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Lower Urinary Tract Symptoms (LUTS) in men

Symptoms & causes

What are lower urinary tract symptoms (LUTS)?

LUTS (lower urinary tract symptoms) describes symptoms related to problems of the lower urinary tract (bladder, prostate and urethra). LUTS are broadly grouped into voiding (obstructive) symptoms or storage (irritative) symptoms. A man may have mainly voiding symptoms, mainly storage symptoms, or a combination of both.

Voiding or obstructive symptoms
Storage or irritative symptoms

  • Hesitancy – a longer than usual wait for the stream of urine to begin

  • Weak stream

  • Straining to urinate

  • Dribbling after urination has finished or an irregular stream

  • A stop/start stream

These are also symptoms typical of OAB (overactive bladder)



  • Urgency – feeling an urgent need to urinate

  • Frequency – a short time between needing to urinate

  • Nocturia – waking from sleep to pass urine two or more times during the night.

  • Urge incontinence – a sudden, intense urge to urinate followed by an uncontrolled loss of urine

How common are LUTS?

LUTS become more common in men as they get older. However, LUTS can also occur in young men, although the cause of the symptoms may be different. A large Australian study has shown that about one in 14 (7%) men in their 40s, and nearly one in three (29%) men over the age of 70, report moderate to severe LUTS. A smaller Australian study of men 35 to 80 years old found that storage symptoms were twice as common as voiding symptoms (28% versus 13%).

 

What causes LUTS?

LUTS, especially if it is painful to urinate, may be caused by an acute problem such as a urinary tract infection, or infection and inflammation of the prostate gland (prostatitis).

Storage symptoms may be due to an overactive bladder (OAB). OAB is when there is a feeling of urgency to urinate, usually with frequency and nocturia can happen with or without urge incontinence (see Table). This type of LUTS may indicate an underlying chronic medical condition such as obesity, diabetes (high glucose levels in the blood), high blood pressure or obstructive sleep apnoea (OSA), or may be due to the effects of smoking. Drinking fluids late at night, too much alcohol or caffeine (tea, coffee, cola drinks), or low levels of physical activity can make storage symptoms worse.

Voiding symptoms are usually due to a blockage at the outlet of base of the bladder, making it more difficult to pass urine. The blockage may be caused by an enlarged prostate gland or scarring of the urethra (the tube that carries the urine). Enlargement of the prostate gland can lead to both storage and voiding symptoms and is a common cause of symptoms in men.

Other causes of LUTS include some medicines, and neurological diseases such as stroke and Parkinson’s disease. LUTS is also linked with depression and erectile dysfunction.

It is common for there to be several factors acting at the same time to cause LUTS and the exact cause is not always easy to find.

Voiding symptoms are usually due to a blockage of the outlet of the bladder making it more difficult to pass urine. The blockage may be caused by an enlarged prostate gland or a urethral stricture (scarring of the urethra). Enlargement of the prostate gland can lead to both storage and voiding symptoms.

Other causes of LUTS include some medicines and neurological diseases such as stroke and Parkinson’s disease. There are also links between LUTS and depression and erectile dysfunction.

It is common for there to be several factors acting at the same time to cause LUTS and the exact cause is not always easy to find.

Diagnosis

When should I see a doctor for LUTS?

LUTS is not just a normal part of ageing so it is a good idea to see your GP if you notice any changes to urination, particularly if the symptoms are affecting your quality of life or interfering with normal daily activities.

Many people think that urinary symptoms in men are a sign of prostate cancer or some other disorder of the prostate. This is not true. Prostate cancer may sometimes be present with urinary symptoms but most often symptoms are not related to prostate cancer, and the LUTS have other causes.

Men can have big prostates but no LUTS, or small prostates and LUTS. So, while a large prostate may be a contributing factor, the presence of LUTS requires a very thorough general check of both physical and psychological health.

If needed, the doctor may refer you to a urologist, who specialise in diseases of the urinary tract and genital organs.

How is the presence and cause of LUTS diagnosed?

The nature of the symptoms being experienced will confirm the presence of LUTS. Further evaluation by a doctor is needed to determine the cause.

The assessment of LUTS starts with a thorough medical history and examination. A medical history includes the type of symptoms, the presence of other health conditions, such as diabetes, high blood pressure, obstructive sleep apnoea (OSA), depression, erectile dysfunction, and a review of any medications. Examination includes height, weight, waist circumference, blood pressure and a general examination.

The tests used to determine the likely cause, depend on the man’s age and details given in the medical history.

