What is the approach for diagnosing and managing lower urinary tract symptoms (LUTS) in men?

Approach to Diagnosis and Management of Male Lower Urinary Tract Symptoms

All men presenting with bothersome LUTS should undergo a structured initial evaluation consisting of medical history, validated symptom questionnaire (IPSS or equivalent), physical examination with digital rectal examination, and urinalysis, with PSA testing reserved only for men with >10 years life expectancy where cancer diagnosis would alter management. 1

Initial Diagnostic Evaluation (Mandatory Components)

Medical History and Symptom Assessment

• Obtain a complete medical history focusing on symptom duration, severity, and impact on daily activities 1
• Use the International Prostate Symptom Score (IPSS) with quality of life question to quantify both storage symptoms (frequency, nocturia, urgency) and voiding symptoms (incomplete emptying, intermittency, straining, weak stream) 1
• The IPSS ranges from 0-35, with scores 0-7 indicating mild symptoms, 8-19 moderate, and 20-35 severe 2

Physical Examination

• Assess the suprapubic area for bladder distention by palpation 1
• Evaluate motor and sensory function in the perineum and lower limbs to exclude neurological disease 1
• Perform digital rectal examination to assess anal sphincter tone, approximate prostate size, consistency, shape, and nodularity suspicious for cancer 1, 3

Urinalysis

• Use dipstick testing to detect hematuria, proteinuria, pyuria, glucosuria, or positive nitrites 1
• If dipstick is abnormal, proceed with microscopic examination and urine culture 1

PSA Testing (Selective, Not Routine)

• Only measure PSA if life expectancy exceeds 10 years AND a prostate cancer diagnosis would change management 1, 3
• Counsel patients about false-positive/false-negative results and potential biopsy complications (infection, bleeding, pain) before ordering 1, 3
• PSA also predicts prostate volume and assists in treatment selection (particularly for 5α-reductase inhibitor candidacy) 1, 3
• If both PSA is elevated AND DRE is abnormal, proceed directly to prostate biopsy 3

Optional Initial Tests Based on Clinical Presentation

Bladder Diary (Frequency-Volume Chart)

• Strongly recommended when nocturia or storage symptoms predominate 1
• Have patients record time and voided volume for each void over at least 3 consecutive 24-hour periods 1
• Identifies nocturnal polyuria (>33% of 24-hour urine output at night) or excessive fluid intake 1

Post-Void Residual (PVR) Measurement

• Measure by transabdominal ultrasound (noninvasive, preferred method) 1
• Repeat measurement if initially elevated due to marked intra-individual variability 1
• Elevated PVR suggests bladder outlet obstruction or detrusor underactivity 1

Uroflowmetry

• Perform before initiating any medical or invasive treatment 1
• Obtain at least 2 flow rates, ideally both with voided volume >150 mL 1
• Maximum flow rate (Qmax) <10 mL/sec suggests obstruction, though cannot distinguish from detrusor underactivity 1

Red Flags Requiring Specialized Evaluation or Referral

Immediately refer or perform additional workup if any of the following are present: 1

• Suspicious DRE findings (nodularity, asymmetry, induration) 1, 3
• Hematuria (visible or microscopic) 1
• Abnormal PSA for age 1
• Pain symptoms 1
• Urinary tract infection 1
• Palpable bladder (suggests significant retention) 1
• Neurological disease affecting bladder function 1

Management Algorithm

Step 1: Minimal or Non-Bothersome Symptoms

• Provide reassurance and education about natural history 1
• Implement lifestyle modifications: reduce evening fluid intake (target ~1 liter total daily output), avoid bladder irritants (caffeine, alcohol), timed voiding 1, 2
• Arrange follow-up monitoring without active treatment (watchful waiting) 1

Step 2: Bothersome Symptoms Without Complications

First-Line Medical Therapy

For voiding symptoms (weak stream, hesitancy, straining):

