Patricia Lewandoski, MD
Akhil Das, MD, FACS
BASICS
DESCRIPTION
• Hesitancy is the delay in the start of micturition.
• Intermittency is the involuntary stopping and starting of the urinary stream during voiding.
• Hesitancy and intermittency are commonly characterized as obstructive (emptying) symptoms. These spectrum of symptoms also include:
– Postvoid dribbling
– Straining to void
– Decreased force of stream
– Incomplete bladder emptying
EPIDEMIOLOGY
Incidence
• Obstructive urinary symptoms and age are highly correlated.
• Patient symptom reporting is influenced by sociodemographic and cultural factors.
• Hesitancy and intermittency is primarily related to BPH and occurs mostly in men.
Prevalence
• Age-stratified prevalence of moderate-to-severe Lower Urinary Tract Symptoms (LUTS) in men:
– 40–50 yr old: ∼20%
– 50–60 yr old: ∼30%
– 60–70 yr old: ∼40%
– 70–80 yr old: ∼56%
RISK FACTORS
• Bladder outlet obstruction:
– In men, primarily related to benign prostatic hypertrophy (BPH), bladder neck contracture, bladder stones, urethral valves, urethral stricture disease, and prostate cancer.
– In women, primarily caused by pelvic floor prolapse/large cystocele, bladder stones, and urethral stricture disease (rarely)
• Detrusor underactivity:
– Idiopathic
– Neurogenic: Diabetes, Parkinson disease, etc.
– Non-neurogenic: Dysfunctional voiding
• Obesity is associated with a higher incidence of LUTS
Genetics
N/A
PATHOPHYSIOLOGY
• Bladder outlet obstruction: Increased resistance to urinary flow due to various etiologies (BPH, stricture, etc.) requires the bladder to generate higher voiding pressures which delays the initiation of micturition and may cause intermittency.
• Inadequate detrusor contraction due to various etiologies delays the start of voiding and may cause intermittency.
ASSOCIATED CONDITIONS
BPH and erectile dysfunction in men
GENERAL PREVENTION
Adequate treatment of LUTS
DIAGNOSIS
HISTORY
• Quantification of lower urinary tract symptoms
– AUA/IPSS symptom index should be used.
– Other obstructive voiding symptoms should be assessed.
– Consider voiding diary if history is unclear.
• Assess for irritative voiding symptoms:
– Cystitis/prostatitis: Can present with acute, severe obstructive symptoms.
• History of hematuria:
– Urethral stricture
– Bladder/kidney stones
– Bladder mass
• Certain pelvic procedures can result in detrusor underactivity.
– Other medical conditions:
Certain neurologic conditions and diabetes can cause detrusor underactivity.
Prior pelvic irradiation can affect bladder contractility.
• History of STD may predispose patients to urethral stricture disease.
• Medications:
– Certain over the counter (OTC) medications for colds or sinusitis may contain phenylephrine which may exacerbate LUTS.
– Antimuscarinics may lead to obstructive symptoms.
PHYSICAL EXAM
• Abdominal exam: Palpate for a distended bladder.
• Focused neurologic exam should be performed. The following should be assessed:
– General mental status
– Ambulatory status
– Lower extremity neuromuscular function
– Anal sphincter tone
• Digital rectal exam (DRE) should be performed:
– Prostatic nodularity, if present, may be a sign of prostate cancer and should be worked up accordingly
– Size should be assessed, although DRE tends to underestimate size
– Bogginess or tenderness: Consistent with prostatitis
• In men, circumcision status, assess for urethral stenosis
• In women:
– Pelvic exam should be performed to assess for masses, pelvic floor prolapse, and/or cystocele.
– Urethral lesions should also be assessed.
• Pediatric considerations:
– Meatal stenosis should be considered in young boys who present with hesitancy and intermittency
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis by dipstick testing or microscopic exam of the sediment should be performed to screen for hematuria and UTI.
– If UTI suspected: Urine culture.
• Serum PSA should be assessed in men with at least a 10-yr life expectancy.
• Renal function tests (BUN and creatinine) are NOT recommended in the initial evaluation of men with LUTS, such as hesitancy or intermittency according to the AUA guidelines for BPH.
Imaging
• Upper tract evaluation (CT scan, IVP, or US) is not recommended as part of the initial work-up of hesitancy and intermittency unless warranted by history, exam, or lab evaluation.
• If urethral stricture disease is suspected, retrograde urethrography (RUG) may be helpful
• Transrectal US should be reserved for patients with an increased suspicion of prostate cancer undergoing prostate needle biopsy
Diagnostic Procedures/Surgery
• Urinary flow rate should be considered:
– May be helpful in patients with complex medical history.
– Should be performed in patients who are to undergo invasive therapy, as this may predict response to surgery.
• Catheterized or scanned PVR should also be considered:
– Will indicate which patients need immediate catheterization for acute urinary retention.
– Helps in diagnosis of voiding dysfunction or in patients with neurologic disease.
• Cystourethroscopy should be considered in patients with possible urethral stricture.
• Urodynamics (pressure flow) study should be considered in certain patients with complicated histories that imply neurologic disease.
Pathologic Findings
BPH findings on pathologic exam include proliferation of the stroma and epithelium.
