Download assessment of lower urinary tract symptoms in younger men

MEN’S HEALTH
ASSESSMENT OF LOWER
URINARY TRACT SYMPTOMS
IN YOUNGER MEN
Lower urinary tract symptoms (LUTS) are common in the ageing male and
represent a significant burden on both the patient and the healthcare system
worldwide.1,2 Accordingly, the majority of clinical trials and guidelines focus on the
older patient, despite the fact that men below these ages will also present with
many of the same symptoms. In this review, the authors explore the challenges of
assessing and managing men below 50 years with LUTS.
Dr Odunayo
Kalejaiye
Urology SpR
Professor
Raj Persad
Consultant
Urologist;
Honorary
Professor of
Urology
Dr Jon Rees
GP Partner
Department
of Urology,
North Bristol
NHS Trust
The aetiology of LUTS is multifactorial with causes
attributed to dysfunction of the bladder and its
outlet – including the prostate, urethra and sphincter;
the neurological innervation of the lower urinary
tract, and medical co-morbidities.1,2 It is important
to consider all these aspects when assessing patients.
While in older men, benign prostatic enlargement
is the commonest cause of male LUTS, in younger
men this is unusual, and other diagnoses should be
considered more likely.
What are LUTS?
Men with urinary symptoms are often characterised
as having ‘prostatism’ or benign prostatic hyperplasia
(BPH). However, given the wide variety of possible
causes of urinary symptoms, a patient is best described
as having LUTS, encouraging a more holistic approach
to their assessment and subsequent management.
LUTS may be divided into:
Storage symptoms
urgency, urinary frequency, nocturia, urgency
incontinence
Voiding symptoms
slow/poor stream, hesitancy, terminal dribbling
Post micturition symptoms
incomplete bladder emptying, post micturition
dribbling
Storage symptoms
were commonest in men
39 years or younger, with
a prevalence of 37.5%
24 | November/December 2013 |
How common are LUTS
in younger men?
The EPIC study,3 a population-based survey which
recruited men aged over 18 years, found that the
prevalence of LUTS increased with age, from 51.3%
in men aged 18-39 years to 62% in those aged 40-59
years. This is compared with a prevalence of 80.7%
in men aged 60 years or older. Storage symptoms
were commonest in men 39 years or younger, with a
prevalence of 37.5%, compared with a prevalence of
19.9% for voiding symptoms in this age group. These
rates increased to 50.6% and 24.1% respectively in
men aged 40-59 years.
Possible causes of LUTS in young men
Overactive bladder (OAB)
OAB is common in young men and is characterised
by the presence of storage symptoms. The cardinal
symptom of OAB is urgency, with or without urge
incontinence. Patients may also complain of urinary
frequency and nocturia.
Benign prostatic enlargement
The Olmsted county study, which followed men aged
40-79 years old for 12 years, provided early evidence
that benign prostatic hyperplasia (BPH) is age related.4
Moderate to severe LUTS was present in 26% aged
40-49 years. In men aged less than 50 years, the
International Prostate Symptom Score (IPSS) increased
by 0.05/year, and the peak flow rate decreased by
1.1% per year.4 It has been suggested that bladder
outlet obstruction due to BPH in young men should
be suspected in men with large prostates (greater than
35mL volume), especially if aged 46-50 years.5
Bladder neck dysfunction
This is a poorly understood non-neurogenic
condition whereby detrusor contraction causes
bladder neck narrowing instead of funnelling,
resulting in a functional obstruction. The mainstay of
MEN’S HEALTH
treatment is the use of α-adrenergic blocker, although TABLE 1. HISTORY TAKING IN PATIENTS
in the longer term many may require surgery.5,6
PRESENTING WITH LUTS
Urethral strictures
The prevalence in the UK of urethral strictures
increases with age from 10 per 100,000 in youths,
to 20 by age 55 and 40 by age 65.7 The causes
are linked to age and may include dermatitis,
balanitis xerotica obliterans (BXO), poor hygiene,
previous surgery for hypospadias, or iatrogenic
causes (e.g. catheters or previous prostate
resection).7 BXO is the commonest identifiable
cause of penile strictures in young and middle aged
adults.7 Strictures are more common in smokers,
and smoking adversely affects the outcome from
urethroplasties. Men with strictures will present
with voiding symptoms or complications of
strictures, such as prostatitis, epididymo-orchitis,
bladder stones or rarely renal failure.7
Ketamine abuse
Ketamine is a class C recreational drug in common
use among young adults; one study reported 0.9%
of 16-24 year olds in the UK admitted ketamine
abuse.8,9 This drug is associated with significant
damage to the urogenital tract including atrophic,
small capacity bladder and ureteric strictures
resulting in hydronephrosis and renal failure in
severe cases.8,9 Patients may present with severe
dysuria or suprapubic pain, frequency (every 15-90
minutes), urgency, urge incontinence and painful
haematuria. Some will return to ketamine as
analgesia for their severe pain. These patients may be
difficult to manage and require a multidisciplinary
approach with input from drug dependency agencies,
pain teams and urologists. The urological damage
may be at least partially reversible with abstinence.8,9
Neurological disorders
Optimal bladder function requires the bladder to
store urine under low pressure and then empty
at a socially acceptable time. This depends on the
detrusor muscle contracting during voiding and
relaxing during filling. In addition, the sphincter
must remain closed during filling and open during
voiding. These interactions are reliant on intact and
coordinated neural control involving the whole
neurological system. Neurological disease may result
in variable dysfunctions of the lower urinary tract
and resultant symptoms. It is therefore important to
exclude new or undiagnosed neurological disorders,
such as multiple sclerosis.
