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Lower Urinary Tract Symptoms

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Overview

Lower urinary tract symptoms (LUTS) are symptoms associated with storage, voiding (passing urine) and post-micturition (after passing urine).

The causes of LUTS include:

  • Structural/functional abnormalities of the lower urinary tract
  • Abnormalities of the nervous system affecting the control of the bladder and sphincter, 
  • Abnormalities affecting the production of urine (such as the renal and endocrine systems)

The urinary tract can grossly be divided into:

  • The upper urinary tract – the kidneys and ureters
  • The lower urinary tract – the bladder and urethra

Epidemiology

  • Lower urinary tract symptoms (LUTS) are common
  • Most elderly men have ≥1 LUTS but symptoms are often mild
    • More troublesome LUTS affect up to 30% of people >65 years old
  • Prevalence of LUTS increases with age, and is around 40% in those ≥75 years old

Causes

Voiding symptoms

Voiding symptoms are symptoms experienced due to impaired urine flow out of the bladder, often due to obstruction. Its causes include:

Overactive bladder

Overactive bladder describes urinary urgency with/without incontinence and the sensation of needing to pass urine again just after urinating. Some of its causes include:

Stress urinary incontinence

Stress urinary incontinence describes the involuntary leakage of urine with exertion (e.g. coughing, laughing, sneezing etc.). Its causes include:

  • Prostatectomy or pelvic surgery
  • Urethral injury
  • Neurological disorders – (multiple sclerosis, spina bifida) 
  • Drugs that:
    • Increase urine production (alcohol, caffeine, diuretics)
    • Relax the bladder outlet (alpha-blockers)
    • Can cause urinary retention, leading to overflow incontinence such as anticholinergic drugs
    • Reduce awareness of the need to pass urine (benzodiazepines and z-drugs)

Acute urinary retention

Acute urinary retention describes an abrupt inability (usually over a few hours) to pass urine. Its causes include:

  • Benign prostatic hyperplasia
  • Prostate cancer
  • Severe constipation
  • Urethral stricture
  • Urethral stones
  • Pelvic tumours
  • Drugs, particularly anticholinergic drugs, sympathomimetics, and opioids

Nocturnal polyuria

Nocturnal polyuria describes excess production and passage of urine during the light. Its causes include:

Presentation

Lower urinary tract symptoms (LUTS) can be divided into:

  • Storage symptoms – the bladder ‘filling too early’ and needing to pass urine sooner:
    • Urgency
    • Polyuria
    • Nocturia
    • Urinary incontinence
    • Feeling the need to urinate again just after passing urine
  • Voiding or obstructive symptoms – problems with urine outflow:
    • Incomplete voiding
    • Poor stream
    • Hesitancy
    • Dribbling
    • Urinary retention
    • Overflow incontinence
  • Post-micturition – problems at the end of passing urine:
    • Post-micturition dribbling
    • Sensation of incomplete emptying

Assessment and Investigations

Physical examinations

Physical examinations may include:

  • An abdominal examination:
    • May show features of a distended bladder such as distention, suprapubic dullness, or suprapubic tenderness
  • An examination of the external genitalia:
    • May identify causes such as phimosis or penile cancer
  • A digital rectal examination:
    • To assess the prostate’s size and consistency and screen for nodules and/or tenderness
  • A focused neurological examination:
    • To evaluate sensory and motor function

Scoring and other assessment

Ask people with bothersome LUTS to complete a urinary frequency-volume chart for at least 3 days. This helps with identifying polyuria, nocturia, and urinary frequency.

The international prostate symptom score (IPSS) can assess the impact of LUTS on a person’s life and classified symptoms as mild, moderate, or severe.

Investigations

Investigations may include:

  • Urine dipstick:
    • To screen for blood, leukocytes, nitrites, protein, and glucose
  • Urea and electrolytes (U&Es) andestimated glomerular filtration rate (eGFR):
    • If renal dysfunction is suspected (e.g. if the person has chronic urinary retention, recurrent urinary tract infections, or a history of renal stones)
  • Consider prostate-specific antigen (PSA) testing:
    • Indicated after properly counselling the patient if:

Management

Overview

After excluding or managing treatable causes, and where referral to secondary care is not needed, the management of LUTS depends on the predominant symptom:

  • Acute urinary retention:
    • If 1st episode: arrange hospital admission for catheterisation and investigations
    • If recurrent/acute-on-chronic episodes: hospital admission or catheterise + offer prevention treatment such as:
      • An alpha-blocker (e.g. alfuzosin)
      • Intermittent urethral catheterisation
        • Long-term indwelling catheter – if intermittent catheterisation not possible
  • Chronic urinary retention:
    • Refer to secondary care and investigate for other causes (e.g. heart failure), check U&Es for renal function
    • Options in secondary care involve regular monitoring, intermittent catheterisation, permanent indwelling catheter, or urostomy. 
  • Predominantly voiding symptoms:
    • 1st-line: conservative measures: pelvic floor muscle training, bladder training, prudent fluid intake
    • If conservative measures fail:
      • Moderate-severe voiding symptoms (IPSS ≥8): offer alpha-blocker
      • Enlarged prostate present: offer 5-alpha reductase inhibitor (e.g. finasteride)
      • Moderate-severe + prostate enlargement: consider alpha-blocker + 5-alpha reductase inhibitor
      • If mixed storage + voiding symptoms unresponsive to alpha-blocker alone, then consider an antimuscarinic drug (e.g. oxybutynin)
      • If treatment fails, refer to secondary care
  • Predominantly overactive bladder symptoms:
    • 1st-line: conservative measures and lifestyle changes (e.g. prudent fluid intake and avoiding constipation, limiting caffeine, alcohol, carbonated drinks etc.) + offer temporary urine containment products (e.g. absorbent pads)
    • Offer a referral for bladder retraining
    • If symptoms persist:
      • Offer an antimuscarinic drug
      • If antimuscarinic contraindicated/not tolerated/not effective: offer mirabegron
      • If treatment fails, refer to secondary care
  • Predominantly nocturnal polyuria:
    • 1st-line: limit fluid intake in late afternoon and evening
    • If limiting fluid intake in the late afternoon and evening is ineffective:
      • Consider loop diuretic (e.g. furosemide) in the late afternoon
      • If loop diuretic is ineffective, refer to secondary care or seek specialist advice to consider using desmopressin at bedtime
  • Predominantly stress urinary incontinence:
    • 1st-line: conservative measures and lifestyle changes (e.g. prudent fluid intake and avoiding constipation, limiting caffeine, alcohol, carbonated drinks etc.) + offer temporary urine containment products 
    • If stress urinary incontinence is not due to prostatectomy: refer to secondary care
    • If stress urinary incontinence is due to prostatectomy:
      • 3 months pelvic floor muscle training
      • If this fails, refer to secondary care 
  • Post-micturition dribble:
    • 1st-line: give advice regarding reducing dribble by ‘milking’ the urethra after passing urine and + offer temporary urine containment products
    • Consider referral to secondary care

Monitoring and Patient Advice

Overview

Follow-up and advice depend on the predominant symptom the patient is experiencing. The International Prostate Symptom Score (IPSS) can be used to assess how LUTS are affecting a person’s life and its score can be interpreted as:

  •  0-7: mildly symptomatic
  • 8-19: moderately symptomatic
  • 20-35: severely symptomatic

Prognosis

  • For some people, LUTS persist and progress, but in others, they may resolve spontaneously
  • Observational studies suggest that few people with LUTS will progress to develop complications such as acute urinary retention, chronic kidney disease, or renal stones

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