Lower Urinary Tract Symptoms

Risk factors associated with lower urinary tract symptoms include obesity; diabetes; kidney, liver or heart disease (and medications taken for their control); obstructive sleep apnoea (OSA) associated with snoring; inflammation of the lower urinary tract and dietary factors (such as high fat and red meat intake or caffeine and alcohol consumption).

Vegetables, exercise and non-steroidal anti-inflammatory drugs (NSAIDs) appear to reduce the risk of developing these symptoms.

Benign prostatic hyperplasia (BPH) is a common cause of LUTS in men and becomes more common with age.

Other causes of LUTS in men include urinary tract infections, bladder muscle over-activity, and blockages in the bladder or along the urethra. Weak pelvic floor muscles can also cause LUTS. Less commonly cancers of the lining of the inside of the bladder or of the prostate may cause urinary symptoms.

LUTS are grouped into two categories: storage symptoms and voiding symptoms.

Storage symptoms include:

• Increased frequency: needing to urinate more often than normal during the daytime and/or Nocturia (being woken to void at night)

• Polyuria is passing larger volumes of urine than normal. This can be either during the day (diurnal) or at night (nocturnal)

• The feeling of having a full bladder occurs more quickly or is stronger than normal

• The urgency of urination can develop with the sudden need to pass urine, which is hard to put off

• Sometimes the bladder loses the feeling of becoming full or needing to pass urine

• Urinary incontinence is the involuntary loss of urine which can be associated with a feeling of urgency (Urge urinary incontinence) or occurs during effort such as exercise, coughing or sneezing (Stress urinary incontinence). Mixed urinary incontinence is when both urgency and stress urinary incontinence exist.

Voiding symptoms include:

• Hesitancy which is the delay experienced when beginning to urinate

• Straining to void may be necessary to start or maintain urination

• The urinary stream may become slower

• Intermittency occurs when urine flow has a tendency to stop and start

• Terminal dribbling may develop in which there is dribbling after the end of urinating

• There is a sensation of incomplete bladder emptying and urinary retention may eventually develop

• Acute urinary retention is the rapid onset discomfort or pain from a full bladder due to an inability to pass urine

• Chronic urinary retention is a long term inability to empty the bladder despite the passage of small volumes of urine and is usually painless

LUTS are a significant source of bother for many people. Some people can become reluctant to leave their house or socialise because of the inconvenience of needing to go to the toilet in a hurry. They can become anxious and depressed which can in turn affect personal relationships. In more advanced cases urinary retention can be painful and can lead to urinary tract infections or bladder stones. Over a long period of time damage to the bladder or kidney function can result.

Sexual dysfunction is also associated with LUTS resulting in such problems as difficulty getting erections or impaired ejaculation.

If you notice any lower urinary tract symptoms, you should see your family doctor to discuss them, their impact on you and your treatment options. As LUTS may progress without treatment, earlier is generally better.

Mild LUTS often don’t need specific medical therapy and can be managed by lifestyle changes (such as reducing caffeine and alcohol intake both in terms of volume and timing). Pelvic floor exercises or ‘bladder retraining’ may also help. Urethral milking involves working the last few drops of urine down the urethra (outflow tube) by running a finger along the underside of the penis at the end of voiding to reduce terminal dribbling.

Some medications taken for other medical conditions can cause LUTS and discussing a change to an alternative with your family doctor may make a significant improvement.

For moderate symptoms, medication is usually trialled in addition to the above measures.

Severe symptoms or those unresponsive to medical therapy are often able to be treated with surgery.

For some men, none of these treatments proves to be effective. Many are able to catheterise themselves on an intermittent basis to drain the bladder but spend the majority of their time catheter free. For the remainder, containment products such as pads, external collecting devices or urinary catheters can provide a significant improvement in quality of life.

A number of different medications exist to help treat LUTS and various combinations may be appropriate depending on the situation.

The alpha-blockers work by affecting receptors on muscle cells in the urinary system causing them to relax. This may lead to a moderate increase in urinary flow and a reduction in urinary symptoms. Examples of this group available in New Zealand are doxazosin, terazosin and tamsulosin.

5-alpha reductase inhibitors block hormonal messages that cause benign prostatic growth. Over time these medications can reduce the prostatic size by up to 30%. They may also be useful in reducing prostate-related bleeding. Finasteride is a medication in this group that is available in New Zealand.

Anticholinergic medications such as Ditropan, Tolterodine or Solifenacin may be used to treat the symptoms if urinary frequency and urgency are a problem. They work by relaxing the bladder but are used with caution if the bladder is not emptying effectively.

Other medication options such as the diuretic, Frusemide or hormone-blocking Desmopressin occasionally have a role and may be useful in certain situations.

Over the years many surgical options have been suggested for the treatment of LUTS due to benign prostatic enlargement. Most of these have fallen out of favour with time as follow-up has shown them to be less effective. Those surgical options with the best outcomes and long-term results are TURP and laser prostatectomy.

For men with LUTS related to bladder overactivity rather than outflow tract obstruction, botulinum toxin (Botox) can be injected into the bladder wall to temporarily paralyse some of the bladder muscle fibres and improve symptoms. Typically this effect lasts for around 9 months but can be repeated if necessary. This is performed under anaesthetic as a day case. The main risks of the operation are blood in the urine, infection and the possibility of temporary complete bladder paralysis with urinary retention. If the last of these occurs, either placement of an indwelling urinary catheter or regular intermittent self-catheterisation will be necessary until the drug effect wears off.

Stress urinary incontinence may need to be treated with the implantation of either a mesh urethral sling or an artificial inflatable sphincter.