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? SpR outlet – including the , 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 (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 , 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 , epididymo-, 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 Neurological disorders Abdomen

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 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 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 Assessment 1,2,7,10,11 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 . 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. 11 symptoms may be managed with α-adrenergic blockers while those with mainly storage symptoms are typically Age (years) PSA (ng/ml) managed with muscarinic receptor antagonists. Anti-muscarinics are associated with signi"cant side 40-49 ≤2.5 effects, such as dry mouth, constipation and re!ux, 50-59 ≤3.5 which are at least partly responsible for their low patient compliance. Patients should be warned that 60-69 ≤4.5 they may need to try several different types of anti- >69 ≤6.5 muscarinics at different doses before "nding the most ef"cacious drug and dose. The dose at which patients Conservative management 1 develop a dry mouth is likely to be the most ef"cacious. There is a theoretical risk of causing urinary retention There is good evidence to suggest that men with mild, in the presence of signi"cant bladder outlet obstruction low bothersome symptoms may be reassured and with the use of anti-muscarinics. In the community, men managed conservatively. In addition, self-management should be warned about this potential risk, and caution reduces symptoms and their progression. The key should be exercised if the prostate volume is large, or aspects of self-management are: there are mixed voiding and storage symptoms or a Patient education history of retention. The new β3 agonist mirabegron (Betmiga) is licensed for use in patients with symptoms Reassurance that their symptoms are not caused of overactive bladder syndrome or storage symptoms. by cancer The results from trials of this and other β3 agonists Periodic monitoring are very encouraging, with a better side effect pro"le

26 | November/December 2013 | MEN’S HEALTH compared to anti-muscarinics. 12 However, real life side effects, reassurance and the use of lifestyle experience with this drug is still awaited. modi"cations. Older men often expect to experience Men with mixed symptoms may be treated with LUTS, while younger men may present with concerns both α-adrenergic blockers and anti muscarinics. that it may signify cancer. Benign causes of LUTS are Men with risk factors for BPH progression could be more common; however there will be a small cohort treated with dual therapy with 5 α-reductase inhibitors who may have signi"cant underlying pathology such and α-adrenergic blockers, although most of these do as cancer. The key to successful management of these not apply to this age group. The side effects of sexual men is in their initial assessment and the majority can be dysfunction must be balanced with the degree of adequately managed in the community. symptom bother. Criteria for referral include: Failed medical management References Abnormal DRE/PSA 1 European Association of Urology guidelines 2012. 2 NICE clinical guidelines 97 – Lower urinary tract symptoms. Complications: renal failure, recurrent/persistent UTI, 3 Irwin D, Milson I, Hunskaar S, et al . Euro Urol urinary retention 2006;50:1306-15. Visible haematuria 4 Jacobsen SJ, Girman CJ, Guess HA, et al. J Urol 1996;155:595-600. Painful LUTS: bladder carcinomas, ketamine bladder 5 Wang CC, Shei Dei Yang S, Chen Y, et al. Euro Urol syndrome, bladder stone(s) 2003;43:386-90. 6 Toh K-L, NG C-K. Int J Urol 2006;13:520-3. Non-visible haematuria in the absence of UTI in men 7 Mundy AR, Andrich DE. BJU Int 2010;107:6-27. aged ≥50 years 8 Chu PS, Ma WK, Wong SC, et al. BJU Int 2008;102:1616-22. Conclusion 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 Young men with LUTS may be managed in a similar 2000;38:563-8. way to older men. However, careful consideration 11 Arya M, Shergill, et al . Viva practice for the FRCS (Urol) must be given to issues such as minimising treatment examination.

New BJFM website now live!

Go to www.bjfm.co.uk today to: Find articles of interest quickly Catch up with what’s new using our simple search; search by author or topic Give us your views by commenting on articles you’ve Understand more about a special read in the journal interest area using our dedicated channels Share content with colleagues.

| November/December 2013 | 27