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Assessment of Lower Urinary Tract Symptoms in Younger Men

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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 The aetiology of LUTS is multifactorial with causes How common are LUTS Kalejaiye attributed to dysfunction of the bladder and its in younger men? Urology SpR outlet – including the prostate, urethra and sphincter; The EPIC study, 3 a population-based survey which the neurological innervation of the lower urinary recruited men aged over 18 years, found that the Professor tract, and medical co-morbidities.1,2 It is important prevalence of LUTS increased with age, from 51.3% Raj Persad to consider all these aspects when assessing patients. in men aged 18-39 years to 62% in those aged 40-59 While in older men, benign prostatic enlargement years. This is compared with a prevalence of 80.7% Consultant is the commonest cause of male LUTS, in younger in men aged 60 years or older. Storage symptoms Urologist; men this is unusual, and other diagnoses should be were commonest in men 39 years or younger, with a Honorary considered more likely. prevalence of 37.5%, compared with a prevalence of Professor of 19.9% for voiding symptoms in this age group. These Urology What are LUTS? rates increased to 50.6% and 24.1% respectively in Men with urinary symptoms are often characterised men aged 40-59 years. Dr Jon Rees as having ‘prostatism’ or benign prostatic hyperplasia GP Partner (BPH). However, given the wide variety of possible Possible causes of LUTS in young men Department causes of urinary symptoms, a patient is best described Overactive bladder (OAB) of Urology, as having LUTS, encouraging a more holistic approach OAB is common in young men and is characterised North Bristol to their assessment and subsequent management. by the presence of storage symptoms. The cardinal NHS Trust LUTS may be divided into: symptom of OAB is urgency, with or without urge incontinence. Patients may also complain of urinary Storage symptoms frequency and nocturia. urgency, urinary frequency, nocturia, urgency incontinence Benign prostatic enlargement The Olmsted county study, which followed men aged Voiding symptoms 40-79 years old for 12 years, provided early evidence slow/poor stream, hesitancy, terminal dribbling that benign prostatic hyperplasia (BPH) is age related. 4 Post micturition symptoms Moderate to severe LUTS was present in 26% aged incomplete bladder emptying, post micturition 40-49 years. In men aged less than 50 years, the dribbling International Prostate Symptom Score (IPSS) increased by 0.05/year, and the peak !ow rate decreased by 1.1% per year. 4 It has been suggested that bladder outlet obstruction due to BPH in young men should Storage symptoms be suspected in men with large prostates (greater than were commonest in men 35mL volume), especially if aged 46-50 years. 5 Bladder neck dysfunction 39 years or younger, with This is a poorly understood non-neurogenic a prevalence of 37.5% condition whereby detrusor contraction causes bladder neck narrowing instead of funnelling, resulting in a functional obstruction. The mainstay of 24 | November/December 2013 | 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 Symptoms Storage vs. voiding vs. postmicturition The prevalence in the UK of urethral strictures Duration increases with age from 10 per 100,000 in youths, Severity: i.e. incontinence episodes to 20 by age 55 and 40 by age 65.7 The causes Degree of bother are linked to age and may include dermatitis, Which symptom is most bothersome balanitis xerotica obliterans (BXO), poor hygiene, Any treatment previously trialled previous surgery for hypospadias, or iatrogenic Impact on quality of life causes (e.g. catheters or previous prostate Any precipitating factors 7 resection). BXO is the commonest identi"able Fluid intake Volume cause of penile strictures in young and middle aged Type of fluid intake 7 adults. Strictures are more common in smokers, Urinary colour and smoking adversely affects the outcome from Timing of fluids, especially late evening urethroplasties. Men with strictures will present Drug history Diuretics, herbal formulations, illicit drug use with voiding symptoms or complications of (especially ketamine) strictures, such as prostatitis, epididymo-orchitis, bladder stones or rarely renal failure.7 Co-morbidities Previous surgery: penile, prostatic or rectal (e.g. for inflammatory bowel disease) Ketamine abuse Previous trauma Ketamine is a class C recreational drug in common Neurological disorders use among young adults; one study reported 0.9% Cardio-respiratory disease: heart failure, of 16-24 year olds in the UK admitted ketamine sleep apnoea abuse. 