Resident Editor: Scott R. Bauer, MD, ScM

Faculty Editor: Benjamin Breyer, MD

BOTTOM LINE ✔ Distinguish obstructive versus storage symptoms with AUASI ✔ Treat mild or minimally bothersome symptoms with behavior/lifestyle change ✔ Severe symptoms, large prostate or higher PSA consider combination medical therapy

Background

• Male LUTS are common (~50% moderate-severe symptoms among men age >70)
  • Most common causes are benign prostatic hyperplasia (BPH), overactive bladder (OAB), and post-prostatectomy urinary incontinence (UI)
  • Acute urinary retention and obstructive nephropathy are rare (<1%/year)
• Diagnosis and management decisions based on patient-reported outcomes (PROs) and non-invasive urodynamic testing (uroflow and post-void residual)
• Benign prostatic hypertrophy (BPH) is a histologic diagnosis associated with obstructive voiding symptoms due to bladder outlet obstruction
• Overactive bladder (OAB) is defined as urinary urgency, frequency, nocturia, and urge incontinence (see Urinary Incontinence chapter), in the absence of other causes like UTI
• Severe LUTS is associated with increased detection of low-risk prostate cancer in the setting of PSA screening trials, likely due to over-detection and higher biopsy rates.

Differential Diagnosis

• Transient causes of LUTS: consider if sudden onset and duration < 6 weeks

• Infection
• Excessive urine production: untreated diabetes, increased fluid intake (>2L/day or large episodic intakes), alcohol, caffeine, hypercalcemia, DI
• Medications: diuretics (increase urine output - consider timing); anticholinergics, narcotics, or calcium channel blockers (impair bladder contraction); sedatives (cause delirium); alpha agonists (increase urinary spincther tone  retention); alpha-antagonists (decrease spincther tone  incontinence)
• Psychiatric comorbidities: anxiety and depression are associated with impaired voiding and increased bother from urinary symptoms
• Restricted mobility: patients cannot reach bathroom in time
• Constipation
• Delerium, cognitive impairment

• Other causes

• Neurologic disease: MS, stroke, Parkinson’s, lumbar disc disease
• Post-surgical: nerve dysfunction after pelvic surgery, post prostatectomy
• GU anatomic abnormalities: pelvic prolapse, urethral strictures, bladder diverticulum
• Multipartity with multiple vaginal deliveries, traumatic delivery

History

• Symptoms are classified as either "obstructive/voiding" or "irritative/storage." Use the American Urologic Association (AUA) Symptom Index Score (see below) to categorize symptoms, initiate treatment, and follow outcomes.
  • Obstructive/voiding symptoms: hesitancy, decreased stream force or caliber, intermittent stream, incomplete voiding, dribbling. Suggest BPH or obstruction.
  • Irritative/storage symptoms: frequency, urgency, nocturia. Suggest OAB or UTI.
• Assess urinary bother: “If you were to spend the rest of your life with your urinary symptoms just as they are now, how would you feel about that?”
• Assess for urinary incontinence: “During the past three months, have you leaked urine (even a small amount)?” (if yes, see Urinary Incontinence chapter)
• Comorbidities (obesity, neurologic disease, diabetes)
• Rule out reversible causes of UI (see “Differential Diagnosis” above)

AUA Symptom Index (AUASI)

Questions	Not at all	Less than 1 time in 5	Less than 1/2 the time	About 1/2 the time	More than 1/2 the time	Almost always
1. Over past month, how often have you had a sensation of not emptying your bladder completely after urinating?	0	1	2	3	4	5
2. Over past month, how often have you had to urinate again less than 2 hours after you finished urinating?	0	1	2	3	4	5
3. Over past month, how often have you stopped and started again several times when you urinated?	0	1	2	3	4	5
4. Over past month, how often have you found it difficult to postpone urination?	0	1	2	3	4	5
5. Over past month, how often have you had a weak urinary stream?	0	1	2	3	4	5
6. Over past month, how many times have you had to push or strain to begin urination?	0	1	2	3	4	5
7. Over past month, how many times did you most typically get up to urinate at night?	0	1	2	3	4	5
The sum of the seven numbers equals the symptom score. 0-7: Mild; 8-20: Moderate; >20: Severe. Obstructive/voiding symptoms= questions #1,3,5,6. Irritative/storage symptoms= questions #2,4,7.

Evaluation

• Physical exam: palpation of abdomen for distended bladder, DRE to evaluate sphincter tone and prostate gland (size, consistency, shape, abnormalities suggestive of prostate cancer).
  • The size of prostate on exam does NOT correlate with degree of obstruction or level of symptoms. Any focal enlargement needs to be evaluated further for prostate cancer.
  • Prostate size is generally underestimated on digital examination.
• Labs: UA (r/o hematuria, proteinuria, pyuria), serum creatinine.
• PSA is an alternative way to assess prostate size. The AUA recommends checking this in workup of men with LUTS thought secondary to BPH (PSA>1.5ng/mL more likely to respond to 5α reductase inhibitors). The risks and benefits of PSA screening for prostate cancer should be explored using shared decision making only among men with life expectancy >10 years and who would want to undergo treatment for prostate cancer if diagnosed.
• Frequency-volume charts, max urinary flow rate, PVR, are all optional tests that can be discussed with the patient and in consultation with a urologist.

Treatment

General principles

• Use the AUA score and obstructive/voiding versus irritative/storage questions to determine the most prominent or bothersome symptoms (there is often overlap).
• Treat reversible causes and comorbid conditions (see above).
• In general, for mild symptoms or those not bothered by their symptoms, watchful waiting and lifestyle modification is indicated.
• For moderate to severe symptoms, patients can be offered watchful waiting, medical therapy, or surgical therapy, depending on preference.
• 35% of patients improve without treatment, 25% fail medical treatment.

