Background Information
Definition
LUTS refers to a group of symptoms related to dysfunction of the bladder / urethra / prostate. LUTS can be grouped as following:
| Obstructive (voiding) LUTS |
Some sources classify the following as post-micturition symptoms:
|
| Storage (irritative) LUTS |
|
Aetiology
Causes of the type of LUTS:
| Obstructive (voiding) LUTS |
|
| Storage (irritative) LUTS | Causes of overactive bladder:
Nocturnal polyuria can be caused by:
Stress urinary incontinence (due to urethral sphincter malfunction) can be caused by:
|
Diagnosis
Investigation and Diagnosis
It is more important to appreciate what assessments are done routinely initially, and what other ones are only offered by a specialist. Exam questions don’t expect one to learn the exact indications, but one would be expected to be able to distinguish between a routinely offered initial test and a specialist-only test (e.g. urine dipstick vs flow-rate measurement).
Initial Assessment (Primary Care)
Tests for ALL patients:
| Test | Purpose |
|---|---|
| Urinalysis | Important differential diagnoses to exclude:
|
| IPSS assessment | To classify the severity of LUTS and the impact on quality of life
Allows baseline assessment and assesses treatment effectiveness |
| Urinary frequency volume chart | To give an indication of the voiding pattern, the severity of symptoms, and the impact on the person’s daily life |
Additional tests to consider:
- Offer PSAProstate-specific antigen testing (if prostate is abnormal on DRE / patient is concerned about prostate cancer / symptoms suggest bladder outlet obstruction secondary to BPHBenign prostate hypertrophy)
- Only if renal impairmentExamples outlined by NICE: - Palpable bladder - Nocturnal enuresis - Recurrent UTI - History of renal stones is suspected → offer serum creatinine and eGFR
Further Assessment (Secondary Care)
- Flow-rate measurement – routine
- Post-void residual volume – routine
- Multichannel cystometry – if surgery is considered
- Cystoscopy – only if indicatedHistory of any of the following: - Recurrent infection - Sterile pyuria - Haematuria - Profound symptoms - Pain
- Imaging of the upper urinary tract – only if indicatedAny of the following: - Chronic retention - Haematuria - Recurrent infection - Sterile pyuria - Profound symptoms - Pain
Management
Storage Symptoms
Approach (step up if ineffective):
- Step 1: conservative management
- Step 2: pharmacological management
- Step 3: invasive management
Conservative Management
Advise on the following:
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Specific training for urinary incontinence:
- Urge incontinence (overactive bladder) → bladder retraining
- Stress incontinence → pelvic floor muscle training for at least 3 months
Offer temporary containment products (for example, pads or collecting devices) if there is urinary incontinence
Pharmacological Management
All patients:
- 1st line: anti-cholinergic (e.g. oxybutynin, tolterodine, darifenacin)
- 2nd line: beta-3 receptor agonist (e.g. mirabegron, vibegron)
If the patient also experiences bothersome nocturia, consider:
- Late afternoon loop diuretic (off-label)
- Desmopressin
- Glaucoma
- Patient of old age / at risk of cognitive impairment / with cognitive impairment
- Known myasthenia gravis
Invasive Management
Consider the following:
- Botulinum toxin A injection (patient must be willing and able to self-catheterise)
- Augmentation cystoplasty (patient must be willing and able to self-catheterise)
- Implanted sacral nerve stimulation
- Artificial sphincter implantation (for stress incontinence)
- Last resort: urinary diversion
Voiding Symptoms
Approach (step up if ineffective):
- All patients should be offered conservative management
- Consider pharmacological management in all patients (as per indications below)
- Last resort (if pharmacological management failed): invasive management
Conservative Management
Advise on the following:
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Urethral milking
Urethral milking refers to applying gentle pressure along the length of the urethra (from the base of the penis towards the meatus) to express residual urine trapped in the urethra after voiding.
– if there is post-micturition dribbling
Pharmacological Management
2 main drug classes are used to manage obstructive LUTS:
| Drug class | MoA | Examples | Indications |
|---|---|---|---|
| Alpha blocker | Block α1-adrenergic receptors in prostatic and bladder-neck→ smooth muscle relaxation → improve urinary flow | Doxazosin, tamsulosin |
|
| 5-alpha reductase inhibitor | Reduce conversion of testosterone into dihydrotestosterone → reduction in prostate volume → improve obstruction | Finasteride |
|
If the patient meets BOTH criteria above, offer combination therapy (an alpha-blocker AND a 5-alpha reductase inhibitor)
As mentioned above, an enlarged prostate (>30 g) is the indication to start a 5-alpha reductase inhibitor. There are 2 ways to estimate the prostate size:
- PSA level correlates with prostate volume (>1.4 ng/mL is approximately >30g)
- Imaging (often trans-rectal ultrasound) can be used to measure prostate volume – this is widely used in clinical practice but not explicitly mentioned in NICE guideline
Note that an alpha blocker gives rapid symptomatic relief (within days to weeks), while a 5-alpha reductase inhibitor has a slow onset of action, with clinically significant effects typically taking 3-6 months to manifest.
Invasive Management
1st line:
- Transurethral resection of the prostate (TURP) – most widely used
- Transurethral vaporisation of the prostate (TUVP)
Other options:
- If prostate <30g → transurethral incision of the prostate (TUIP)
- If prostate >80g → open prostatectomy is preferred
If surgery is not appropriate (e.g. patient does not wish to undergo surgery, surgery is contraindicated):
- 1st line: intermittent bladder catheterisation
- 2nd line: indwelling urethral / suprapubic catheterisation