8,9 This drug is associated with signi"cant damage to the urogenital tract including atrophic, small capacity bladder and ureteric strictures resulting in hydronephrosis and renal failure in BXO is the commonest severe cases. 8,9 Patients may present with severe dysuria or suprapubic pain, frequency (every 15-90 identi!able cause of penile minutes), urgency, urge incontinence and painful strictures in young and haematuria. Some will return to ketamine as analgesia for their severe pain. These patients may be middle aged adults dif"cult to manage and require a multidisciplinary approach with input from drug dependency agencies, pain teams and urologists. The urological damage TABLE 2. EXAMINATION AND ADJUNCTS may be at least partially reversible with abstinence. 8,9 IN PATIENTS PRESENTING WITH LUTS Examination Abdomen Neurological disorders Optimal bladder function requires the bladder to Urinary retention store urine under low pressure and then empty Surgical scars at a socially acceptable time. This depends on the External genitalia detrusor muscle contracting during voiding and Phimosis relaxing during "lling. In addition, the sphincter Meatal stenosis must remain closed during "lling and open during Balanitis xerotica obliterans voiding. These interactions are reliant on intact and Penile cancer coordinated neural control involving the whole Digital rectal examination neurological system. Neurological disease may result Anal tone in variable dysfunctions of the lower urinary tract Prostate: size, irregularity, tenderness, and resultant symptoms. It is therefore important to bogginess exclude new or undiagnosed neurological disorders, Rectal mass such as multiple sclerosis. Adjuncts Urinalysis Urinary tract infection Assessment 1,2,7,10,11 Diabetes Proteinuria The correct management of these patients is Haematuria dependent on eliciting the correct information from Frequency volume chart the patient and determining, as well as managing, Should be completed over 3 consecutive days their expectations. There will be men whose only Diagnose nocturnal polyuria reason for seeking medical attention will be prompted IPSS: for men considering treatment by public health posters associating LUTS with a | 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 The value or otherwise symptoms and underlying pathology. of checking the patient’s Assessment would ideally comprise a focused PSA is controversial 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 Lifestyle modi"cations are an important adjunct and function tests should be requested. include the following: The value or otherwise of checking the patient’s PSA is controversial. Current NICE guidance suggests Fluid reduction at speci"c times especially late in the this may be offered in an adequately counselled man evenings with LUTS suggestive of bladder outlet obstruction, if Avoidance of stimulants: caffeine, alcohol, "zzy the prostate is abnormal on digital rectal examination drinks (DRE) or the patient is concerned about prostate cancer.2 The PSA may be used as a surrogate for Distraction techniques: penile squeeze, breathing prostate volume;10 a prostate volume of greater exercises, perineal pressure, mental distraction than 30mL is associated with a 3 times greater risk techniques of acute urinary retention (AUR) and BPH-related Bladder retraining and pelvic !oor exercises surgery.10 The PSA thresholds for volumes greater than 30ml are: Review of medications and optimisation of drug timings 1.3ng/mL for ages 50-59 Weight reduction if obese 1.5ng/mL for ages 60-69 Treatment of constipation Abnormal PSA Urethral milking There is no PSA below which the risk of prostate Adequate !uid intake: ensure urine is a light straw cancer is zero. The PSA is expected to rise with age colour; 1500ml/day should be adequate and the use of age speci"c PSA ranges (see below) as a basis for referral to secondary care is recommended. 1 The PSA may be elevated by BPH, prostatitis, UTI or Initial treatment recent instrumentation of the urinary tract. 11 It is also The options for men who have failed conservative advisable to repeat the PSA after a reasonable interval management include α-adrenergic blockers (e.g. and send mid-stream urine to exclude an asymptomatic tamsulosin, alfuzosin), muscarinic receptor antagonists UTI. A normal PSA which is rising signi"cantly may be (e.g. solifenacin), 5 α-reductase inhibitors (e.g. a third indication for referral. A PSA velocity of greater "nasteride, dutasteride) and the novel β3 adrenoceptor than 0.75ng/ml/year or a PSA doubling time less than agonist, mirabegron. Men with predominantly voiding 3 years indicates a signi"cant PSA rise.
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