Assessment and management of lower urinary tract symptoms in men
Intended for healthcare professionals
Evidence and practice    

Assessment and management of lower urinary tract symptoms in men

Brett Craig Dawson Clinical nurse practitioner, University College London Hospital, London, England

Why you should read this article:
  • To learn about the main types of lower urinary tract symptoms (LUTS) affecting men

  • To understand the primary causes of LUTS in men

  • To familiarise yourself with the available options for managing LUTS in men

Lower urinary tract symptoms (LUTS) is a broad term that covers a range of urinary issues, which are often categorised as storage and voiding symptoms. Storage symptoms include increased frequency, nocturia, urgency and urge incontinence, while voiding symptoms include hesitancy, suboptimal flow, dribbling and incomplete emptying. In men, the most common causes of LUTS are benign prostatic hyperplasia (prostate enlargement) and overactive bladder. This article provides an overview of the anatomy of the prostate and outlines the assessment process for men presenting with LUTS. It also explains the recommended lifestyle modifications, medicines and surgical interventions available to male patients who are experiencing these symptoms.

Nursing Standard. doi: 10.7748/ns.2023.e11996

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

brett.dawson1@nhs.net

Conflict of interest

None declared

Dawson BC (2023) Assessment and management of lower urinary tract symptoms in men. Nursing Standard. doi: 10.7748/ns.2023.e11996

Published online: 27 March 2023

Lower urinary tract symptoms (LUTS) is a broad term that covers a range of urinary symptoms. Bothersome LUTS occurs in around 41% of men over the age of 40 years (De Ridder et al 2015) with underlying pathophysiology such as diabetes mellitus, malignancy and infection being common causes of these symptoms (National Institute for Health and Care Excellence (NICE) 2015). In male patients, the most prevalent causes of LUTS are benign prostatic hyperplasia (prostate enlargement) leading to bladder outflow obstruction, and overactive bladder (Abdelmoteleb et al 2016). LUTS can be categorised as (Abdelmoteleb et al 2016):

  • Storage symptoms – including increased frequency, nocturia, urgency and urge incontinence.

  • Voiding symptoms – including hesitancy, suboptimal flow, dribbling and incomplete emptying.

Post-micturition symptoms, such as post-void dribbling and an incomplete emptying sensation, may also be considered separately.

LUTS can be bothersome for patients and may negatively affect their quality of life, while there are also significant healthcare costs associated with its treatment (Welliver et al 2022). If the underlying cause of these symptoms is not managed appropriately, severe complications may develop, such as obstructive nephropathy, sepsis and acute urinary retention (Speakman and Cheng 2014). Due to uncertainty and variations in practice, clinical guidelines have been developed to provide clear recommendations for healthcare professionals on how to diagnose, monitor and treat male patients presenting with LUTS (NICE 2015, Lerner et al 2021, Gravas et al 2022). This article describes the anatomy of the prostate, details the assessment process for men presenting with LUTS and outlines the management options available for these patients.

Anatomy of the prostate

Since benign prostatic hyperplasia is one of the most common causes of LUTS in men (Abdelmoteleb et al 2016), it is important that healthcare professionals understand the anatomy of the prostate. The prostate is a dense fibromuscular gland, located directly inferior to the bladder, that wraps around the proximal urethra. The prostate develops laterally as epithelial buds from the urogenital sinus wall (Yu and Jiang 2020). Following fetal growth and pubertal development, timely androgen exposure has a fundamental role in further growth and development of the prostate (Vickman et al 2020). Testosterone, produced in the testes, travels through the prostate, and is converted to dihydrotestosterone by the enzyme 5-α reductase. Testosterone or dihydrotestosterone bind to 5-α reductase, subsequently increasing the transcription of androgen-dependent genes and stimulating proliferation of cells, leading to prostatic growth (Youn et al 2018).

