Male LUTS

ICS definitions:

LUTS

Symptom related to the lower tract … may originate from bladder, urethra, prostate and/or adjacent pelvic floor or pelvic organs, or at times be referred from similarly innervated anatomy e.g. lower ureter

Storage symptoms

Urgency, frequency, urge incontinence, nocturia

Voiding symptoms (obstructive)

Poor flow, hesitancy, intermittency, straining, splitting/spraying

Post micturition symptoms

Post micturition dribbling, sensation of incomplete emptying

Benign prostatic enlargement (BPE)

Increased volume of the prostate gland, usually secondary to BPH

Benign prostatic hyperplasia (BPH)

Histological changes related to benign prostatic growth

Benign prostatic obstruction (BPO)

BOO secondary to BPE

Bladder outlet obstruction (BOO)

Diagnosis based on urodynamic findings, generally with relevant signs and symptoms, manifest by abnormally slow urine flow rate, with evidence of abnormally high detrusor voiding pressures, with or without a high PVR.

Can be functional (bladder neck obstruction, DSD, pelvic floor overactivity) or mechanical (prostatic enlargement, urethral stricture)

Male LUTS have a wide differential diagnosis – not always the prostate.

Work up

Don’t forget bladder diary, questionnaires, flow rate

History

Detailed history of urinary symptoms

Storage/voiding/mixed, level of bother, duration, aggravating factors, incontinence

Red flags or associated symptoms

Haematuria, pain, UTIs, systemic symptoms, fevers, family history of cancers
Nocturnal enuresis

Previous trauma or instrumentation, risks for stricture

Medical history

Competing co-morbidities, preclusions to GA, contra-indications to alpha blockers

Medications

Anticoagulants, immunosuppressants, diuretics, cholinergics, antipsychotics, SGLT2i

Surgical history

Sexual function

Social history

Smoking, alcohol, family and plans for future children

Examination

General examination

Frailty, habitus, performance status

Abdominal and pelvic exam

DRE, genitals, pads, SUI, excoriation, abdominal scars, herniae, palpable bladder

Neurological exam if required

Adjuncts

Bladder diary
Flow rate and post void residual
Questionnaires – e.g. IPSS

Investigations

Urine culture and microscopy

+/- cytology if indicated

Bloods

Renal function, FBC, PSA if indicated

Imaging

Ultrasound KUB

?Cystoscopy – if needed – not routine prior to initial treatment

If concerns for haematuria, stricture, bladder cancer, foreign body
No significant correlation between cystoscopic and urodynamic findings

?Urodynamics – if needed – not routine prior to initial treatment

If doubt about the diagnosis (symptoms don’t match other information), failure of previous treatments, if will change management
EAU – men > 80 years with voiding symptoms, men < 50 years, high PVR > 300 mL, voiding symptoms with QMax > 10 mL / sec, unable to get flow rate with volume > 150 mL, previous unsuccessful invasive treatments.
May help identify DO and poor compliance and allow appropriate counselling – DO may not improve with BOO surgery, or BOO may be absent and treatment directed to OAB.
UPSTREAM – UK RCT published 2020 – routine UDS did not change % of patients undergoing surgery or IPSS at 18 months.

Novel non-invasive tests for diagnosing BOO:

Intravesical prostatic protrusion – measure in mid-sagittal plane on ultrasound with volume 150 – 250 mL; correlates with BPO on urodynamic testing
Bladder wall thickness on ultrasound – correlates well with urodynamics
Ultrasound estimated bladder weight
Penile cuff non invasive pressure-flow test

International Prostate Symptom Score IPSS

8 items – 7 symptom questions and 1 quality of life question; all scores 0 – 5
Storage – frequency, urgency, nocturia
Voiding – weak stream, intermittency, straining, poor emptying
QoL – “If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? (0 delighted, 6 terrible).

Totals:

0 – 7 mild

8 – 19 moderate

20 – 35 severely symptomatic

Pros:

Validated in multiple populations
Allows quantitative comparison over time
Allows quantitative comparison between patients
Takes into account quality of life
Integral in research on LUTS
Translated into multiple languages
Can be self administered or physician administered reliably

Cons:

Doesn’t consider incontinence
Doesn’t include post micturition symptoms
Doesn’t differentiate bother between symptoms
Some cross cultural differences – acceptance of ageing etc