Other tests include one or more of:

  • Urinalysis: urine tests to check for signs of infection or cancer in the urinary tract or kidneys
  • Blood tests to check the function of the kidneys and liver, blood sugar and fats, Prostate Specific Antigen (PSA) and possibly other tests depending on the circumstances
  • Digital rectal examination (DRE): to check if prostate disease is present. The doctor places a gloved finger in the rectum (back passage) to check the size and shape of the prostate, and to feel for problems with the prostate gland
  • urination diary: a diary recording the pattern and frequency of urination and whether the volumes passed are large or small. These diaries are particularly helpful for men with storage symptoms. If there is concern about large volumes, urine may be collected over 24 hours to measure to the total amount
  • Ultrasound: used to measure the amount of urine left in the bladder after urination and to check the prostate
  • MRI: under certain circumstances, for example if cancer is suspected, the prostate may be looked at using magnetic resonance imaging (MRI)
  • Cystoscopy: a small video telescope is inserted into the penis via the urethra.
  • Sleep study: OSA is present in 50 per cent of men over 40. Severe OSA is frequently associated with LUTS and so should always be considered. Severe OSA need not be accompanied by sleepiness.

Treatment

How are LUTS treated?

When deciding on the best treatment, the doctor will take into account the type of LUTS, the cause of the LUTS and other factors such as the degree of bother caused by the LUTS and lifestyle factors.

Lifestyle changes or managing other health conditions such as diabetes or hypertension may be the first option. If symptoms are not very bothersome, the best approach may be to monitor the LUTS through regular checks with the doctor.

If the LUTS are bothersome, oral medicines (tablets) can help. The medicine suggested by the doctor will depend on the type and cause of LUTS. In some cases several medicines may be tried to see whether they improve the symptoms.

Surgery is only done in severe cases of prostate enlargement or other serious causes of obstruction. Surgery is the most effective treatment for relieving symptoms caused by an enlarged prostate but it has potential side-effects.

LUTS treatments

Management of underlying conditions and lifestyle measures


  • Managing medical conditions such as obesity, hypertension, obstructive sleep apnoea, heart conditions, kidney conditions and diabetes; review of use of medicines.

  • Changes in diet, including a reducing intake of processed and refined foods, particularly refined carbohydrate, increase both aerobic and resistance physical activity,, minimise and preferably stop alcohol intake and limit caffeine to the early parts of the day.


Oral medicines (tablets)


  • alpha-blockers – relax the bladder outlet and the muscles of the prostate gland; used to help symptoms due to prostate enlargement

  • anticholinergics (or antimuscarinics) – reduce contraction of the bladder; used to help storage symptoms or overactive bladder

  • Long-acting phosphodiesterase inhibitors (tadalafil) – used to treat erectile dysfunction but also help reduce symptoms of LUTS

  • 5-alpha reductase inhibitors – only used if the prostate is enlarged and usually taken in combination with alpha-blockers. Note that 5-alpha reductase inhibitors may lead to erectile dysfunction and loss of libido (sex drive) which can be long lasting


Surgery (for LUTS due to prostate enlargement or other obstruction)


  • Transurethral resection of the prostate (TURP)

  • Bladder neck incision

  • holmium laser enucleation (HoLEP)

  • Green light laser (PVP)

  • Urolift

  • Rezum

  • Aqua-ablation



Prevention

Can LUTS be prevented?

A man is less likely to get LUTS if he has a healthy lifestyle and body weight, does not smoke and gets treatment for any medical conditions such as diabetes, high blood pressure or sleep apnoea. For a man with LUTS, reducing caffeine and alcohol (these substances can irritate the bladder), avoiding large amounts of fluid before bed, preventing constipation (straining to pass stools can affect pelvic floor muscles, which are important for both bowel and bladder control), and losing weight may help to improve the symptoms.

When should I see a doctor for LUTS?

LUTS is not just a normal part of ageing so it is a good idea to see your GP if you notice any changes to urination, particularly if the symptoms are affecting your quality of life or interfering with normal daily activities.

Many people think that urinary symptoms in men are a sign of prostate cancer or some other disorder of the prostate. This is not true. Prostate cancer may sometimes be present with urinary symptoms but most often symptoms are not related to prostate cancer, and the LUTS have other causes.

Men can have big prostates but no LUTS, or small prostates and LUTS. So, while a large prostate may be a contributing factor, the presence of LUTS requires a very thorough general check of both physical and psychological health.

If needed, the doctor may refer you to a urologist, who specialise in diseases of the urinary tract and genital organs.

Bothersome LUTS need not, and should not, just be considered a part of aging. If you have these symptoms discuss them with your GP and make sure to take this information sheet along.

Last modified: July 25, 2018
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