Self-management for men with lower urinary tract symptoms

Treatment for men with lower urinary tract symptoms (LUTS) has developed into a “cascade” that escalates from watchful waiting through medical treatment to surgery. Self-management can help men to adopt lifestyle and behavioral modifications that will avoid or delay an escalation in treatment and reduce symptoms. Although many of these interventions are advised to men with LUTS, it is usually in a nonstandardized and unsystematic way. Recent work in this area has defined a self-management program for men with uncomplicated LUTS using formal methods and assessed its effectiveness in a randomized controlled trial. Self-management significantly reduced the frequency of escalation through the treatment cascade and reduced urinary symptoms (as effective as medication), suggesting that self-management could be considered as first-line treatment for men with LUTS.     

Urodynamic studies in the evaluation of young men presenting with lower urinary tract symptoms

AIM: To evaluate the usefulness of urodynamic study in young men with lower urinary tract symptoms (LUTS). METHODS: We reviewed the charts of 50 men with LUTS aged 50 years and below. Those with neurological diseases, urethral trauma or strictures were excluded. All underwent multichannel urodynamic studies (UDS). The pre- and post-UDS diagnoses and treatment modalities were compared. RESULTS: Mean age was 38.1 years (17-49). The main pre-UDS diagnoses included prostatitis in seven (14%), overactive bladder in seventeen (34%) and benign prostatic hyperplasia in nine (18%). Pre-UDS management ranged from anticholingeric agents for thirteen (26%), alpha-adrenergic antagonists for nine (18%), antibiotics for six (12%). Abnormal UDS were noted in 36 (72%), including detrusor overactivity in 9 (18%), detrusor underactivity/acontractility in 5 (10%) and bladder outlet obstruction in 21 (42%). Fourteen (28%) had primary bladder neck dysfunction and five (10%) had benign prostatic hyperplasia. Post-UDS management included anticholingeric agents for ten (26%), alpha-adrenergic antagonists for seventeen (34%), catheterization for four (10%), behavioral therapy for three (6%), surgery for three (6%). None were prescribed antibiotics. Following UDS, the diagnosis had to be updated in 40 (80%) and concomitant change in management was required in 34 (68%). CONCLUSION: Young men presenting with LUTS have different underlying etiologies. Clinical diagnosis and treatment are often empiric and inaccurate. Urodynamic study is useful in the evaluation of this group of patients as it aids in arriving at an accurate diagnosis and guides treatment therapy.     

Office evaluation of men with lower urinary tract symptoms

In the past decade, the symptom score has been considered the essential part of the evaluation of patients with lower urinary tract symptoms (LUTS). At the University of Wisconsin, the author's have stopped routine use of symptom scores because of their limited utility in dealing with the patient's concerns. Except from men electing invasive treatment, the authors do not serve the patients better with urodynamic testing either. Bothersomeness, not symptom score or objective measures is what drives the decision making process in benign prostatic hyperplasia (BPH) management. Generally, the authors now select patients for treatment according to the degree to which they are bothered by their LUTS.     

Lower urinary tract symptoms, prostate volume and uroflow in norwegian community men

OBJECTIVE: To describe lower urinary tract symptoms, prostate volume and peak urinary flow rate, and investigate the relationships among urological variables in a community sample of Norwegian men. MATERIALS AND METHODS: A cross-sectional study of 611 men, aged 55-70 years, who underwent a clinical urological examination including uroflowmetry, residual urine measurement, and transrectal ultrasonography of the prostate. All the men completed a questionnaire which included the International Prostate Symptom Score (IPSS). RESULTS: Severe symptoms were reported by 5%, while 23.6% reported moderate symptoms, and the overall median IPSS was 4 (q1 = 25th percentile, 1; q3 = 75th percentile, 9). The median peak flow rate was 15 ml/s (q1 = 11; q2 = 22) while median prostate volume was 30 cm(3) (q1 = 23; q3 = 38), with little variation evident across the narrow age range of 55-70 years. A positive modest correlation (r = 0.176) was found between IPSS and prostate volume, and a negative correlation between IPSS and peak flow rate (r = -0.278). There was a modest correlation between body mass index (BMI) and prostate size, but no significant correlation between BMI and IPSS. CONCLUSION: In this population-based study, moderate lower urinary tract symptoms were reported by 24% and severe symptoms by 5% of community men. The distribution of lower urinary tract symptoms, prostate volume and peak urinary flow rate in Norwegian men is comparable to that described in similar studies conducted in Spain, Holland and USA.     

