Lower urinary tract symptoms explained

Lower urinary tract symptoms
Synonym:	LUTS, prostatism
Specialty:	Urology

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men^[1] over 40% of older men are affected^{[2] [3] [4] [5]} but lower urinary tract symptoms also affect women.^[6] The condition is also termed prostatism in men, but LUTS is preferred.^[7]

Symptoms and signs

Symptoms can be categorised into:

Filling (storage) or irritative symptoms

• Increased frequency of urination
• Increased urgency of urination
• Urge incontinence
• Excessive passage of urine at night

Voiding or obstructive symptoms

• Poor stream^[8] (unimproved by straining)
• Hesitancy^[8]
• Terminal dribbling^[8]
• Incomplete voiding^[8]
• Urinary retention^[9]
• Overflow incontinence (occurs in chronic retention)^[9]
• Episodes of near retention^[9]

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.^[10] 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.^[9]

Causes

• Benign prostatic hyperplasia (BPH)
• Bladder stone
• Cancer of the bladder and prostate
• Detrusor muscle weakness and/or instability
• Diabetes
• Use of ketamine^[11]
• Neurological conditions; for example multiple sclerosis, spinal cord injury, cauda equina syndrome
• Prostatitis, including IgG4-related prostatitis^{[12] [13] [14]}
• Urethral stricture
• Urinary tract infections (UTIs)^[15]

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,^[16] urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy and/or cystoscopy.

Treatment

Treatment will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given; appropriate medication would be administered to treat benign prostatic hyperplasia.

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.^[17] 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).^[18] The improved urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.

Physical activity

Physical activity has been recommended as a treatment for urinary tract symptoms. A 2019 Cochrane review of six studies involving 652 men assessing the effects of physical activity alone, physical activity as a part of a self-management program, among others.^[19] The evidence from this review states that there are important uncertainties whether physical activity is helpful in men experiencing urinary symptoms caused by benign prostatic hyperplasia.

Medications

With benign prostatic enlargement causes of LUTS, people may be offered a variety of medications (as a single drug or combining them) when there are persistent moderate symptoms:^[20]

• Alpha blockers
• 5-alpha reductase inhibitors
• Phosphodiesterase inhibitors
• Muscarinic receptor antagonists
• Plants extracts (phytotherapy)
• Beta-3 agonist

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:

• Ablation procedures – used in treating both bladder tumours^[21] and bladder outlet obstruction, such as prostate conditions.^[22]
• Bladder-neck incision (BNI)
• Removal of the prostate – open, robotic, and endoscopic techniques are used.
• Stenting of the prostate^[23] and urethra.
• Transurethral resection of the prostate (TURP)
• Transurethral microwave thermotherapy
• Urethral dilatation, a common treatment for strictures.

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.^[24]
• Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.^[25]
• Once symptoms arise, their progress is variable and unpredictable with about one third of patients improving, one third remaining stable and one third deteriorating.

Further reading

• Speakman MJ, Kirby RS, Joyce A, Abrams P, Pocock R . Guideline for the primary care management of male lower urinary tract symptoms . BJU International . 93 . 7 . 985–990 . May 2004 . 15142148 . 10.1111/j.1464-410X.2004.04765.x .
• Juliao AA, Plata M, Kazzazi A, Bostanci Y, Djavan B . American Urological Association and European Association of Urology guidelines in the management of benign prostatic hypertrophy: revisited . Current Opinion in Urology . 22 . 1 . 34–39 . January 2012 . 22123290 . 10.1097/MOU.0b013e32834d8e87 . 41964732 .
• NHS; Cancer Screening Programmes. Prostate Cancer Risk Management.

