Matthew J. Resnick, MD
David F. Penson, MD, MPH
BASICS
DESCRIPTION
• The lower urinary tract infection (LUTS) complex includes both obstructive and storage urinary symptoms.
– Obstructive urinary symptoms include urinary hesitancy, intermittency, post-void dribbling, and straining to void.
– Storage urinary symptoms include urinary frequency, nocturia, and urinary urgency.
• While benign prostatic hyperplasia (BPH) frequently contributes to the development of LUTS, there are numerous other etiologies that must be considered in patients presenting with new urinary symptoms.
• LUTS may result from structural or functional abnormalities of the genitourinary tract.
EPIDEMIOLOGY
Incidence
• There is a well-described relationship between age and the development of LUTS.
• A few data specifically address the incidence of LUTS, given the basically negligible low case-fatality rate and the often slow onset of symptoms.
Prevalence
• Disease prevalence is highly variable due to differences in disease definition.
• The Olmsted County Study revealed age-dependent increases in the prevalence of moderate-to-severe LUTS from 26% (40–49 yr) to 46% (70–79 yr)
• 21.1% of patients in the National Health and Nutrition Examination Survey (NHANES) reported at least one symptom of LUTS.
• Various community-based studies estimate the age-stratified prevalence of moderate–to-severe LUTS in men as follows:
– 40–50 yr old: ∼20%
– 50–60 yr old: ∼30%
– 60–70 yr old: ∼40%
– 70–80 yr old: ∼50–60%
RISK FACTORS
• Bladder outlet obstruction (BOO; male)
– Benign prostatic hyperplasia
– Urethral stricture disease/bladder neck contracture
– Prostate/bladder cancer
– Bladder calculi
• BOO (female)
– Pelvic organ prolapse
– Bladder calculi
– Urethral stricture disease
• Bladder (detrusor) hypocontractility
– Idiopathic
– Neurogenic
• Obesity, diabetes, and caffeine intake all have been associated with increased risk of LUTS
Genetics
• Increased risk of moderate-to-severe LUTS in men with a family history of BPH.
• The precise contribution of genetic and environmental factors to the development of LUTS remains largely unknown.
PATHOPHYSIOLOGY
• BOO necessitates generation of higher bladder pressures to overcome outlet resistance.
• Bladder “remodeling” secondary to longstanding outlet obstruction results in overactive bladder syndrome, storage symptoms, and over time, decreased contractility.
• LUTS may result from numerous conditions of the central and peripheral nervous systems.
• Result in either detrusor overactivity (storage symptoms) or detrusor hypocontractility (urinary retention/inadequate emptying).
ASSOCIATED CONDITIONS
Erectile dysfunction
GENERAL PREVENTION
NA
DIAGNOSIS
HISTORY
• Essential to quantify LUTS for both diagnosis and treatment planning
– Use the validated AUA Symptom Score (AUASS) often referred to a the AUA Symptom Index [AUA-SI]) or International Prostate Symptom Score (I-PSS) (1–7 mild; 8–19 moderate; 20–35 severe)
– Attention should be paid to nature (obstructive/storage) and duration of LUTS
• Consider voiding diary (frequency/volume charts) if the patient is unable to elaborate the nature of his or her symptoms
• Elicit history of prior urinary tract infection or prostatitis
• Elicit history of prior hematuria (gross or microscopic)
• Elicit history of prior urologic/pelvic surgery
– Prior lower urinary tract intervention predisposes to stricture/bladder neck contracture
– Disruption of pelvic plexus with pelvic surgery may result in detrusor hypocontractility
• Elicit history of other medical conditions
– Neurologic disease—overactivity or bladder hypocontractility
– Diabetes—bladder hypocontractility
– History of sexually transmitted infection(s)—urethral stricture disease
– History of pelvic radiation—urethral stricture disease or bladder hypocontractility
• Elicit family history of genitourinary disease (BPH/LUTS, prostate cancer, prostatitis)
• Review medications as certain antihistamines, antimuscarinics, sympathomimetics, and bronchodilators may exacerbate LUTS.