Assessment1,2,7,10,11
The correct management of these patients is
dependent on eliciting the correct information from
the patient and determining, as well as managing,
their expectations. There will be men whose only
reason for seeking medical attention will be prompted
by public health posters associating LUTS with a
Symptoms
Storage vs. voiding vs. postmicturition
Duration
Severity: i.e. incontinence episodes
Degree of bother
Which symptom is most bothersome
Any treatment previously trialled
Impact on quality of life
Any precipitating factors
Fluid intake
Volume
Type of fluid intake
Urinary colour
Timing of fluids, especially late evening
Drug history
Diuretics, herbal formulations, illicit drug use
(especially ketamine)
Co-morbidities
Previous surgery: penile, prostatic or rectal
(e.g. for inflammatory bowel disease)
Previous trauma
Neurological disorders
Cardio-respiratory disease: heart failure,
sleep apnoea
BXO is the commonest
identifiable cause of penile
strictures in young and
middle aged adults
TABLE 2. EXAMINATION AND ADJUNCTS
IN PATIENTS PRESENTING WITH LUTS
Examination
Abdomen
Urinary retention
Surgical scars
External genitalia
Phimosis
Meatal stenosis
Balanitis xerotica obliterans
Penile cancer
Digital rectal examination
Anal tone
Prostate: size, irregularity, tenderness,
bogginess
Rectal mass
Adjuncts
Urinalysis
Urinary tract infection
Diabetes
Proteinuria
Haematuria
Frequency volume chart
Should be completed over 3 consecutive days
Diagnose nocturnal polyuria
IPSS: for men considering treatment
| November/December 2013 | 25
MEN’S HEALTH
possible diagnosis of prostate cancer. These men
can often be reassured and discharged. However,
it is important not to miss important bothersome
symptoms and underlying pathology.
Assessment would ideally comprise a focused
history and examination with relevant tests, as shown
in Tables 1 and 2. In patients with urinary retention
or clinical signs of renal impairment or failure, renal
function tests should be requested.
The value or otherwise of checking the patient’s
PSA is controversial. Current NICE guidance suggests
this may be offered in an adequately counselled man
with LUTS suggestive of bladder outlet obstruction, if
the prostate is abnormal on digital rectal examination
(DRE) or the patient is concerned about prostate
cancer.2 The PSA may be used as a surrogate for
prostate volume;10 a prostate volume of greater
than 30mL is associated with a 3 times greater risk
of acute urinary retention (AUR) and BPH-related
surgery.10 The PSA thresholds for volumes greater
than 30ml are:
1.3ng/mL for ages 50-59
1.5ng/mL for ages 60-69
The value or otherwise
of checking the patient’s
PSA is controversial
Lifestyle modifications are an important adjunct and
include the following:
Fluid reduction at specific times especially late in the
evenings
Avoidance of stimulants: caffeine, alcohol, fizzy
drinks
Distraction techniques: penile squeeze, breathing
exercises, perineal pressure, mental distraction
techniques
Bladder retraining and pelvic floor exercises
Review of medications and optimisation of drug
timings
Weight reduction if obese
Treatment of constipation
Abnormal PSA
Urethral milking
There is no PSA below which the risk of prostate
cancer is zero. The PSA is expected to rise with age
and the use of age specific PSA ranges (see below) as
a basis for referral to secondary care is recommended.