DIFFERENTIAL DIAGNOSIS
• Bladder outlet obstruction
– BPH—common cause of hesitancy and intermittency in men
– Bladder neck contracture (ie, after prostate surgery)
– Urethral stricture disease
• Bladder stone
• Foreign body
• Cancer (prostate, bladder, urethral)
• Prostatitis
• UTI
• Bladder neck dyssynergia
• Detrusor-sphincter dyssynergia
• Pelvic organ prolapse
• Detrusor underactivity (more common cause of hesitancy and intermittency in women):
• Diabetes mellitus
• Parkinson disease
• Multiple sclerosis
• Interstitial cystitis
• Radiation cystitis
• Spinal cord injury/lumbosacral disk disease
• Medications: Noradrenergic drugs are less likely than selective serotonin reuptake inhibitors (SSRIs) to cause sexual dysfunction but more likely to cause urinary hesitancy
TREATMENT
GENERAL MEASURES
• When the effect of LUTS on quality of life was studied, most important factors for seeking treatment were the severity and degree of bother.
• Treatments are tailored to the degree of bother and the severity of the disease
• Review medications (anticholinergics, sympathomimetics, and opioids) to determine if any are potential cause; consider alternatives
• Mild symptoms: Watchful waiting and conservative measures
– Limit fluid intake
– Avoid diuretics
– Avoid coffee, tea, alcohol which may irritate the bladder
MEDICATION (2)
First Line
• For patients with evidence of infection, appropriate antibiotic therapy should be initiated.
• For men with hesitancy and intermittency presumably due to BPH/BOO:
– α-adrenergic antagonists (alfuzosin, doxazosin, tamsulosin, terazosin, silodosin) reduce resistance at the bladder outlet and provide symptom relief.
– At maximal doses, all agents are felt to be equally effective.
– Side effect profiles may include syncope, orthostatic hypotension, retrograde ejaculation, asthenia, and nasal congestion.
• 5α-reductase inhibitors (5ARIs) (finasteride 5 mg/d and dutasteride 0.5 mg/d) reduce prostate volume, prevent progression of BPH, and improve symptoms in clinical trials.
– These drugs can cause decreased libido, sexual dysfunction, and reduce PSA by ∼50% and are of little use in men without evidence of clinical BPH.
• Combination therapy: MTOPS study showed a 67% 5-yr risk reduction in BPH progression in men on combination therapy (doxazosin and finasteride) compared to placebo and better than either agent alone (39% and 34%, respectively).
Second Line
• Combination therapy combining an 5ARI with an α-blocker may be useful
• If ED and BPH/BOO coexist daily tadalafil (2.5–5 mg PO QD) can be used
SURGERY/OTHER PROCEDURES
• Urethral stricture disease and/or bladder neck contractures should be addressed using appropriate endoscopic or open procedures.
• Cystocele and/or pelvic floor prolapse in women should be addressed surgically if indicated.
• For men with hesitancy and intermittency presumably due to BPH/BOO who do not respond to medical management:
– Transurethral resection of the prostate (TURP) remains the gold standard surgical approach in patients who do not respond to medical management to BPH.
Can be combined with various laser techniques to facilitate tissue hemostasis and removal
• Transurethral laser vaporization or enucleation.
• Transurethral microwave heat treatment (TUMT): Minimally invasive therapy is somewhat effective in the treatment of LUTS due to BPH.
– Simple open prostatectomy is often reserved for patients with large prostates (>100 cc) who are not candidates for TURP.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Behavioral interventions, such as timed voiding or double voiding
Complementary & Alternative Therapies
Saw palmetto (Serenoa repens ) has been reported to improve LUTS due to BPH/BOO. Randomized clinical studies have produced contradictory results.
ONGOING CARE
PROGNOSIS (3)
• 25% of untreated patients with moderate-to-severe LUTS presumably due to BPH/BOO experience clinical progression of symptoms within 5 yr.
• Randomized clinical trials of patients receiving α-blocker therapy indicate that >1/2 will report a >25% improvement in symptoms within 3 mo of initiating treatment.
• 5–10% of men with moderate-to-severe LUTS will fail medical therapy and will require surgical intervention for their condition.
COMPLICATIONS
• Patients with disease progression who do not receive appropriate treatment may experience the following complications:
– Renal insufficiency
– UTI
– Stone formation
– Acute urinary retention
– Secondary bladder dysfunction
FOLLOW-UP
Patient Monitoring
• After appropriate treatment has been initiated and patients report improvement, annual follow-up should include:
• History and physical exam, urinalysis, PSA
– Uroflowmetry and postvoid residual urine as needed
Patient Resources
MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/003143.htm
REFERENCES
1. Rosenberg MT, Staskin DR, Kaplan SA, et al. A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting. Int J Clin Pract. 2007;61:1535–1546.
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. Takeda M, Araki I, Kamiyama M, et al. Diagnosis and treatment of voiding symptoms. Urology. 2003;62:11–19.
ADDITIONAL READING
McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185(5):1793–1803.
See Also (Topic, Algorithm, Media)
• Bladder Outlet Obstruction (BOO)
• Lower Urinary Tract Symptoms (LUTS)
• Prostate, Benign Hypertrophy
• Prostatitis, General
CODES
ICD9
• 788.61 Splitting of urinary stream
• 788.64 Urinary hesitancy
• 788.69 Other abnormality of urination
ICD10
• R39.11 Hesitancy of micturition
• R39.13 Splitting of urinary stream
• R39.19 Other difficulties with micturition
CLINICAL/SURGICAL PEARLS
• Hesitancy and intermittency is often associated with BPH and generally represents LUTS associated with an obstruction.
• Increasing hesitancy may be seen before an episode of retention.
• In men, the incidence increases with age.
• Pressure-flow studies are helpful in determining obstruction vs. detrusor underactivity.