The majority of lower urinary tract symptoms (LUTS) can be managed in general practice without urological intervention. The aims of management are to minimise symptoms and to prevent irreversible bladder damage or renal impairment. To do this requires a structured assessment aimed at classifying the LUTS as mild, moderate or severe. With practice this can be done quickly and efficiently in a routine consult. Many patients present with symptoms are concerned about prostate cancer. This should be regarded as a separate issue with different diagnostic steps.
I would strongly suggest using the International Prostate Symptom Score (IPSS) sheet, which is filled in by patients in the waiting room. This validated questionnaire gives an objective score from seven questions covering obstructive and irritative symptoms. This can be combined with the International Index of Erectile Function (IIEF) score sheet, which can act as a vascular health screening tool, a useful motivator for lifestyle change. IPSS score results – mild up to seven, moderate 8 to 19 and severe from 20 to 35. Both score questionnaires are available online.
Voiding history is important. A sequential story can be easy to remember for patients. Capture nocturia (times), urgency, urge incontinence, hesitancy (time), intermittent flow, incomplete emptying, daytime frequency, haematuria, dysuria, previous UTI’s, constipation, and stone disease. Hesitancy time is the most reliable measure of dysfunction. Examination includes general abdominal and DRE.
Useful investigations include a urine dipstick or MSU and an Hba1c if diabetes is suspected. PSA should be discussed and used if over 50 or younger with a family history. For patients with moderate to severe symptoms flow rate and residual urine value is a better test than an ultrasound alone. It is an objective measure of real-world function that can predict pathology and guide treatment choices.
In mild cases, advise weight loss, correction of diabetes, salt reduction and evening fluid restriction. Medication has a role in moderate symptoms. Highly selective alpha blockers (tamsulosin / silodosin) have less hypotension, but Prazosin can be useful in hypertensive patients at higher doses. Retrograde ejaculation is a common side effect.
Five alpha reductase (5AR) inhibitors – (finasteride / dutasteride) shrink the gland, but may cause sexual side effects and decrease athletic performance. Combination alpha/5AR is the drug of choice in older men with larger glands.
Complicated or severe LUTS should have a full urological assessment which may include cystoscopy. It is likely that surgery could be used, or combination medical therapy.
- LUTS affects up to 50% of older men
- Accurate history is paramount
- Treatment depends on severity
References available on request.
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Author competing interests: nil relevant disclosures.
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