BPH

• Follow improvement by monitoring the AUASI (clinically meaningful effect = decrease of 3-6 in overall score).
• Behavioral/lifestyle treatment (1^st line, especially for mild or minimally bothersome symptoms)
  • Recommend weight loss, regular exercise, double voiding after each urination, voiding in sitting position, scheduled voiding (every 2-3 hours)
• Medical treatment (2^nd line)
  • Alpha-1 blockers: doxazosin (Cardura), terazosin (Hytrin), tamsulosin (Flomax).
    • Equal effectiveness, improve AUASI by 6-9 points in 1-6 weeks.
    • Advise patients not to take at the same time as phosphodiesterase type 5-inhibitors (i.e. sildenafil), as this may potentiate hypotension.
    • Side effects: orthostatic hypotension (esp doxazosin and terazosin – consider dosing at bedtime), dizziness, retrograde ejaculation, fatigue
  • 5-alpha reductase inhibitors – finasteride (Proscar), dutasteride (Avodart)
    • Improve AUASI by 4-5 points and 25% reduction in prostate volume over 3-12 months.among men with larger prostates (> 40g), PSA>1.5 ng/mL is recommended as surrogate.
    • Not effective as monotherapy.
    • PSA may be decreased by 50%, and thus, should interpret PSA with caution.
    • Side effects: impotence, decreased libido, depression. Sexual side effects may persistent after discontinuation.
  • Combination therapy more likely to reduce risk of BPH progression compared to monotherapy alone.
  • Saw palmetto berry (common herbal therapy) not effective in large, multicenter RCTs.
• Surgical treatments: transurethral resection of prostate (TURP), transurethral incision of prostate (TUIP), open simple prostatectomy, laser prostatectomy, transurethral needle ablation (TUNA), aquablation (rezuum), urolift.

OAB

• Follow improvement by monitoring the AUA symptom score or OAB-specific scores, such as OABSS or OAB-q.
• Behavioral/lifestyle treatment (1^st line)
  • Recommend weight loss, regular exercise, scheduled voiding (every 2-3 hours)
  • Pelvic floor muscle training (referal to physical therapy, confirm provider offers pelvic PT to men, 8-12 sessions to assess response, continue exercises at home).
  • Bladder training and urge suppression (referral to Urology NP)
  • Fluid management (<2L/day, drink smaller amounts spread out throughout the day, stop drinking 5hrs before sleep).
  • Avoid dietary irritants including spicy foods, alcohol, caffeine, and citrus foods.
• Medical treatment (2^nd line): Anti-muscarinics
  • Darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine or trospium (equally effective)
  • Extended release forms may reduce side effects.
  • Contraindicated in untreated narrow-angle glaucoma, may exacerbate existing cardiac arrthymias.
  • Side effects: dry mouth, constipation, and dry eyes (50% self-discontinuation within 6 months).
  • Avoid in elderly. If starting among older patients who are aware of risks, start at half of lowest dose, uptitrate slowly and monitor for subclinical urinary retention and other anticholinergic side effects.
• Advanced treatments: sacral neuromodulation, peripheral tibial nerve stimulation, onabotulinumtoxinA bladder injections.

Symptom-specific behavioral/lifestyle recommendations:

Nocturia

• Urinate before bedtime
• Use a bedside urinal to limit sleep disruption and fall risk
• Limit food and fluid intake 5 hours before bedtime
• Avoid caffeine after noon time
• Avoid salty food in the afternoon and evening
• Increase daily exercise in morning
• Sleep in a cool dark room, avoid TV/computer work 1 hour before bed
• Maintain a healthy weight

Post-void dribbling

• Apply pressure to the perineum behind the scrotum and lift forward. Milk the penile urethra forward to help expel urine retained in the urethra.
• Shake penis to remove any residual drops.
• Use tissue to blot the tip of penis to assure no leakage.

When to refer

• Refer to urology for consideration of surgical treatment if medical therapy fails, for a diagnostic procedure, second opinion, or if patient has had complete obstruction.
•  Indications for referral to a Urologist:
  • H/o prostate or bladder cancer
  • Abnormal DRE
  • Sterile hematuria
  • Bladder pain
  • Elevated PSA
  • Palpable bladder
  • History/risk of urethral strictures
  • Neurogenic bladder (due to stroke, spinal cord injury, Parkinson’s)
  • Renal compromise due to urinary retention
  • Bladder stones
  • Persistent or recurrent urinary retention (PVR>150cc in older adults)
  • Chronic urinary tract infections

 

References

American Urologic Association, Clinical Guidelines in the Management of BPH, Revised 2011.

Marberger M. Medical management of lower urinary tract symptoms in men with benign prostatic enlargement. Adv Ther. 2013 Apr;30(4):309-19.

McConnell JD, Roehrborn CG, et al.  The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia.  N Engl J Med. 2003 Dec 18;349(25):2387-98.

Sarma AV, Wei JT. Benign Prostatic Hyperplasia and Lower Urinary Tract Symptoms. N Engl J Med 367;3: 248-257, July 19, 2012.

Schenk JM, Kristal AR, Arnold KB, Tangen CM, Neuhouser ML, Lin DW, White E, Thompson IM, Association of symptomatic benign prostatic hyperplasia and prostate cancer: results from the prostate cancer prevention trial. Am J Epidemiol. 173(12):1419-28, 2011.

Gormley EA, Lightner DJ, Faraday M, and Vasavada SP. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol 2015; 193(5): 1572-80.

Ouslander JG. Management of overactive bladder. N Engl J Med 2004; 350(8): 786-99.