MANAGING LOWER URINARY TRACT SYMPTOMS (LUTS) IN THE COMMUNITY
URINARY SYMPTOMS IN MEN
Exclude red flags such as haematuria, symptoms of advanced prostate cancer (weight loss, bone pain) and neurological causes especially spinal cord compression. Thereafter, determine if likely primary bladder outflow obstruction - prostatic enlargement, stricture, or simple overactive bladder, as management will differ. Click below for more.
URINARY SYMPTOMS IN WOMEN
Once red flag symptoms such as haematuria or pelvic masses have been excluded, and infection ruled out or treated, this comes down to management of bladder emptying issues, overactive bladder and stress incontinence. The latter is managed under gyanecology and phyiotherapy usually. For more advice on the Urological aspects, please click below
NOCTURNAL POLYURIA
Passing more than 1/3rd of the total 24 hour urine volume in the 8 hours overnight is a common reason for having to get up more frequently. Termed nocturnal polyuria, it is a fluid balance, not bladder emptying problem, and is frequently assocaited with other medical conditions, medications and fluid intake.
LUTS in Men
Around half of men will suffer from urinary symptoms, especially after age 40 when prostatic hyperplasia starts to develop.
If haematuria present please refer according to national guidelines - 2 week wait if visible and age over 45, or if non-visible (dipstick) then with associated dysuria or raised blood white count over age of 60. Urgent non-2ww if otherwise, but consider nephrological pathology especially if young patient, significant proteinuria, hypertension or raised creatinine.
History:
Assessment to distinguish bladder outflow obstruction (poor flow, straining, incomplete emptying) from overactive bladder (frequency, urgency, nocturia). Specifically ask about nocturnal polyuria - excess volume of urine produciton at night, as this is a medical fluid balance issue, not urological. Exclude neurological issues eg MS, spinal cord compression, cerebrovascular disease.
Determine risk factors for prostate cancer - family history, ethnicity, age.
Assess effects of comorbidity and medication eg diuretics, anti-hypertensives, CNS conditions.
IPSS score can be used to stratify level of symptoms.
Examination:
to include genitalia, exclude palpable bladder and perform prostate examination to assess for size and indications of prostate cancer, (nodularity, hardness).
Investigations:
Urine dipstick
Discuss PSA testing according to NHS prostate risk management guidelines - implications of test, risk of inaccuracy and uncertainty of treatment outcomes if cancer.
Bladder diary (intake and output recorded over three 24 hour periods with jug) to quantify symptoms, and exclude nocturnal polyuria and excess intake.
Ultrasound if palpable bladder, raised creatinine, UTI, and if persistent symptoms after initial treatment to assess prostate size and post void residual volume.
Management:
If suspicion of prostate cancer based on DRE or PSA, refer via rapid access if treatment likely to influence life expectancy (generally 10+ years for localised disease), or if risk of metastatic disease (PSA >20, new onset bone pain / weight loss).
Lifestyle measures - avoid caffeine, fizzy or acidic drinks, alcohol. Drink around 2 litres per day to keep urine dilute, and avoid evening fluids if night time waking a problem. Aim for ideal body weight. Stop smoking.
Try bladder training exercises (see link below)
If outflow obstruction suspected, treat with medication if desired. Alpha blocker such as Tamsulosin 400mcg MR od will help around 2/3rd of men, but commonly causes retrograde ejaculation and can cause postural hypotension / dizziness - caution when starting.
If prostate significantly enlarged, consider 5-alpha reductase inhibitor such as finasteride 5mg od, which works over 6 months plus to shrink prostate by 20% and prevent progression of symptoms. Can cause reduced libido, erectile dysfunction, tiredness.
If overactive bladder symptoms dominant, and no major outflow problem, consider trial of generic anti-muscarinic eg tolterodine 2mg bd, or mirabegron 50mg od if anti-cholinergic contra-indicated (elderly, cognitive impairment) or unsuccessful / side effects.
Refer to specialist if severe symptoms, intolerance of medication, significant post-void residual (>150ml), UTIs, renal impairment if likely of urological origin.
Discuss with men the options of minimally invasive or traditional surgery instead of long term medication and the implication of long term bladder damage if outflow obstruction is inadequately managed.
LUTS in Women
Initial assessment needs to rule out haematuria, UTI and symptoms of pelvic fullness / pain, in which case urgent scan and referral is required.
If haematuria present please refer according to national guidelines - 2 week wait if visible and age over 45, or if non-visible (dipstick) then with associated dysuria or raised blood white count over age of 60. Urgent non-2ww if otherwise, but consider nephrological pathology especially if young patient, significant proteinuria, hypertension or raised creatinine.
History:
Determine if bladder emptying issues - poor flow, straining, incomplete emptying, vs overactive bladder - frequency, urgency +/- urge incontinence, nocturia, vs stress incontinence - leakage on coughing, straining etc.
Exclude faecal incontinence issues, symptoms of fistula (continuous leakage), history of previous pelvic cancer, previous incontinence surgery or neurological causes, which would require specialist referral.
Examination:
Exclude palpable bladder, and vaginal examination to assess for prolapse, atrophy, lichen sclerosis or pelvic masses.
Investigations:
Urine dipstick
Ultrasound if suspected incomplete emptying, recurrent infections, or raised creatinine
Consider bladder diary (input vs output measured in a jug over three 24 hour periods). This not only quantifies the level of problem, but also rules out excessive intake, and nocturnal polyuria - more than 1/3rd of total urine production over night - a fluid balance issue.
Management:
lifestyle advice - avoid caffeine, fizzy or acidic drinks, alcohol, achieve ideal body weight, fluid intake of around 2 litres per day to keep urine dilute.
Urge abatement / bladder training exercises (see leaflet below), under continence physio if necessary.
Trial of generic anti-muscarinic eg tolterodine 2mg bd, or mirabegron 50mg od if anti-cholinergic contra-indicated (elderly, cognitive impairment) or unsuccessful / side effects.
Consider vaginal oestrogen treatment if post-menopausal atrophy.
Refer onwards if these measures fail for further assessment, or if main problem is incomplete bladder emptying.
Nocturnal Polyuria
History:
Frequent night time waking to pass good volumes of urine
No problem with stream
No daytime issue
Excess caffeine intake causing diuresis during day and fluid imbalance
Associated hypertension (amlodipine causing fluid retention), heart failure, CKD, obstructive sleep apnoea, ageing
Examination:
Signs of associated medical conditions eg oedema
Exclude significant prostate / outflow issues.
Investigations:
Bladder diary if required
Dipstick to exclude significant proteinuria and glycosuria.
Management:
Caffeine avoidance
Evening fluid avoidance
Elevate feet during day if oedema
Consider late afternoon does of diuretic eg furosemide 20mg at 5pm to force diuresis prior to bed.
Very carefully consider desmopressin (50mcg in males, 25mcg in females) sublingual, but restrict fluid intake for 1 hour before and 8 hours after, and use with caution over age 65 (Noqdirna specifically licensed in this age group). Note contra-indications especially cardiac insufficiency and those on diuretics or with history of low sodium. Monitor serum sodium at one week and one month and stop if low.