The normal size of the prostate gland is 20 cubic centimetres (cc) (Ramsamy et al 2016), and a prostate volume larger than 30cc is defined clinically as benign prostatic hyperplasia (Huh et al 2012). Five lobes form the prostate gland: anterior and posterior lobes, two lateral lobes and a median lobe. Histologically, the prostate comprises three anatomical zones: central, peripheral and transitional. The central zone forms the base of the gland and surrounds the ejaculatory ducts, while the peripheral zone makes up 70% of the gland (Sinnott et al 2015) and surrounds the central zone and distal prostatic urethra. The transitional zone is a small portion surrounding the urethra between the urinary bladder and the verumontanum (Aaron et al 2016).

Figure 1 shows the anatomy of the prostate.

Figure 1.

Anatomy of the prostate

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Assessment of lower urinary tract symptoms

An initial assessment of the patient’s symptoms can be conducted by a healthcare professional, such as a doctor or appropriately trained nurse, in an outpatient clinic setting. It is important to recognise that LUTS can have widespread effects on a person’s quality of life, potentially affecting their social life and highly personal areas such as sexual health. Therefore, the patient should be given time to explore and discuss these issues with the healthcare professional in a supportive and private environment.

Medical and symptom history

The initial assessment should include a full medical history to identify the possible causes of LUTS, as well as a review of the patient’s current medicines to identify any of these that can exacerbate symptoms – for example antidepressants, antihistamines, bronchodilators and anticholinergics (NICE 2015, Hashimoto et al 2017). The patient’s allergy status should also be ascertained.

A symptom history should be taken to determine the duration and severity of the patient’s LUTS, as well as the effects of these on their quality of life. To assist with this, the validated International Prostate Symptom Score (IPSS) questionnaire can be used, which the patient may complete before attending the outpatient clinic. This tool uses seven questions related to symptoms experienced and an additional question related to quality of life, all during the past month (Temi et al 2015). The questions cover incomplete emptying, frequency, intermittency, urgency, weak urine stream, straining and nocturia, and are scored based on the frequency of the patient’s symptoms. Information from the IPSS can also determine if the patient’s symptoms are bothersome, as well as if they are predominantly storage or voiding issues based on the subscores (Ito et al 2020). The IPSS can also be used to evaluate the effectiveness of subsequent management interventions (Gravas et al 2022), although it does not assess incontinence and post-micturition symptoms.

European Association of Urology (EAU) (Gravas et al 2022) guidelines recommend using a validated urinary input and output chart (bladder diary) – such as the International Consultation on Incontinence Questionnaire bladder diary (Bright et al 2014) – for at least three days as part of a LUTS assessment. A bladder diary can also identify nocturnal polyuria (increased urine production at night).

Further information such as the patient’s daily fluid intake and the type of fluid consumption can aid understanding of factors that may be exacerbating the patient’s LUTS, such as caffeine and alcohol consumption (Gravas et al 2022). Information about the patient’s smoking status should also be included in the initial assessment, since it has been identified that there is a higher prevalence of male LUTS in former and current smokers compared with non-smokers (Kawahara et al 2020).

Blood tests and urinalysis

Urinalysis should be performed to identify or rule out urinary tract infection (UTI) as the cause of a patient’s LUTS; if UTI is identified, a urine culture should be requested to inform appropriate treatment based on the bacteria present. If the urinalysis has demonstrated microscopic haematuria or the patient has reported gross haematuria, a urethrocystoscopy (endoscopic examination of the bladder and urethra) is required to identify or rule out malignancy (Gravas et al 2022).

Venous sampling to obtain the patient’s prostate-specific antigen (PSA) levels and renal function levels is a crucial aspect of the initial assessment of LUTS. Renal function tests provide information on the patient’s glomerular filtration rate and creatinine levels; a decline in glomerular filtration rate and a rise in creatinine levels compared with their actual or perceived baseline can indicate renal insufficiency. These tests are important because hydronephrosis (swelling of one or both kidneys due to a build-up of urine), renal insufficiency and urinary retention are prevalent in patients with benign prostatic hyperplasia (Akdemir et al 2012).

PSA is excreted by the prostate. Serum PSA levels are commonly measured in prostate cancer diagnosis, but can be elevated in large benign adenomas. Therefore, the use of PSA density (serum PSA level divided by the prostate volume) is recommended for male patients presenting with LUTS to provide a more accurate indicator of prostate cancer risk (Nordström et al 2017). A serum PSA level of >0.15 nanograms per mL may be suggestive of prostate cancer, requiring further assessment (Adhyam and Gupta 2012).