The PSA may be elevated by BPH, prostatitis, UTI or
recent instrumentation of the urinary tract.11 It is also
advisable to repeat the PSA after a reasonable interval
and send mid-stream urine to exclude an asymptomatic
UTI. A normal PSA which is rising significantly may be
a third indication for referral. A PSA velocity of greater
than 0.75ng/ml/year or a PSA doubling time less than
3 years indicates a significant PSA rise.11
Age (years)
PSA (ng/ml)
40-49
≤2.5
50-59
≤3.5
60-69
≤4.5
>69
≤6.5
Conservative management1
There is good evidence to suggest that men with mild,
low bothersome symptoms may be reassured and
managed conservatively. In addition, self-management
reduces symptoms and their progression. The key
aspects of self-management are:
Patient education
Reassurance that their symptoms are not caused
by cancer
Periodic monitoring
26 | November/December 2013 |
Adequate fluid intake: ensure urine is a light straw
colour; 1500ml/day should be adequate
Initial treatment1
The options for men who have failed conservative
management include α-adrenergic blockers (e.g.
tamsulosin, alfuzosin), muscarinic receptor antagonists
(e.g. solifenacin), 5α-reductase inhibitors (e.g.
finasteride, dutasteride) and the novel β3 adrenoceptor
agonist, mirabegron. Men with predominantly voiding
symptoms may be managed with α-adrenergic blockers
while those with mainly storage symptoms are typically
managed with muscarinic receptor antagonists.
Anti-muscarinics are associated with significant side
effects, such as dry mouth, constipation and reflux,
which are at least partly responsible for their low
patient compliance. Patients should be warned that
they may need to try several different types of antimuscarinics at different doses before finding the most
efficacious drug and dose. The dose at which patients
develop a dry mouth is likely to be the most efficacious.
There is a theoretical risk of causing urinary retention
in the presence of significant bladder outlet obstruction
with the use of anti-muscarinics. In the community, men
should be warned about this potential risk, and caution
should be exercised if the prostate volume is large, or
there are mixed voiding and storage symptoms or a
history of retention. The new β3 agonist mirabegron
(Betmiga) is licensed for use in patients with symptoms
of overactive bladder syndrome or storage symptoms.
The results from trials of this and other β3 agonists
are very encouraging, with a better side effect profile
MEN’S HEALTH
compared to anti-muscarinics.12 However, real life
experience with this drug is still awaited.
Men with mixed symptoms may be treated with
both α-adrenergic blockers and anti muscarinics.
Men with risk factors for BPH progression could be
treated with dual therapy with 5α-reductase inhibitors
and α-adrenergic blockers, although most of these do
not apply to this age group. The side effects of sexual
dysfunction must be balanced with the degree of
symptom bother. Criteria for referral include:
side effects, reassurance and the use of lifestyle
modifications. Older men often expect to experience
LUTS, while younger men may present with concerns
that it may signify cancer. Benign causes of LUTS are
more common; however there will be a small cohort
who may have significant underlying pathology such
as cancer. The key to successful management of these
men is in their initial assessment and the majority can be
adequately managed in the community.
Failed medical management
References
Abnormal DRE/PSA
1 European Association of Urology guidelines 2012.
2 NICE clinical guidelines 97 – Lower urinary tract symptoms.
3 Irwin D, Milson I, Hunskaar S, et al. Euro Urol
2006;50:1306-15.
4 Jacobsen SJ, Girman CJ, Guess HA, et al. J Urol
1996;155:595-600.
5 Wang CC, Shei Dei Yang S, Chen Y, et al. Euro Urol
2003;43:386-90.
6 Toh K-L, NG C-K. Int J Urol 2006;13:520-3.
7 Mundy AR, Andrich DE. BJU Int 2010;107:6-27.
8 Chu PS, Ma WK, Wong SC, et al. BJU Int 2008;102:1616-22.
9 Wood D, Cottrell A, Baker SC, et al. BJU Int 2011;107:1881-4.
10 Marberger MJ, Andersen JT, Nickel JC, et al. Euro Urol
2000;38:563-8.
11 Arya M, Shergill, et al. Viva practice for the FRCS (Urol)
examination.
Complications: renal failure, recurrent/persistent UTI,
urinary retention
Visible haematuria
Painful LUTS: bladder carcinomas, ketamine bladder
syndrome, bladder stone(s)
Non-visible haematuria in the absence of UTI in men
aged ≥50 years
Conclusion
Young men with LUTS may be managed in a similar
way to older men. However, careful consideration
must be given to issues such as minimising treatment
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