• Start α1-adrenergic blocker (tamsulosin, alfuzosin, silodosin) as first-line therapy 1, 2
• Onset of action is rapid (4 weeks for symptom improvement) 1
• Improves IPSS by 3-10 points on average 2
• Common adverse effects: dizziness, orthostatic hypotension, ejaculatory dysfunction (especially tamsulosin/silodosin) 1
• Warn patients undergoing cataract surgery about intraoperative floppy iris syndrome risk 1

For large prostates (>30-40 cc) or PSA >1.5 ng/mL:

• Add 5α-reductase inhibitor (finasteride 5 mg daily or dutasteride 0.5 mg daily) to α-blocker 1, 4, 5
• Combination therapy reduces progression risk to <10% versus 10-15% with monotherapy 2
• 5α-reductase inhibitors require 3-6 months for symptom improvement but reduce prostate volume by 18-28% 1, 4, 5
• Reduce risk of acute urinary retention by 57-68% and need for surgery by 48-64% over 4 years 1, 4, 5
• Adverse effects: reduced libido, erectile dysfunction, ejaculatory dysfunction 1

For storage symptoms (urgency, frequency) predominating:

• Consider β3-agonist (mirabegron) or anticholinergic (trospium) if no significant bladder outlet obstruction 1, 2
• Reduces voiding frequency by 2-4 episodes/day and incontinence episodes by 10-20/week 2
• Anticholinergics should only be prescribed by urologists due to urinary retention risk 6

Alternative for patients with concurrent erectile dysfunction:

• Phosphodiesterase-5 inhibitor (tadalafil 5 mg daily) improves both LUTS and erectile function 1, 2

Step 3: Follow-Up Assessment

• Re-evaluate at 4-12 weeks after starting α-blockers, β3-agonists, or PDE5 inhibitors 1
• Re-evaluate at 3-6 months after starting 5α-reductase inhibitors 1
• Repeat IPSS, consider PVR and uroflowmetry 1
• If inadequate response or intolerable side effects, consider changing medication class or adding combination therapy 1

Step 4: Specialized Evaluation Before Surgery

Perform these tests before any invasive therapy: 1

• Validated symptom questionnaire (if not already done) 1
• Frequency-volume chart 1
• Uroflowmetry (at least 2 measurements) 1
• Post-void residual measurement 1
• Prostate imaging (transrectal or transabdominal ultrasound) to determine size and configuration 1

Pressure-flow urodynamic studies are indicated when: 1

• Qmax >10 mL/sec (to confirm obstruction before surgery) 1
• Need to distinguish bladder outlet obstruction from detrusor underactivity 1
• Previous surgical failure 1

Step 5: Surgical Intervention

Indications for surgery: 1, 2

• Persistent bothersome symptoms despite optimal medical therapy
• Recurrent acute urinary retention
• Recurrent urinary tract infections due to obstruction
• Bladder stones
• Renal insufficiency from obstruction
• Gross hematuria refractory to medical therapy

Surgical options:

• Transurethral resection of prostate (TURP) or holmium laser enucleation (HoLEP): most effective, improving IPSS by 10-15 points 2

• Retreatment rates: TURP 5%, HoLEP 3.3% 2

• Complications: incontinence (5-10%), erectile dysfunction (5-10%), retrograde ejaculation (65-75%) 2

• Minimally invasive procedures (water vapor therapy, prostatic urethral lift): lower complication rates but higher retreatment rates 2

• Incontinence 0-8%, erectile dysfunction 0-3%, retrograde ejaculation 0-3% 2

• Retreatment rates 3.4-21% 2

Common Pitfalls to Avoid

• Do not assume elevated PSA always indicates cancer: approximately 75% of men with symptomatic BPH have PSA <4 ng/mL 3
• Do not start anticholinergics without confirming absence of significant bladder outlet obstruction (risk of urinary retention) 6
• Do not expect rapid improvement with 5α-reductase inhibitors; counsel patients that 3-6 months of therapy is needed 1
• Do not perform pressure-flow studies routinely; reserve for Qmax >10 mL/sec or when diagnosis is uncertain 1
• Do not overlook underlying malignancy, infection, or neurological disease as alternative causes of LUTS 1, 6