Key points

  • Lower urinary tract symptoms (LUTS) can be bothersome for patients and may negatively affect their quality of life

  • If the underlying cause of LUTS is not managed appropriately, severe complications may develop, such as obstructive nephropathy, sepsis and acute urinary retention

  • Lifestyle modifications should initially be implemented for men presenting with LUTS

  • The first-line medicine recommended for men experiencing moderate-to-severe LUTS is an α1-blocker

  • Various surgical management options are available if lifestyle modifications and pharmacological management have been unsuccessful or if the patient is unwilling to trial medicines

Urodynamic testing

Urodynamic testing includes a range of invasive and non-invasive tests used to assess the functioning of the bladder and urethra in storing and releasing urine. Despite the literature indicating that several non-invasive tests demonstrate high sensitivity and specificity, evidence is limited, and invasive urodynamics remains the ‘gold standard’ for diagnosing bladder outlet obstruction (Malde et al 2017).

The routine use of urodynamics in LUTS assessment has been debated. Lewis et al (2020) conducted a multicentre randomised controlled trial of 820 men with LUTS, with the findings suggesting that urodynamics should not be routinely used in LUTS assessments.

Uroflowmetry

Uroflowmetry involves a cost-effective, non-invasive test that can be performed to assess the patient’s flow time, maximum flow rate (Qmax) and average flow rate. The curve on the graph produced by the urine flow (Figure 2) is generated by detrusor contraction strength and bladder outlet resistance. However, in men with abnormal voiding, uroflowmetry is unable to determine the underlying mechanism of reduced flow and cannot differentiate between reduced bladder contraction strength and increased bladder outlet resistance.

Figure 2.

Urine flow graph

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A Qmax of >15mL per second and a bell-shaped curve indicates a normal voiding pattern, while a Qmax of <15mL per second may be caused by benign prostatic hyperplasia, urethral strictures, detrusor underactivity or dysfunctional voiding, with the shape of the curve on the graph being important in determining the underlying diagnosis (Morgia and Russo 2018). The flow test should be repeated if <150mL of urine is produced.

Post-void residual urine

After urination, a non-invasive post-void residual ultrasound scan can be performed to determine the volume of urine remaining in the bladder, with a threshold of 50mL being a predictor of bladder outflow obstruction, although this may also be associated with detrusor dysfunction (Gravas et al 2022). Studies by McConnell et al (2003) and Roehrborn (2006) found that a high post-void residual baseline was associated with an increased risk of symptom progression. Acute and chronic urinary retention may occur due to benign prostatic hyperplasia, leading to severe pain, and one third of patients undergoing surgical intervention for benign prostatic hyperplasia will require catheterisation (Devlin et al 2020).

Invasive urodynamics

Urodynamic cystometry involves artificially filling the bladder with 0.9% sodium chloride via a catheter. A specialised urethral catheter detects pressure in the bladder (intravesical) while a rectal catheter detects pressure in the abdomen; these pressures are then subtracted to provide the pressure in the detrusor muscle (Yao 2022). In the UK, NICE (2015) guidelines only recommend considering cystometry in patients with LUTS who are considering surgical management options.

A voiding cystourethrogram takes radiological images of the urinary tract after artificially filling the bladder via a catheter with contrast material that is easily seen on X-ray imaging, then recording images as the material flows out. This procedure can be useful in diagnosing bladder diverticula, urethral pathology and vesicoureteral reflux (Gravas et al 2022).

Medical imaging

The recommended modality for assessing the prostate is a transrectal ultrasound scan, although transabdominal ultrasound, computed tomography (CT) scans or magnetic resonance imaging (MRI) may also be used to determine the prostate size (Gravas et al 2022). Transrectal ultrasound can also be used to determine whether the median lobe of the prostate protrudes into the bladder (Duijn et al 2022, Gravas et al 2022), which will potentially cause bladder outlet obstruction and can affect the patient’s suitability for certain surgical interventions.

