Lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) refer to a group of medical symptoms, that affect approximately 40% of older men.^[1] LUTS is a recent term for what used to be known as prostatism.^[2]

Symptoms and signs

Symptoms can be categorised into:

Filling (Storage) 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 (unimproved by straining)^[3]
• Hesitancy (worsened if bladder is very full)^[3]
• Terminal dribbling
• Incomplete voiding
• Overflow incontinence (occurs in chronic retention)^[3]
• Episodes of near retention^[3]

As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer.^[2] Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis.^[4]

Causes

• Benign prostatic hyperplasia (BPH) with obstruction
• Detrusor muscle weakness and/or instability
• Urinary Tract Infection (UTI)
• Chronic prostatitis
• Urethral stricture
• Urinary stone
• Malignancy: prostate or bladder
• Neurological disease, e.g. multiple sclerosis, spinal cord injury, cauda equina syndrome
• IgG4-related prostatitis^[5][6][7]

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,^[8] 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:

• 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.^[9]

Voiding position

Other treatments include lifestyle advice,^[10] for example sitting down while urinating. A meta-analysis^[11] 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.^[12]
• Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.^[13]
• 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