lower urinary tract symptom (LUTS, prostatism)
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Etiology
- causes of outflow obstruction
- increased urine flow (polyuria)
- detrusor overactivity
- older age
- irritation
- urinary tract infection
- caffeine, spices, alcohol, carbonation
- benign prostatic hypertrophy
- bladder stones
- urethritis
- prostatitis, prostate cancer, bladder cancer
- neurogenic bladder
- obstructive sleep apnea
- exacerbation by medications
- 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)
- lower abdominal exam
Clinical manifestations
- irritative symptoms
- obstructive symptoms
- urinary hesitancy, difficulty initiating urination
- straining
- a weak urinary stream, prolonged urination, dribbling
- urinary retention
- overflow incontinence
Laboratory
- urinalysis
- pyuria suggests infection
- hematuria may be sign of: infection, malignancy
- glycosuria suggests poorly-controlled diabetes mellitus
- 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
Diagnostic procedures
- 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
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]
- control urinary urgency with pelvic floor muscle contraction
- lifestyle modification* for AUA symptom index < 8[3]
- pharmaceutical management
- tamsulosin
- 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]
- fesoterodine (or other parasympatholytic) may be used with tamsulosin[15]
- 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]
More general terms
Additional terms
References
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/21987200
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/21095413
- ↑ 3.0 3.1 3.2 3.3 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 - ↑ Deprecated reference
- ↑ 5.0 5.1 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. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24508634 <Internet> http://www.jurology.com/article/S0022-5347%2814%2900249-3/abstract
- ↑ Rees J, Bultitude M, Challacombe B The management of lower urinary tract symptoms in men. BMJ. 2014 Jun 24;348:g3861 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24963071
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/22396371 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/24231531
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/25216271 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/24022553
- ↑ Radomski SB. Update on medical therapy for male LUTS. Can Urol Assoc J. 2014 Jul;8(7-8 Suppl 5):S148-50. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25243039 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/16986051 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/25210556 Free PMC Article
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/25032191 Free PMC Article
- ↑ 15.0 15.1 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: https://www.ncbi.nlm.nih.gov/pubmed/26104505 Free PMC Article
- ↑ 16.0 16.1 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: https://www.ncbi.nlm.nih.gov/pubmed/28499730
- ↑ 17.0 17.1 17.2 17.3 17.4 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022.
- ↑ Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med 2012 Jul 20; 367:248 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22808960 https://www.nejm.org/doi/full/10.1056/NEJMcp1106637
- ↑ 19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 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: https://www.ncbi.nlm.nih.gov/pubmed/31039103
- ↑ Talebraza S et al Geriatrics Evaluation & Management Tools American Geriatrics Society. 2021 https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007/
- ↑ 21.0 21.1 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: https://www.ncbi.nlm.nih.gov/pubmed/37967894 PMCID: PMC10646682 Free PMC article https://www.bmj.com/content/383/bmj-2023-075219