Sexual function in men with lower urinary tract symptoms

PURPOSE: Recently there have been several alternatives not only to improve symptoms but to retain an acceptable quality of life as well as to reduce the complications. Therefore the objective of this study was to evaluate quantitatively and qualitatively the degree of erectile dysfunction in the population of men with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Total 252 men with LUTS were investigated using the International Prostate Symptom Score (I-PSS) and sexual function inventory (SFI) consisting of sexual drive, erection and ejaculation. Spearman's rank order correlation was used to determine the degree of any correlation between age, the total I-PSS, the individual I-PSS questions and the various sexual function scores. RESULTS: 208 patient data were available for analysis. There were poor function patients in 67.8% for sexual drive, in 46.2% for erection and in 47.1% for ejaculation. On the other hand, 24% considered their sexual drive to be a big or medium problem, 20.7% for erection and 18.3% for ejaculation. Overall, 27.4% of the men were mostly or very dissatisfied with their sex life. There was a significant correlation between a patient's age and his score for each of the three sexual variables (p < 0.05). Furthermore, a significant correlation was noticed between the total I-PSS and the SFI score (p < 0.05). It might be suggested that the more symptomatic a patient for LUTS, the poorer his sexual function will be. CONCLUSIONS: About 20% men with LUTS are bothered by their sexual symptoms. Erectile dysfunction in dependent of age and the extent of LUTS. Consideration of the high population of erectile dysfunction in men with LUTS is necessary to the treatment of their urinary symptoms.     

下尿路症状男性人群勃起功能调查

目的:了解下尿路症状(LUTS)男性人群的勃起功能障碍(ED)患病情况,探讨LUTS与ED之间的相关性。方法:2011年11月~2012年8月,抽取1 000例40~80岁、有固定性伴侣的男性人群,采用国际前列腺症状评分(IPSS)及国际勃起功能指数(IIEF-5)评估LUTS和ED的严重程度,单因素Logistic回归分析LUTS与ED的相关性。结果:40~80岁男性人群的LUTS患病率为42.81%(426/995),ED患病率为76.18%(758/995)。其中426例有LUTS症状患者的ED患病率为82.16%(350/426),569例无LUTS症状的ED患病率为71.70%(408/569)。随着LUTS严重程度的增高,ED的患病率明显升高。Logistic回归分析显示,年龄、LUTS严重程度与ED的关联存在统计学显著意义(P0.01)。结论:LUTS患者存在很高的ED发生率。年龄越大,LUTS症状愈严重者患ED的风险更高。     

Uncommon causes of irritative lower urinary tract symptoms

Bladder symptoms accompanying a spectrum of disorders, ranging from urethral syndrome to interstitial cystitis, may be caused by potentially reversible factors. Some non-steroidal anti-inflammatory agents, particularly tiaprofenic acid, can cause frequency, urgency and suprapubic pain which is reversed upon discontinuing the medication. Anabolic steroids and GnRH agonists can on occasion cause bladder i irritability. Approximately half of women with bladder endometriosis have frequency and dysuria, usually without hematuria. Mycoplasma, ureaplasma and chlamydia are all associated with urethral syndrome. Cystitis may be caused by herpes simplex virus, herpes zoster, human T-lymphotrophic virus type 1, cytomegalovirus, toxoplasma and candida. Some work-related toxins may cause bladder effects without neoplasm. Foods high in tyrosine, tyramine and aspartate may exacerbate painful bladder syndrome. A search for potential non-bacterial sources of irritative lower urinary tract symptoms is warranted in evaluating women with such symptoms.EDITORIAL COMMENT: Irritative urinary tract symptoms — frequency, urgency, postvoid fullness and dysuria — are common complaints voiced by female patients of all ages. The evaluation of irritative lower urinary tract symptoms should include an extensive history, including onset, chronicity, severity, associated symptoms and inciting activities. A voiding and fluid intake diary should be obtained to assess daily patterns. Clinical tests to consider include urine culture and sensitivity, urethral and vaginal cultures, postvoid residual determination, cystourethroscopy, bladder washing or bladder biopsy. In most cases this evaluation will uncover the cause of the symptoms and guide appropriate treatment. However, in some instances the etiology of the symptoms remains unknown. Dr Nygaard presents a thorough review of uncommon causes of irritative lower urinary tract symptoms that we should all keep in mind.     