External links

• LUTS in men – Patient.info
• LUTS in women – Patient.info

Notes and References

1. Web site: Lower Urinary Tract Symptoms in Women Doctor. patient.info. 7 September 2017.
2. Tavoosian A, Reis LO, Aluru P, Khajavi A, Aghamir SM . 2022-08-01 . Comparison of Tamsulosin and Tadalafil effects in LUTS treatment considering patients' atherosclerosis risk level . Annals of Medicine and Surgery . en . 80 . 104137 . 10.1016/j.amsu.2022.104137 . 35846856 . 9283796 . 2049-0801.
3. Parsons JK, Bergstrom J, Silberstein J, Barrett-Connor E . Prevalence and characteristics of lower urinary tract symptoms in men aged > or = 80 years . Urology . 72 . 2 . 318–321 . August 2008 . 18554695 . 2597492 . 10.1016/j.urology.2008.03.057 .
4. Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P . Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction . BJU International . 108 . 7 . 1132–1138 . October 2011 . 21231991 . 10.1111/j.1464-410X.2010.09993.x . 28287734 .
5. Book: Roehrborn CG, McConnell JD . Chapter 38: Etiology, pathophusiology, epidemiology, and natural history of benign prostatic hyperplasia. . Campell's Urology . WB Saunders Co . 2002 . 1309 .
6. Takahashi S, Takei M, Nishizawa O, Yamaguchi O, Kato K, Gotoh M, Yoshimura Y, Takeyama M, Ozawa H, Shimada M, Yamanishi T, Yoshida M, Tomoe H, Yokoyama O, Koyama M . 6 . Clinical Guideline for Female Lower Urinary Tract Symptoms . Lower Urinary Tract Symptoms . 8 . 1 . 5–29 . January 2016 . 26789539 . 10.1111/luts.12111 . 879639 .
7. Abrams P . New words for old: lower urinary tract symptoms for "prostatism" . BMJ . 308 . 6934 . 929–930 . April 1994 . 8173393 . 2539789 . 10.1136/bmj.308.6934.929 .
8. Lukacz ES, Sampselle C, Gray M, Macdiarmid S, Rosenberg M, Ellsworth P, Palmer MH . A healthy bladder: a consensus statement . International Journal of Clinical Practice . 65 . 10 . 1026–1036 . October 2011 . 21923844 . 3206217 . 10.1111/j.1742-1241.2011.02763.x .
9. Lepor H . Pathophysiology of lower urinary tract symptoms in the aging male population . Reviews in Urology . 7 Suppl 7 . 7 . S3–S11 . 2005 . 16986059 . 1477625 .
10. Clinical Knowledge Summary; Urological cancer – suspected
11. Winstock AR, Mitcheson L, Gillatt DA, Cottrell AM . The prevalence and natural history of urinary symptoms among recreational ketamine users . BJU International . 110 . 11 . 1762–1766 . December 2012 . 22416998 . 10.1111/j.1464-410X.2012.11028.x . free .
12. Montironi R, Scarpelli M, Cheng L, Lopez-Beltran A, Burattini M, Kirkali Z, Montorsi F . Immunoglobulin G4-related disease in genitourinary organs: an emerging fibroinflammatory entity often misdiagnosed preoperatively as cancer . European Urology . 64 . 6 . 865–872 . December 2013 . 23266239 . 10.1016/j.eururo.2012.11.056 .
13. Yoshimura Y, Takeda S, Ieki Y, Takazakura E, Koizumi H, Takagawa K . IgG4-associated prostatitis complicating autoimmune pancreatitis . Internal Medicine . 45 . 15 . 897–901 . 1 Sep 2006 . 16946571 . 10.2169/internalmedicine.45.1752 . free .
14. Nishimori I, Kohsaki T, Onishi S, Shuin T, Kohsaki S, Ogawa Y, Matsumoto M, Hiroi M, Hamano H, Kawa S . 6 . IgG4-related autoimmune prostatitis: two cases with or without autoimmune pancreatitis . Internal Medicine . 46 . 24 . 1983–1989 . 17 Dec 2007 . 18084121 . 10.2169/internalmedicine.46.0452 . free . 10126/3103 . free .
15. Khasriya R, Barcella W, De Iorio M, Swamy S, Gill K, Kupelian A, Malone-Lee J . Lower urinary tract symptoms that predict microscopic pyuria . International Urogynecology Journal . 29 . 7 . 1019–1028 . July 2018 . 28971220 . 6004270 . 10.1007/s00192-017-3472-7 .
16. Web site: Prostate-Specific Antigen (PSA) Test – NCI. March 21, 2022. www.cancer.gov.
17. Web site: De Jong Y, Pinckaers JH, Ten Brinck RM, Lycklama à Nijeholt AA . Influence of voiding posture on urodynamic parameters in men: a literature review. 2014-07-02. Nederlands Tijdschrift voor urologie.
18. de Jong Y, Pinckaers JH, ten Brinck RM, Lycklama à Nijeholt AA, Dekkers OM . Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-analysis . PLOS ONE . 9 . 7 . e101320 . 2014 . 25051345 . 4106761 . 10.1371/journal.pone.0101320 . free . 2014PLoSO...9j1320D .
19. Silva V, Grande AJ, Peccin MS . Physical activity for lower urinary tract symptoms secondary to benign prostatic obstruction . The Cochrane Database of Systematic Reviews . 4 . CD012044 . April 2019 . 30953341 . 6450803 . 10.1002/14651858.CD012044.pub2 . Cochrane Urology Group .
20. Web site: Sumedia-Online Professionals . EAU Guidelines: Management of Non-neurogenic Male LUTS. 2021-02-15. Uroweb. en-US.
21. Kramer MW, Wolters M, Cash H, Jutzi S, Imkamp F, Kuczyk MA, Merseburger AS, Herrmann TR . 6 . Current evidence of transurethral Ho:YAG and Tm:YAG treatment of bladder cancer: update 2014 . World Journal of Urology . 33 . 4 . 571–579 . April 2015 . 24935098 . 10.1007/s00345-014-1337-y . 8976911 .
22. Elshal AM, Elmansy HM, Elhilali MM . Transurethral laser surgery for benign prostate hyperplasia in octogenarians: safety and outcomes . Urology . 81 . 3 . 634–639 . March 2013 . 23332997 . 10.1016/j.urology.2012.11.042 .
23. Fitzpatrick JM. Non-surgical treatment of BPH. Edinburgh: Churchill Livingstone, 1992.
24. Boyle P, Robertson C, Mazzetta C, Keech M, Hobbs FD, Fourcade R, Kiemeney L, Lee C . 6 . The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study . BJU International . 92 . 4 . 409–414 . September 2003 . 12930430 . 10.1046/j.1464-410x.2003.04369.x . 7709214 .
25. http://hcd2.bupa.co.uk/fact_sheets/html/bph.html Enlarged prostate gland – treatment, symptoms and cause