Male LUTS & BPH

Male Lower Urinary tract Symptoms (LUTS)

Before treating elderly men who present with urinary symptoms for Benign prostatic enlargement, it is important to rule out other Urological and Non-urological causes for Urinary symptoms.

Other Urological Causes:

  • Overactive Bladder
  • Bladder under-activity or failure
  • Prostate cancer
  • Obstructive conditions like urethral stricture, meatal stenosis and phimosis

Non-urological Causes:

  • Congestive cardiac failure
  • Chronic renal failure
  • Dependent pedal oedema
  • Sleep-apnoea

These conditions can cause nocturnal polyuria (over-production of urine at the night time) that can be presenting with complaints of night-time frequency (Nocturia).

Approach to the Management of LUTS

In this section, we will discuss the types of urinary symptoms that include Storage, Voiding and Post-micturition symptoms. Then we will see how we could start the conservative management from the symptoms and basic investigative tools like International prostate Symptom score (IPSS) and Bladder diary.

Then briefly discuss the indications for further treatment escalation and referral to secondary care. 

Finally, we will see what kind of invasive treatment options available and expected improvement in different clinical scenarios.

Types of Urinary Symptoms

Lower Urinary symptoms are primarily caused by the failure of the storage and voiding function of the bladder. The non-urological conditions that cause polyuria can also cause some of the urinary symptoms like urinary frequency.

The disturbances to the storage function of the bladder causes frequency both during day time and night time (Nocturia), urgency and incontinence.

When the voiding function of the bladder is impaired by obstructive conditions or bladder under-activity, they cause voiding symptoms. These are hesitancy, poor flow, intermittency, terminal dribbling and need to strain.

The usual post micturition symptoms include, Post-micturition dribbling and feeling of inadequate emptying.

Clinical Assessment & Investigations

Objectives of Clinical Assessment

  • Identification of Red-flags
    • Haematuria 
    • Palpable Bladder
    • Painful Bladder
    • Mass, suspected malignancy
    • Significant Complications of BPH

redflags

Refer immediately if any of these identified

 

 

Clinical Assessment & Investigations

  • Abdominal & Digital Rectal examination
  • MSU dipstick
  • Serum PSA
  • Flow rate & Bladder scan

Differential Diagnosis

  • Urinary Tract Infection
  • Conditions causing Over-production of Urine (Polyuria)
  • Bladder and Prostate Malignancy
  • Neurological Conditions (Multiple Sclerosis, Parkinson’s disease)

Benign Prostatic Enlargement (BPH)

The prevalence of BPH increases with age from as high as 40% in men in their fifties to 90% in men in their nineties. Because of such a high prevalence of symptomatic BPH, it is of public health importance. This makes it necessary for the primary care clinicians to be able to manage the initial assessment and treatment of this condition in the primary care. This is supported by the NICE guidelines on Lower Urinary Tract Symptoms. After excluding other causes of BPH as mentioned above, it is important to stratify the risk of BPH in terms of the risk of progression and risk of BPH related complications.

  • Differential Diagnosis

table

Conservative Treatment

The conservative management of BPH needs to be tailor made to the individual patient’s symptom severity and risk.

Low Risk

  • Watchful waiting
  • Lifestyle Interventions
  • Beverage advice
  • Alpha Blockers, Antimuscarinics

Intermediate Risk

  • Same as above
  • Combination Treatment
  • Referral Planning

High Risk

  • Consider referral
  • Combination treatment
Indications for Referral
  • Red-flag symptoms or signs
  • Failure of conservative Treatment
  • Severe symptoms on presentation
  • Correctable causes like tight urethral meatus or tight fore-skin
  • Signs of complications (Retention, Urinary infections, Kidney failure, Bladder stones)
Specialist Management
  • Detailed Assessment including Flow rate estimation, bladder scan
  • Combination Medical Therapy if not tried fully
  • Urodynamic assessment if appropriate

Indications for Surgical Treatment

  • Refractory urinary retention
  • Recurrent urinary tract infections due to prostatic obstruction
  • Recurrent gross hematuria
  • Renal insufficiency secondary to bladder outlet obstruction
  • Bladder stones
  • Permanently damaged or weakened bladders
  • Large bladder diverticula that do not empty well secondary to an enlarged prostate

Surgical Treatment

  • Trans-Urethral Resection of Prostate
  • Bladder Neck Incision
  • Laser Enucleation of Prostate