# Lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men – over 40% of older men are affected – but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.

## Symptoms and signs

Symptoms can be categorised into:

### Filling (storage) or irritative symptoms

* Increased frequency of urination
* Increased urgency of urination
* Urge incontinence
* Excessive passage of urine at night

### Voiding or obstructive symptoms

* Poor stream (unimproved by straining)
* Hesitancy (worsened if bladder is very full)
* Terminal dribbling
* Incomplete voiding
* Urinary retention
* Overflow incontinence (occurs in chronic retention)
* Episodes of near retention
As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer. Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis. Also, recently a report of lower urinary tract symptoms even with malignant features in the prostate failed to be associated with prostate cancer after further laboratory investigation of the biopsy.

## Causes

* Benign prostatic hyperplasia (BPH)
* Bladder stone
* Cancer of the bladder and prostate
* Detrusor muscle weakness and/or instability
* Diabetes
* Use of ketamine
* Neurological conditions; for example multiple sclerosis, spinal cord injury, cauda equina syndrome
* Prostatitis, including IgG4-related prostatitis
* Urethral stricture
* Urinary tract infections (UTIs)

## Diagnosis

The International Prostate Symptom Score (IPSS) can be used to gauge the symptoms, along with physician examination. Other primary and secondary tests are often carried out, such as a PSA (Prostate-specific antigen) test, urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy and/or cystoscopy.

## Treatment

Treatment will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given; appropriate medication would be administered to treat benign prostatic hyperplasia.

### Lifestyle changes

Other treatments include lifestyle advice; for example, avoiding dehydration in recurrent cystitis.
Men with prostatic hypertrophy are advised to sit down whilst urinating. A 2014 meta-analysis found that, for elderly males with LUTS, sitting to urinate meant there was a decrease in post-void residual volume (PVR, ml), increased maximum urinary flow (Qmax, ml/s), which is comparable with pharmacological intervention, and decreased the voiding time (VT, s). The improved urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.
Physical activity
Physical activity has been recommended as a treatment for urinary tract symptoms. A 2019 Cochrane review of six studies involving 652 men assessing the effects of physical activity alone, physical activity as a part of a self-management program, among others. The evidence from this review states that there are important uncertainties whether physical activity is helpful in men experiencing urinary symptoms caused by benign prostatic hyperplasia.

### Medications

With benign prostatic enlargement causes of LUTS, people may be offered a variety of medications (as a single drug or combining them) when there are persistent moderate symptoms:
* Alpha blockers
* 5-alpha reductase inhibitors
* Phosphodiesterase inhibitors
* Muscarinic receptor antagonists
* Plants extracts (phytotherapy)
* Beta-3 agonist
If medical treatment fails, or is not an option; a number of surgical techniques to destroy part or all of the prostate have been developed.

### Surgical treatment

Surgical treatment of LUTS can include:
* Ablation procedures – used in treating both bladder tumours and bladder outlet obstruction, such as prostate conditions.
* Bladder-neck incision (BNI)
* Removal of the prostate – open, robotic, and endoscopic techniques are used.
* Stenting of the prostate and urethra.
* Transurethral resection of the prostate (TURP)
* Transurethral microwave thermotherapy
* Urethral dilatation, a common treatment for strictures.

## Epidemiology

* Prevalence increases with age. The prevalence of nocturia in older men is about 78%. Older men have a higher incidence of LUTS than older women.
* Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.
* Once symptoms arise, their progress is variable and unpredictable with about one third of patients improving, one third remaining stable and one third deteriorating.