Lower Urinary Tract Symptoms (LUTS)
  Diagnosis And Treatment Protocols For Lower Urinary Tract Symptoms (LUTS)
John J. Wrenn, MD

Approximately 50% of men will develop Lower Urinary Tract Symptoms (LUTS) as they age, and many will require medical or surgical therapy directed at the prostate. Benign Prostatic Hyperplasia (BPH) is the most common cause of LUTS in men.

BPH-related symptoms can be secondary to hyperplasia of the prostatic epithelium resulting in mechanical obstruction of the prostatic urethra or secondary to increased muscular tone of the abundant smooth muscle in the prostate. Because of these two different mechanisms of obstruction, prostate size does not always correlate with the degree of symptoms.
LUTS are not always secondary to the prostate in men, and can be related to overactive bladder, urethral stricture disease, neurologic dysfunction, urinary tract infection, urothelial malignancy, diabetes and other medical conditions. It is imperative that a thorough history and physical be performed prior to initiating therapy. This rules out other potential causes that may not respond to prostate-directed therapy. A urinalysis should always be obtained to determine the presence of hematuria, glucosuria, proteinuria or infection.

While there is some controversy about the use of PSA screening for prostate cancer, in symptomatic patients a PSA should be obtained to help rule out prostate cancer and also provide a gross assessment of prostatic volume. This may help determine appropriate therapeutic options. A PSA of greater than 1 is associated with a prostate volume of 30cc or more. An International Prostate Symptom Score (IPSS) is also a useful tool that can help assess symptom severity and provide a baseline reference for therapeutic response.
If the initial evaluation is consistent with LUTS secondary to BPH, then therapy may be indicated if the symptoms are affecting a patient’s quality of life. LUTS tend to develop slowly in many men who are content to live with their symptoms without therapy. If the symptoms are bothersome to the patient, an initial course of medical therapy is worthwhile, but the patient should be made aware that there are surgical options that can eliminate the need for lifelong medical treatment.

LUTS fall into two categories, irritative and obstructive. Irritative symptoms include frequency, urgency, nocturia and urge incontinence, and obstructive symptoms include hesitancy or difficulty initiating the stream, straining to void, a reduced flow, an intermittent stream or a sensation of incomplete emptying. The type of symptoms and the size of the prostate should be considered when choosing first line therapy.

Medical Treatment

If the patient has primarily irritative symptoms with a small prostate, then an anticholinergic medication like oxybutynin or an alpha blocker is appropriate. If the symptoms are primarily obstructive and the prostate is small, an alpha blocker is the preferred therapy. For larger prostates, an alpha blocker or 5 alpha reductase inhibiter (Finasteride, Avodart) are options for single agent therapy.

A combination therapy is often effective with the alpha blocker, for immediate relief, and a 5 alpha reductase inhibitor, for a reduction in the prostate volume. This has been shown to reduce the risk of retention and surgery with long-term follow up. After six months of therapy, the alpha blocker can be weaned in a portion of men without compromising symptom relief.
If the initial treatment proves ineffective, additional evaluation should include a post-void residual urine measurement, a urine flow rate, or urodynamics if there is a suspicion of an underlying bladder condition. Renal chemistries and imaging may be indicated, to rule out obstructive uropathy with potential for renal damage. Cystoscopy is performed to assess the prostatic urethral anatomy and to rule out bladder pathology.

If medical therapy has not provided satisfactory relief of LUTS, or if the patient prefers to avoid long-term medical therapy, a variety of surgical options are available for treatment ranging from minimally invasive office procedures to hospital-based surgical treatments.
The gold standard surgical management for BPH is Transurethral Resection of the Prostate (TURP). TURP is associated with the greatest improvement in urinary flow and is quite durable to 10 years follow up. The procedure does require a general or spinal anesthetic and has greater risks than some of the less invasive treatments, but is very well tolerated with high satisfaction rates. 
Variations on the TURP include Transurethral Incision of the Prostate (TUIP) for smaller prostates, Holmium Laser Enucleation of the Prostate (HOLEP) which has less potential for blood loss, Electrovaporization of the Prostate (EVP), and laser vaporization with a variety of devices, including Holmium and Greenlight lasers in a hospital setting.

The EVOLVE laser can be used in the office under local anesthetic, and is the only office procedure that closely replicates the hospital-based procedures in tissue removal. Transurethral Needle Ablation of the Prostate (TUNA) and Microwave Thermotherapy are also office-based, and tend to be more comparable to medical therapy in efficacy than the other surgical approaches. The choice of the treatment is based on patient desire, prostate size, convenience and side-effect profile.

An Evolving Field
BPH therapy is an evolving field with exciting new therapies continuing to unfold. Ongoing research includes investigation of transrectally injected drugs, including Botulinum Toxin and other novel small molecules, as direct therapy for prostatic enlargement and increased muscular tone. Future patients may have the option of coming in one or two times a year for a simple five-minute injection that will provide durable relief without many of the systemic side effects associated with oral medications or the risks associated with a surgical procedure.

To learn more about treatment of LUTS and BPH, contact Alliance Urology Specialists at 336-274-1114.

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