Lower urinary tract symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH) Symptoms

Table: Lower Urinary Tract Symptoms in Men

Source: National Clinical Guideline Centre (UK). The Management of Lower Urinary Tract Symptoms in Men. London: Royal College of Physicians (UK); 2010. (NICE Clinical Guidelines, No. 97). Appendix A, Scope. Available from: http://www.ncbi.nlm.nih.gov/books/NBK65067/

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Introduction

Lower urinary tract symptoms (LUTS) are common in men and can significantly impact quality of life. These symptoms are often associated with Benign Prostatic Hyperplasia (BPH), a non-cancerous enlargement of the prostate gland. BPH is prevalent among aging men and often leads to various urinary symptoms due to obstruction of urine flow or irritation of the lower urinary tract.

Symptoms of BPH

LUTS are broadly categorized into three groups: storage symptoms, voiding symptoms, and post-micturition symptoms.

1. Storage Symptoms: These are related to bladder storage problems.
   • Increased Daytime Frequency: Needing to urinate more frequently during the day.
   • Nocturia: Waking up several times during the night to urinate.
   • Urgency: A sudden, compelling need to urinate that is difficult to postpone.
   • Urinary Incontinence: Involuntary leakage of urine.
   • Altered Bladder Sensation: Changes in the way the bladder feels, which can be described as normal, increased, reduced, absent, or non-specific.
2. Voiding Symptoms: These symptoms are due to the difficulty of emptying the bladder.
   • Slow Stream: Reduced force of the urinary stream.
   • Splitting or Spraying: The urine stream splits or sprays instead of forming a single stream.
   • Intermittent Stream: The urine stream starts and stops intermittently.
   • Hesitancy: Difficulty in starting urination.
   • Straining and Terminal Dribble: Needing to strain to urinate and the continuation of urine dribbling after the main flow has finished.
3. Post-Micturition Symptoms: These occur after urination.
   • Feeling of Incomplete Emptying: The sensation that the bladder has not been completely emptied.
   • Post-Micturition Dribble: The involuntary leakage of urine immediately after urination.

Clinical Presentation and Physical Examination

Patients presenting with BPH typically report a combination of these symptoms. During a physical examination, a digital rectal examination (DRE) is conducted to assess the size and consistency of the prostate. BPH is often indicated by a uniformly enlarged, smooth, and firm prostate without nodules, which helps differentiate it from prostate cancer.

Diagnostic Evaluation

Diagnosis of BPH is usually based on the symptom assessment and clinical findings. Common diagnostic tools include:

1. International Prostate Symptom Score (IPSS)

The IPSS is a standardized questionnaire that assesses the severity of urinary symptoms. It consists of seven questions related to symptoms of BPH, each scored from 0 to 5, based on the frequency of the symptoms:

• The IPSS is made up of eight questions that cover seven symptom indexes:
  • Incomplete emptying: How often do you feel like you haven't emptied your bladder? 
  • Frequency: How often do you urinate less than every two hours? 
  • Intermittency: How often do you stop and start urinating several times in a row? 
  • Urgency: How often do you have trouble waiting to urinate? 
  • Weak stream: How often do you have a weak urine stream? 
  • Nocturia: How many times do you usually get up at night to urinate? 
  • Straining: How often do you strain when you urinate? 
• Score Breakdown:
  • 0: Not at all
  • 1: Less than 1 in 5 times
  • 2: Less than half the time
  • 3: About half the time
  • 4: More than half the time
  • 5: Almost always

The total score can range from 0 to 35, with severity classified as:

• Mild: 0–7
• Moderate: 8–19
• Severe: 20–35

2. Urinalysis

Urinalysis is used to exclude other causes of LUTS such as urinary tract infections (UTIs), hematuria, or bladder stones. The presence of leukocytes or nitrites may suggest a UTI, while the presence of red blood cells may indicate hematuria, warranting further investigation.

3. Serum Prostate-Specific Antigen (PSA)

PSA testing measures the level of prostate-specific antigen in the blood. Elevated PSA levels can be indicative of BPH, prostatitis, or prostate cancer. The PSA level is considered alongside patient age and prostate volume:

• Normal PSA levels:
  • Age <50 years: PSA <2.5 ng/mL
  • Age 50–59 years: PSA <3.5 ng/mL
  • Age 60–69 years: PSA <4.5 ng/mL
  • Age ≥70 years: PSA <6.5 ng/mL

A PSA level higher than the age-adjusted normal range may prompt further diagnostic procedures, such as a prostate biopsy, to rule out prostate cancer.

4. Ultrasound

Ultrasound, particularly transrectal ultrasound (TRUS), is used to measure the size of the prostate gland and to assess the post-void residual (PVR) urine volume, which indicates how much urine remains in the bladder after urination:

• Prostate Volume:
  • Normal: ≤20 mL
  • Mild Enlargement: 20–30 mL
  • Moderate Enlargement: 30–50 mL
  • Severe Enlargement: >50 mL
• Post-Void Residual Volume:
  • Normal: <50 mL
  • Borderline: 50–100 mL
  • Elevated: >100 mL (significant if persistently above 200 mL, indicating impaired bladder emptying)

5. Uroflowmetry

Uroflowmetry measures the flow rate of urine during urination, providing objective data on the degree of urinary obstruction. The two main parameters assessed are:

• Peak Flow Rate (Qmax):
  • Normal: ≥15 mL/sec
  • Mild Obstruction: 10–14 mL/sec
  • Moderate Obstruction: 5–9 mL/sec
  • Severe Obstruction: <5 mL/sec
• Average Flow Rate (Qavg): The average flow rate is also measured, with lower values suggesting greater obstruction.

Management of BPH

The treatment of BPH is guided by the severity of symptoms and patient preferences. Options include:

1. Lifestyle Modifications: Reducing fluid intake at night, avoiding caffeine and alcohol, and scheduling voiding can help manage mild symptoms.
2. Medications:
   • Alpha-Blockers: Relax the muscles in the prostate and bladder neck, improving urine flow.
   • 5-Alpha Reductase Inhibitors: Reduce prostate size by blocking the hormone responsible for prostate growth.
   • Combination Therapy: Combines both alpha-blockers and 5-alpha reductase inhibitors for more severe symptoms.
3. Minimally Invasive Procedures and Surgery:
   • Transurethral Resection of the Prostate (TURP): The surgical removal of a portion of the prostate.
   • Laser Therapy: Uses laser energy to remove obstructive prostate tissue.
   • Prostatic Urethral Lift (Urolift): A minimally invasive procedure that lifts and holds the enlarged prostate tissue away from the urethra.

Conclusion

BPH and associated LUTS are common in older men and can significantly impact daily life. Early identification and appropriate management are crucial for alleviating symptoms and improving quality of life. A combination of lifestyle changes, medications, and possibly surgery can be tailored to each patient's needs to manage this condition effectively.