• Elicit history of sexual dysfunction
• Evaluate overall fitness to undergo invasive procedure(s)
PHYSICAL EXAM
• Abdominal exam to assess suprapubic region for bladder distension
• Focused neurologic exam should be performed with particular attention to:
– General mental status
– Ambulatory status
– Motor and sensory function of the lower extremities and perineum
– Anal sphincter tone
• In men:
– Inspection of the urethral meatus should be performed to rule out meatal stenosis
– Digital rectal exam (DRE) should be performed to evaluate for:
Prostatic enlargement
Nodularity or firmness suggestive of prostate cancer
Bogginess or tenderness suggestive of prostatitis
Anal sphincter tone, abnormalities of which suggest neurologic disease
• In women:
– Speculum exam should be performed to evaluate for mass, prolapse, and urethral abnormalities
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis should be performed to evaluate for urinary tract infection or hematuria.
• Serum PSA should be considered as a diagnostic test (as opposed to a screening test).
• Serum creatinine is not recommended in the evaluation of routine LUTS associated with BPH.
Imaging
• Imaging with CT or ultrasound (US) is not recommended as routine procedure.
• Upper tract imaging with either CT or US may be considered in the context of:
– Acute symptom onset
– History of upper urinary tract infection or stone disease
– History of renal insufficiency
– Recent onset of nocturnal enuresis
• Prostate imaging with transrectal or transabdominal US may provide information for treatment planning and is considered optional
Diagnostic Procedures/Surgery
• Assessment of post-void residual urine with US imaging or catheterization is optional.
– May aid in the noninvasive assessment of bladder function
• Assessment of urinary flow rate is optional that may predict response to invasive therapy.
• Pressure flow urodynamic studies are not indicated in the evaluation of the uncomplicated patient with LUTS
– May be useful in patients with mixed symptoms or neurologic disease to develop a therapeutic strategy
• Cystourethroscopy is not recommended for the uncomplicated patient with LUTS.
– May be helpful to assess prostate configuration as it relates to invasive therapies
– May be useful in patients with mixed symptoms or neurologic disease to develop a therapeutic strategy
– May be useful in patients with a history suggestive of urethral stricture/bladder neck contracture
Pathologic Findings
Histopathology of BPH reveals proliferation of both stromal and glandular prostatic elements.
DIFFERENTIAL DIAGNOSIS
• BOO:
– Urethral Stricture/bladder neck contracture
– Bladder stone
– Cancer (prostate, bladder, urethral)
– Prostatitis
– Urinary tract infection
– Detrusor-sphincter dyssynergia
– Pelvic organ prolapse
• Detrusor hypocontractility
– Diabetes mellitus
– Parkinson disease
– Multiple sclerosis
– Radiation cystitis
– Spinal cord injury
– Lumbosacral disc disease
– Bladder stone
TREATMENT
GENERAL MEASURES (1,2)
• Treatment should be offered to men with moderate to severe symptoms (AUASS or IPSS ≥8) who are bothered enough to consider therapy.
• Men with demonstrable sequelae of BPH/BOO (renal failure secondary to obstruction, bladder calculi, etc.) should be counseled on benefits of treatment.
• Treatment is tailored to symptom type (obstructive, storage, mixed).
MEDICATION
First Line
• α-Adrenergic blockers: relax prostatic/bladder neck smooth muscle tone and improve symptoms (all appear to have equal effectiveness)
– Alfuzosin 10 mg/d
– Doxazosin start 1 mg/d to max. 8 mg
– Silodosin 8 mg/d
– Tamsulosin start 0.4 mg to max. 0.8 mg
– Terazosin start 1 mg/d to max. 20 mg
– Side effects include syncope, orthostasis, retrograde ejaculation, asthenia, and nasal congestion
• 5α-Reductase inhibitors: reduce prostatic volume
– Finasteride or dutasteride
– Side effects include decreased libido and sexual dysfunction
– Reduce PSA by ∼50% and correction should be used when evaluating risk for cancer
• Combination therapy (α-adrenergic blocker + 5α-reductase inhibitor) should be considered in men with moderate to severe symptoms and prostatic enlargement.
