jong; R.M. ten Brinck; J.H.F.M. Pinckaers; A.A.B. Lycklama à Nijeholt. "Influence of voiding posture on urodynamic parameters in men: a literature review" (PDF). Nederlands Tijdschrift voor urologie. Retrieved 2014-07-02.
  16. de Jong, Y; Pinckaers, JH; Ten Brinck, RM; Lycklama À Nijeholt, AA; Dekkers, OM (2014). "Urinating Standing versus Sitting: Position Is of Influence in Men with Prostate Enlargement. A Systematic Review and Meta-Analysis". PLOS ONE. 9 (7): e101320. Bibcode:2014PLoSO...9j1320D. doi:10.1371/journal.pone.0101320. PMC 4106761. PMID 25051345.
  17. Boyle P, Robertson C, Mazzetta C, et al. (September 2003). "The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study". BJU Int. 92 (4): 409–14. doi:10.1046/j.1464-410x.2003.04369.x. PMID 12930430.
  18. Enlarged prostate gland —treatment, symptoms and cause
Classification

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