Role of phytotherapy in men with lower urinary tract symptoms

PURPOSE OF REVIEW: Serenoa repens extract is a popular phytotherapeutic agent in men with lower urinary tract symptoms. Although the exact mechanism of action is unknown, the agent is generally well accepted for its easy availability and good tolerability. This paper reviews the evidence of its efficacy in comparison with placebo, 5-alpha reductase inhibitor and alpha-1 adrenoreceptor antagonist. RECENT FINDINGS: Serenoa repens extract is comparable with 5-alpha reductase (finasteride) and alpha-1 antagonist in the treatment of benign prostatic hyperplasia in terms of symptom score and peak urinary flow rate improvement, but has a lower incidence of associated sexual dysfunction. Furthermore, long-term usage (36 months) of Serenoa repens decreases the progression rate of the condition as compared with watchful waiting. In addition, the efficacies of Serenoa repens are proven in several placebo-controlled trials. SUMMARY: Serenoa repens has proven its role in the management of benign prostatic hyperplasia and will remain as a viable first-line treatment option.     

Intermittent tamsulosin therapy in men with lower urinary tract symptoms

PURPOSE: We investigated in what is to our knowledge the first prospective study the safety and efficacy of intermittent tamsulosin therapy in patients with lower urinary tract symptoms. MATERIALS AND METHODS: This study was performed between January 2001 and February 2003 in 140 patients. In phase 1 of this study patients received 1, 0.4 mg tamsulosin capsule daily for 3 months and were reevaluated after 3 months. At this assessment uroflowmetry, International Prostate Symptom Score and ultrasonographic estimation of residual urine were determined. In phase 2 responders to tamsulosin therapy were then randomized into 1 of 3 groups, namely group 1--continued 4 mg tamsulosin once daily every day, group 2--0.4 mg tamsulosin once daily every other day and group 3--discontinued tamsulosin. Efficacy assessments were done again at 4, 12 and 24 weeks. RESULTS: There were no statistically differences among the patients in groups 1 and 2 at 6 months for International Prostate Symptom Score, maximum or average urine flow, or residual urine. Differences between patients in groups 1 and 3 were statistically significant at 6 months. Differences between patients in groups 2 and 3 were also statistically significant at 6 months for these parameters. CONCLUSIONS: Tamsulosin at a dose of 0.4 mg once daily and 0.4 mg once daily every other day for lower urinary tract symptoms provide comparable improvements in urinary flow and symptoms. Each treatment was well tolerated.     

Saw palmetto for the treatment of men with lower urinary tract symptoms

PURPOSE: A comprehensive review of the literature on the use of saw palmetto in men with lower urinary tract symptoms is provided. MATERIALS AND METHODS: A literature search of studies that have assessed the mechanism of action and clinical results of saw palmetto in men with benign prostatic hyperplasia was performed. RESULTS: A variety of potential mechanisms of action of saw palmetto have been demonstrated through in vitro studies, including 5-alpha reductase inhibition, adrenergic receptor antagonism and intraprostatic androgen receptor blockade. Clinical evidence of the relevance of these effects is largely unavailable. The use of saw palmetto in men with benign prostatic hyperplasia is safe with no recognized adverse effects. No effect on serum prostate specific antigen has been noted. Placebo controlled trials and meta-analyses have suggested that saw palmetto leads to subjective and objective improvement in men with lower urinary tract symptoms. However, most studies are significantly limited by methodological flaws, small patient numbers and brief treatment intervals. CONCLUSIONS: Evidence suggests that saw palmetto may have a significant effect on urinary flow rates and symptom scores compared to placebo in men with lower urinary tract symptoms. However, large scale, placebo controlled trials are needed to assess the efficacy of saw palmetto.     

