Lower Urinary Tract Symptoms in Male Adults

Background

• Lower urinary tract symptoms (LUTS) commonly refer to storage symptoms, voiding symptoms, and postmicturition symptoms.
• It most commonly affects older adults ≥ 40-45 years old.
• Bladder outlet obstruction related to benign prostatic enlargement from benign prostatic hyperplasia is the most common cause of LUTS, but other differential diagnoses should also be considered.

Evaluation

• Perform complete history and physical (Strong recommendation), including
  • evaluation with validated symptom scores (Strong recommendation)
  • digital rectal exam (DRE) (Strong recommendation)
  • bladder diary for ≥ 3 days if there are prominent storage symptoms, overactive bladder symptoms, or nocturia (Strong recommendation)
  • assessment of neurologic function
• Initial testing includes:
  • urinalysis (Strong recommendation)
  • serum prostate-specific antigen (PSA) (if it will impact management decision-making for prostate cancer) (Strong recommendation)
  • postvoid residual (PVR) (Weak recommendation)
  • uroflowmetry (Weak recommendation).
• Additional workup depends on findings from history and physical and initial testing.
  • If patients present with nocturia, carefully evaluate possible underlying etiologies in addition to benign prostatic hyperplasia-related bladder outlet obstruction.
  • If DRE is abnormal or if serum PSA is elevated, consider diagnostic workup for prostate cancer.
  • If neurological etiology is suspected, consider pressure flow studies and other evaluations related to neurological conditions.
  • Abnormal urinalysis may indicate benign prostatic hyperplasia (BPH) as the cause of LUTS, but other etiologies, such as urinary tract infections, malignancies, diabetes mellitus, or renal or cardiovascular causes, are also possible.
  • If there is large PVR, hematuria, or history of urolithiasis, consider ultrasound of upper urinary tract (Weak recommendation).
  • Pretreatment testing for deciding the appropriate management modalities include:
    • renal function evaluation (Strong recommendation)
    • uroflowmetry (Strong recommendation)
    • ultrasound assessment of prostate (Strong recommendation for surgical management planning; Weak recommendation for medical management planning)
    • urethrocystoscopy (Weak recommendation)
    • pressure flow studies (Weak recommendation).

Management

Initial Considerations

• For patients with underlying causes of LUTS other than bladder outlet obstruction (BOO) caused by BPH, they should be managed accordingly.
• Consider consultation with urologists if there are severe symptoms, abnormal prostate or imaging findings, comorbidities, or suspicion of BPH-unrelated etiologies (Weak recommendation).

Conservative and Medical Management

• For patients with no bothersome symptoms, offer watchful waiting with or without lifestyle advice and self-care information (Strong recommendation).
• For patients who have bothersome symptoms, initial management generally involves lifestyle advice and self-care information, together with behavioral and/or medical management if it is necessary.
  • For patients with predominant bladder storage symptoms, medical management options include anticholinergics (Strong recommendation) or beta-3 agonist (Weak recommendation).
  • For patients with symptoms that are not predominantly bladder storage symptoms, medical management options include
    • monotherapy with alpha blockers, phosphodiesterase-5 inhibitors (PDE5Is), or 5-alpha reductase inhibitors (5-ARIs) (Strong recommendation)
    • combination therapy with alpha blockers plus 5-ARIs (Strong recommendation), 5-ARIs plus PDE5Is, alpha blockers plus anticholinergics (Weak recommendation), or alpha blockers plus beta-3 agonists (Weak recommendation)
  • See for additional information Benign Prostatic Hyperplasia (BPH) (for information on conservative or behavioral management)

Procedural Management

• For patients with bothersome symptoms inadequately relieved by conservative or medical management, or complications of BPH arise, offer surgical or procedural management.
• Management of patients who can tolerate anesthesia and suspension of anticoagulation or antiplatelet therapy:
  • For patients with prostate size < 30 mL and no middle lobe, perform transurethral incision of prostate (TUIP) as the preferred management option (Strong recommendation).
  • For patients with prostate size 30-80 mL, perform monopolar or bipolar transurethral resection of prostate (TURP) as preferred management option (Strong recommendation).
  • For patients with prostate size > 80 mL, preferred management options include
    • holmium laser enucleation of prostate (Ho:LEP) (Strong recommendation)
    • bipolar transurethral enucleation of prostate (B-TUEP) (Weak recommendation)
    • open prostatectomy if Ho:LEP or B-TUEP is not available (Strong recommendation)
• For high-risk patients who can tolerate anesthesia, but cannot suspend anticoagulation or antiplatelet therapy, perform green light laser photoselective vaporization of prostate (PVP) as preferred management option (Strong recommendation).
• For high-risk patients with prostate size < 70 mL and no middle lobe, who cannot tolerate anesthesia and desire for ejaculatory function preservation, consider prostatic urethral lift (PUL) (Weak recommendation).