Management of lower urinary tract symptoms

Lifestyle modifications

Lifestyle modifications should initially be implemented for men presenting with LUTS. Lin and Freedland (2015) found that these patients may benefit from: consuming a diet that includes fruits, vegetables, protein, vitamins and polyunsaturated fatty acids; undertaking regular physical activity; and maintaining a healthy body weight. Box 1 details some of the recommended lifestyle modifications for men with LUTS.

Box 1.

Recommended lifestyle modifications for men with lower urinary tract symptoms

  • Reduce fluid intake at specific times to reduce urinary frequency when it is most inconvenient, for example at night or when going out in public

  • Use relaxed and double-voiding techniques

  • Use urethral milking to prevent post-micturition dribbling

  • Employ distraction techniques such as penile squeeze, breathing exercises, perineal pressure and mental ‘tricks’ to take the mind off the bladder and toileting

  • Undertake bladder retraining that encourages ‘holding on’ when experiencing urgency to increase bladder capacity and the time between voiding

  • Moderate or avoid caffeine and alcohol intake

  • Receive a medication review to optimise the time of medicines administration or substitute medicines for others that have fewer urinary effects

  • Receive assistance when dexterity, mobility or mental state are impaired

(Adapted from Gravas et al 2022)

It is also important to consider the psychological effects such as stress, anxiety and depression that can result from prolonged LUTS (Pethiyagoda et al 2021). Healthcare professionals should take a supportive and compassionate approach when discussing lifestyle modifications to improve patients’ quality of life, and may need to refer patients to psychological services where appropriate.

Pharmacological management

When lifestyle modifications are unsuccessful or not appropriate, the first-line medicine recommended for men experiencing moderate-to-severe LUTS is an α1-blocker, for example tamsulosin hydrochloride, alfuzosin hydrochloride, doxazosin or terazosin (NICE 2015, Lerner et al 2021, Gravas et al 2022). The mechanism of action of α1-blockers inhibits the effect of noradrenaline (norepinephrine) on the smooth muscle cells in the prostate, thereby reducing prostate tone and bladder outflow obstruction (Sung et al 2020). Noted adverse effects such as ejaculatory dysfunction and postural hypotension should be discussed with the patient before commencing this treatment (Joint Formulary Committee 2022).

Other types of medicines that may be prescribed for male LUTS include 5α-reductase inhibitors and phosphodiesterase-5 inhibitors. 5α-reductase inhibitors include finasteride and dutasteride, and guidelines differ slightly in terms of their recommendations regarding the use of these medicines. EAU (Gravas et al 2022) guidelines recommend using 5α-reductase inhibitors in patients with a prostate volume >40cc and/or an elevated PSA concentration >1.4 nanograms per mL, whereas NICE (2015) and American Urological Association (Lerner et al 2021) guidelines recommend use in patients with a prostate volume >30cc or a PSA >1.4 nanograms per mL and who are considered to be at high risk of progression.

McConnell et al (2003) demonstrated that the use of finasteride alone or in combination with the α1-blocker doxazosin reduced the risk of acute urinary retention and the requirement for surgery. Adverse effects of 5α-reductase inhibitors include reduced libido, erectile dysfunction and ejaculatory dysfunction, with gynaecomastia (male breast development) occurring in 1-2% of patients (Gravas et al 2022). De Nunzio et al (2016) also identified improved patient outcomes for dual therapy using an α-blocker and a 5α-reductase inhibitor, compared with monotherapy.

Erectile dysfunction is commonly reported by men presenting with LUTS (Obiatuegwu et al 2021). NICE (2015) guidelines state that phosphodiesterase-5 inhibitors – which are commonly used to treat erectile dysfunction – should not be used solely to treat LUTS in men. However, later guidelines from the EAU (Gravas et al 2022) and American Urological Association (Lerner et al 2021) recommend the use of the phosphodiesterase-5 inhibitor tadalafil 5mg daily for men with LUTS, irrespective of whether they are also experiencing erectile dysfunction. In the UK, tadalafil 5mg once daily is licensed for male LUTS secondary to benign prostatic hyperplasia (Joint Formulary Committee 2022).