Variability of pressure-flow studies in men with lower urinary tract symptoms

The objective of this study was to assess the short-term test-retest variability of pressure-flow studies (PFS) in men with lower urinary tract symptoms (LUTS). By choosing a short interval between two consecutive PFS, but notably not performing two tests within a single session, both tests represent the same routine testing procedure. Eighty-nine patients with LUTS suggestive of bladder outlet obstruction or detrusor underactivity, who received PFS, were asked to undergo a second urodynamic evaluation within 4 weeks after the initial test. At both visits, specialized physicians performed the PFS. Obstruction was quantified using the Abrams-Griffiths number (AG number). Each patient was classified as obstructed, unobstructed, or equivocally obstructed according to the International Continence Society nomogram. As expected, no systematic difference was observed in AG number between the first and the second visit at the group level. There was, however, considerable variation at the individual level. The average within-patient standard deviation was 14 cm H(2)O. This finding shows that if a patient's AG number is 30 at the first visit, his true AG number can be any value between 30 +/- 1.96 * 14 = 3 to 57, owing to random variability alone. The average within-patient standard deviation did not differ significantly between sub-groups of obstruction and other variables such as patient age, symptom score, prostate volume, or residual volume. The variability appeared to increase slightly with an increased interval between visits. Of all patients, 39% changed at least one category of obstruction at the second visit and 3% changed from definitely obstructed to definitely unobstructed or vice versa. We conclude that PFS cannot stand the test of serving as a gold standard to identify bladder outlet obstruction in patients with LUTS.     

Videourodynamic analysis in men with lower urinary tract symptoms: Correlation between age and prostate size with lower urinary tract dysfunction

ObjectivesLower urinary tract symptoms (LUTS) are highly prevalent in aging men. In this study we examined the relationship between age, total prostate volume (TPV), and videourodynamic study findings.MethodsWe retrospectively analyzed a total of 971 men ≥ 40 years of age referred to us for investigation of LUTS. We analyzed the distribution of the different videourodynamic study diagnoses in male LUTS by correlating their age and prostate size.ResultsThe most common diagnosis in the bladder outlet obstruction (BOO) group differed significantly by age and poor relaxation of the external sphincter (PRES) in those aged < 50 years; bladder neck dysfunction in those aged 50–69 years, and benign prostatic obstruction in those ≥ 60 years. Detrusor overactivity was the most common diagnosis in all ages in the bladder dysfunction group, and the cases of hyperactivity with impaired contractility (DHIC) increased with age. In patients < 50 years of age, PRES was the most common diagnosis in the BOO group in both those with small prostates (total prostate volume ≤ 40 mL) and large prostates (total prostate volume > 40 mL). In patients aged 50–69 years, the most common diagnosis in those with BOO and a small prostate was bladder neck dysfunction, and that in those with BOO and a large prostate was benign prostatic obstruction. Similar results were observed in patients aged ≥ 70 years. In all age groups, the majority of patients with detrusor overactivity, hypersensitive bladder, detrusor underactivity, and DHIC had a small prostate.ConclusionIn male LUTS, the diagnoses in the BOO group differed by age and prostate volume. In young patients with BOO, the leading diagnosis was PRES, and the contribution of prostate volume to BOO increased with age. As age increased, the bladder function became more complex with an increased percentage of patients with DHIC. Both bladder outlet and bladder functions were affected by age.     

The role of anticholinergic drugs in men with lower urinary tract symptoms

PURPOSE OF REVIEW: Male lower urinary tract symptoms are often attributed to benign prostatic hyperplasia. However, coexisting overactive bladder may be responsible for storage symptoms in a substantial proportion. Treatment of these symptoms with anticholinergic drugs has been considered hazardous in benign prostatic hyperplasia because of concerns that they may predispose to acute urinary retention. We present recent research evidence on the effectiveness and safety of anticholinergics for male lower urinary tract symptoms. RECENT FINDINGS: Two systematic reviews and a large randomized controlled trial recently evaluated anticholinergic drugs in men with lower urinary tract symptoms. These studies provided good evidence that anticholinergics are effective at improving both urodynamic and patient-reported outcomes. Postvoid residual urine volumes and urine flow rates were not significantly affected, and acute urinary retention was rare. SUMMARY: In men with lower urinary tract symptoms treatment may need to be directed at both the prostate and the bladder, and a pragmatic approach therefore seems appropriate. Men presenting with lower urinary tract symptoms should undergo comprehensive clinical evaluation before benign prostatic hyperplasia is treated, if indicated. Should symptoms fail to resolve, addition of anticholinergic drugs may be considered in the absence of significant postvoid residual urine volumes.     

