Lower urinary tract symptoms

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 can be categorised into:

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

• Poor stream^[8] (unimproved by straining)
• Hesitancy^[8] (worsened if bladder is very full)^{[citation needed]}
• 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.^[7] 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]

• 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]

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 will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given^{[medical citation needed]}; appropriate medication would be administered to treat benign prostatic hyperplasia.

Other treatments include lifestyle advice; for example, avoiding dehydration in recurrent cystitis.^{[citation needed]}

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.^[18]

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.^[19]

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.^{[citation needed]}

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.

• 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.^{[citation needed]}

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