Surgical management

Various surgical management options are available for men presenting with LUTS, if lifestyle modifications and pharmacological management have been unsuccessful or if they are unwilling to trial medicines due to their adverse effects.

Transurethral resection of the prostate

Transurethral resection of the prostate (TURP) is considered the ‘gold standard’ surgical procedure for benign prostatic hyperplasia (Michalak et al 2015), and involves removing tissue from the transitional zone of the prostate.

After TURP, almost all men will temporarily experience mild burning, frequent urination and haematuria, while 65-75% will experience retrograde ejaculation (where semen enters the bladder during ejaculation) and <10% will experience erectile dysfunction (The British Association of Urological Surgeons 2021a). Other complications include urethral injury, post-operative retention, incontinence and incidental diagnosis of prostate cancer from histopathology results. Eredics et al (2018) identified that TURP has a 0.1% 30-day in-hospital mortality rate and a reintervention rate at eight years of around 13%.

Appropriate patient selection for this procedure is important, with EAU (Gravas et al 2022) guidelines recommending the use of TURP in men with moderate-to-severe LUTS and prostate volume of 30cc-80cc.

Alternative surgical procedures

Several alternative surgical procedures to TURP are available, including transurethral incision of the prostate, holmium laser enucleation of the prostate (HoLEP), laser vaporisation of the prostate, prostatic urethral lift and Rezum.

Transurethral incision of the prostate should be offered to men with a prostate volume <30cc, without median lobe protrusion (Gravas et al 2022). Similar adverse effects to TURP are common in transurethral incision of the prostate.

HoLEP is an invasive surgical option that involves using a holmium laser to peel out the central part of the prostate gland to create a wider channel, thus improving urine flow (The British Association of Urological Surgeons 2021b). It offers several advantages over TURP, including fewer complications, reduced length of stay and shorter catheterisation time (Michalak et al 2015). NICE (2015) recommends the use of HoLEP in men with prostate volume <80cc; however, the EAU (Gravas et al 2022) and American Urological Association (Lerner et al 2021) recommend offering HoLEP to men as an alternative to TURP, with prostates as large as 800cc being successfully enucleated (Vincent and Gilling 2015). HoLEP and TURP have comparable effects on sexual function (Gravas et al 2022).

Laser vaporisation of the prostate uses the same laser insertion technique as other surgical options, but the energy produced by the lithium-triborate crystal enables a higher energy application and faster tissue vaporisation through a larger laser beam area (Castellani et al 2021). Laser vaporisation of the prostate can be offered as an alternative to TURP (Gravas et al 2022), but has shown a 22% conversion rate to TURP (Elmansy et al 2012). Men who are at increased risk of bleeding should be considered for this technique over TURP (Lerner et al 2021).

Younger men who would like to preserve sexual function may want to be considered for minimally invasive techniques such as prostatic urethral lift, since no significant effects on sexual function have been reported with this procedure (Gravas et al 2022). Prostatic urethral lift involves placing implants into the prostate to pull excess tissue away, so that it does not obstruct the urethra (Knight et al 2022). Prostatic urethral lift may be suitable if the patient’s prostate volume is <70cc and there is no median lobe protrusion. However, complications associated with this procedure include haematuria, dysuria, pelvic pain, urgency, infection and incontinence (Gravas et al 2022).

Rezum is a minimally invasive technique that involves injecting hot water vapour into the capsule of the prostate, targeting the median lobe. NICE (2020) recommends the Rezum procedure for patients with moderate-to-severe LUTS and a moderately enlarged prostate (30cc-80cc). The most common adverse effects associated with this procedure are dysuria, haematuria, haematospermia (blood in the semen), urgency and UTI, while sexual dysfunction has not been reported (Westwood et al 2018).

Conclusion

Nurses and other healthcare professionals should be aware that, for men presenting with LUTS, assessment is crucial to identify underlying issues and to develop an appropriate management plan. Lifestyle modifications should initially be implemented for these patients, before considering pharmacological and surgical management options. Male patients with LUTS should be provided with all the information necessary to make an informed choice regarding the management of their symptoms.

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