Management of lower urinary tract symptoms in men with progressive neurological disease

PURPOSE OF REVIEW: Progressive neurological disease can cause lower urinary tract symptoms similar to those seen in bladder outflow obstruction. Increasingly common with age, these two groups of conditions often coexist. The complex pathophysiology of men with this combination of problems is often poorly understood and suboptimally managed, mostly with long-term indwelling catheters. This review looks at recent diagnostic advances and emerging therapeutic alternatives. RECENT FINDINGS: For various neurogenic bladder disorders, urodynamic studies may demonstrate typical constellations of abnormalities, but no pathognomonic features. Other modalities such as sphincter electromyography and central nervous system imaging have been proposed to aid diagnosis. Functional brain imaging has helped to understand the complex nature of bladder storage and micturition control. A new generation of bladder-selective antimuscarinics has graduated through phase-III randomized controlled trials and these are now available for routine use. These agents are as efficacious as oxybutynin but have better side-effect profiles. Modern minimally invasive techniques such as desensitizing bladder instillations or injections of botulinum toxin have safely been used and are achieving excellent results. SUMMARY: Urodynamic studies are important and increasingly regarded as mandatory in all men considered for outflow surgery. Neurogenic bladder and sphincter dysfunction can be managed conservatively or with new minimally invasive techniques. Surgery should be reserved for severely symptomatic treatment failures. A working knowledge of common neurological disease associated with lower urinary tract dysfunction is important for urologists to diagnose these conditions or initiate an appropriate referral. This article gives an overview of recent work that has implications for the diagnosis and management of neurological disorders of micturition.     

Prevalence of conditions potentially associated with lower urinary tract symptoms in men

OBJECTIVE: To estimate the frequency of conditions associated with lower urinary tract symptoms (LUTS, typically included when assessing benign prostatic hyperplasia, BPH), as other causes of LUTS should be excluded when diagnosing BPH, using data from the Olmsted County Study of Urinary Symptoms and Health Status among Men. SUBJECTS AND METHODS: During 1989-91, Caucasian men aged 40-79 years were randomly selected from the Olmsted County population. Before contact, eligibility was determined by reviewing the community medical records. Baseline exclusion criteria included comorbid pre-existing conditions or treatments, e.g. prostate, bladder or lower back surgery, bladder neck contracture or cancer, diabetes with lower extremity amputation, and neurological diseases, including Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, tabes dorsalis and stroke. Men with these conditions were excluded from the Olmsted County Study at baseline, because these conditions are potentially associated with LUTS. RESULTS: Of the 5100 randomly sampled men, 13.4% met at least one of the pre-existing exclusion criteria. Individually, the frequency of exclusions was 7.8% for prostate cancer or surgery, 4.8% for back surgery, 1.3% for bladder surgery and 1.4% for neurological conditions. All other conditions represented <1.0% of the study exclusions. Older men were more likely to meet at least one of the exclusion criteria, with men in their fifth to eighth decade having a total exclusion frequency of 1.4%, 5.4%, 8.5% and 32.8%, respectively. The most common reason for men in their fifth decade to be excluded was lower back surgery (0.9%), whereas the most common reason in the eighth was prostate surgery (21.8%). CONCLUSIONS: In men, conditions that may contribute to LUTS, other than BPH, are prevalent in the community and increase in frequency with age. It is important that other conditions associated with LUTS be excluded before a definitive diagnosis of BPH. Any oversight in this initial evaluation can potentially result in misclassification bias, misdiagnosis and incorrect treatment of patients.     

Comparison of voiding parameters in men and women with lower urinary tract symptoms

AIM: The aim of this study was to compare voiding parameters by using urodynamic investigations in men and women with lower urinary tract symptoms (LUTS). METHODS: A total of 164 individuals (76 men and 88 women) completed the International Prostate Symptom Score (IPSS) and underwent a detailed urodynamic investigation. Patients were stratified by voiding function, which included bladder voiding efficiency (BVE) of < 80% and of >or= 80%. RESULTS: IPSSs were similar in the men and women except for voiding symptoms for those with a BVE of >or= 80% (12 for men vs. 9 for women, P=0.016). When voiding parameters were compared according to BVE in men and women, respectively, maximum flow rate (Q(max)) (P=0.002), average flow rate (Q(ave)) (P=0.003), voided volume (P=0.037), post-void residual (PVR) (P<0.001), and bladder outlet obstruction index (P=0.016) were different for men with a BVE of < 80% and men with a BVE of >or= 80%. However, for women with a BVE of < 80% or >or= 80%, PVR (P<0.001), detrusor pressure at maximum flow rate (P=0.022), and opening detrusor pressure (P=0.024) were different. CONCLUSIONS: The voiding parameters of women differ from those of men according to voiding function. The present results show that a pressure-flow study may represent a difference according to BVE in women as well as in men. Our findings suggest that opening detrusor pressure in women reflects the urethral and detrusor during voiding phase accurately as detrusor pressure at maximum flow rate does.