• Tadalafil 2.5–5 mg/d can treat combined LUTS and erectile dysfunction (ED).
• Antimuscarinic agents can be used alone or in combination for overactivity/storage symptoms
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Urethroplasty or directly visualized incision of urethral stricture (DVIU) should be considered for stricture/bladder neck contracture
• Prolapse repair should be considered for women with urinary symptoms and prolapse
• Numerous surgical options exist for men with BPH/BOO. Some of these include:
– Transurethral resection of the prostate (TURP)
– Transurethral microwave therapy (TUMT)
– Transurethral laser vaporization of the prostate
– Transurethral laser enucleation of the prostate
– Simple open or laparoscopic prostatectomy (generally reserved for men with prostate volume > 80–100 cc)
• There are a few high-quality comparative-effectiveness data upon which clinical decisions can be based
– Patients and physicians must weigh potential benefits and harms of treatments.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Behavioral interventions including timed voiding, double voiding, and biofeedback may improve symptoms.
Complementary & Alternative Therapies
Saw palmetto is widely used to treat LUTS with little benefit in randomized trials (CAMUS trial) (3).
ONGOING CARE
PROGNOSIS
• 20% of men with untreated LUTS experience progression within 5 yr (MTOPS trial). Options for men with BPH/BOO include:
– Combination therapy reduces risk of progression by 66% (2).
• 5–10% of men with moderate-to-severe LUTS will require surgical intervention (MTOPS).
COMPLICATIONS
• Complications of BPH/LUTS include:
– Recurrent UTIs
– Renal insufficiency
– Bladder stone formation
– Urinary retention
– Secondary bladder dysfunction
FOLLOW-UP
Patient Monitoring
• Monitoring with serial AUASS or IPSS to quantify symptom intensity and bother
• Urinalysis, serum PSA, urinary flow rate, and post-void residual as clinically indicated
Patient Resources
Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=59&display=1
REFERENCES
1. AUA Guideline on the Management of Benign Prostatic Hyperplasia (BPH). 2012. http://www.auanet.org/content/clinical-practice-guidelines. Accessed November 23, 2013.
2. McConnell JD, Roehrborn CG, Bautista OM, 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;349:2387–2398.
3. Barry MJ, Meleth S, Lee JY, et al. Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial. JAMA. 2011;306:1344–1351.
ADDITIONAL READING
• McNicholas TA, Kirby RS, Lepor H. Evaluation and nonsurgical management of benign prostatic hyperplasia. In: Wein AJ, Kavoussi LR, Novick AC, et al. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2010.
• Roehrborn CG. Benign prostatic hyperplasia: etiology, pathophysiology, epidemiology, and natural history. In: Wein AJ, Kavoussi LR, Novick AC, et al. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2010.
See Also (Topic, Algorithm, Media)
• Bladder Outlet Obstruction (BOO)
• LUTS Algorithm 
• Prostate, Benign Hyperplasia/Hypertrophy (BPH)
• Reference Tables: AUA Symptom Index/International Prostate Symptom Score (I-PSS)
CODES
ICD9
• 788.41 Urinary frequency
• 788.64 Urinary hesitancy
• 788.99 Other symptoms involving urinary system
ICD10
• R35.0 Frequency of micturition
• R39.9 Unsp symptoms and signs involving the genitourinary system
• R39.11 Hesitancy of micturition
CLINICAL/SURGICAL PEARLS
• Quantification of symptoms is paramount in the management of LUTS.
• Treatment should be offered to men with moderate to severe symptoms (AUASS ≥8).
• Treatment should be tailored to symptoms and prostate volume and may include behavioral intervention, medical management, or surgical intervention.