MEN’S HEALTH ASSESSMENT OF LOWER URINARY TRACT SYMPTOMS IN YOUNGER MEN Lower urinary tract symptoms (LUTS) are common in the ageing male and represent a significant burden on both the patient and the healthcare system worldwide.1,2 Accordingly, the majority of clinical trials and guidelines focus on the older patient, despite the fact that men below these ages will also present with many of the same symptoms. In this review, the authors explore the challenges of assessing and managing men below 50 years with LUTS. Dr Odunayo Kalejaiye Urology SpR Professor Raj Persad Consultant Urologist; Honorary Professor of Urology Dr Jon Rees GP Partner Department of Urology, North Bristol NHS Trust The aetiology of LUTS is multifactorial with causes attributed to dysfunction of the bladder and its outlet – including the prostate, urethra and sphincter; the neurological innervation of the lower urinary tract, and medical co-morbidities.1,2 It is important to consider all these aspects when assessing patients. While in older men, benign prostatic enlargement is the commonest cause of male LUTS, in younger men this is unusual, and other diagnoses should be considered more likely. What are LUTS? Men with urinary symptoms are often characterised as having ‘prostatism’ or benign prostatic hyperplasia (BPH). However, given the wide variety of possible causes of urinary symptoms, a patient is best described as having LUTS, encouraging a more holistic approach to their assessment and subsequent management. LUTS may be divided into: Storage symptoms urgency, urinary frequency, nocturia, urgency incontinence Voiding symptoms slow/poor stream, hesitancy, terminal dribbling Post micturition symptoms incomplete bladder emptying, post micturition dribbling Storage symptoms were commonest in men 39 years or younger, with a prevalence of 37.5% 24 | November/December 2013 | How common are LUTS in younger men? The EPIC study,3 a population-based survey which recruited men aged over 18 years, found that the prevalence of LUTS increased with age, from 51.3% in men aged 18-39 years to 62% in those aged 40-59 years. This is compared with a prevalence of 80.7% in men aged 60 years or older. Storage symptoms were commonest in men 39 years or younger, with a prevalence of 37.5%, compared with a prevalence of 19.9% for voiding symptoms in this age group. These rates increased to 50.6% and 24.1% respectively in men aged 40-59 years. Possible causes of LUTS in young men Overactive bladder (OAB) OAB is common in young men and is characterised by the presence of storage symptoms. The cardinal symptom of OAB is urgency, with or without urge incontinence. Patients may also complain of urinary frequency and nocturia. Benign prostatic enlargement The Olmsted county study, which followed men aged 40-79 years old for 12 years, provided early evidence that benign prostatic hyperplasia (BPH) is age related.4 Moderate to severe LUTS was present in 26% aged 40-49 years. In men aged less than 50 years, the International Prostate Symptom Score (IPSS) increased by 0.05/year, and the peak flow rate decreased by 1.1% per year.4 It has been suggested that bladder outlet obstruction due to BPH in young men should be suspected in men with large prostates (greater than 35mL volume), especially if aged 46-50 years.5 Bladder neck dysfunction This is a poorly understood non-neurogenic condition whereby detrusor contraction causes bladder neck narrowing instead of funnelling, resulting in a functional obstruction. The mainstay of MEN’S HEALTH treatment is the use of α-adrenergic blocker, although TABLE 1. HISTORY TAKING IN PATIENTS in the longer term many may require surgery.5,6 PRESENTING WITH LUTS Urethral strictures The prevalence in the UK of urethral strictures increases with age from 10 per 100,000 in youths, to 20 by age 55 and 40 by age 65.7 The causes are linked to age and may include dermatitis, balanitis xerotica obliterans (BXO), poor hygiene, previous surgery for hypospadias, or iatrogenic causes (e.g. catheters or previous prostate resection).7 BXO is the commonest identifiable cause of penile strictures in young and middle aged adults.7 Strictures are more common in smokers, and smoking adversely affects the outcome from urethroplasties. Men with strictures will present with voiding symptoms or complications of strictures, such as prostatitis, epididymo-orchitis, bladder stones or rarely renal failure.7 Ketamine abuse Ketamine is a class C recreational drug in common use among young adults; one study reported 0.9% of 16-24 year olds in the UK admitted ketamine abuse.8,9 This drug is associated with significant damage to the urogenital tract including atrophic, small capacity bladder and ureteric strictures resulting in hydronephrosis and renal failure in severe cases.8,9 Patients may present with severe dysuria or suprapubic pain, frequency (every 15-90 minutes), urgency, urge incontinence and painful haematuria. Some will return to ketamine as analgesia for their severe pain. These patients may be difficult to manage and require a multidisciplinary approach with input from drug dependency agencies, pain teams and urologists. The urological damage may be at least partially reversible with abstinence.8,9 Neurological disorders Optimal bladder function requires the bladder to store urine under low pressure and then empty at a socially acceptable time. This depends on the detrusor muscle contracting during voiding and relaxing during filling. In addition, the sphincter must remain closed during filling and open during voiding. These interactions are reliant on intact and coordinated neural control involving the whole neurological system. Neurological disease may result in variable dysfunctions of the lower urinary tract and resultant symptoms. It is therefore important to exclude new or undiagnosed neurological disorders, such as multiple sclerosis. Assessment1,2,7,10,11 The correct management of these patients is dependent on eliciting the correct information from the patient and determining, as well as managing, their expectations. There will be men whose only reason for seeking medical attention will be prompted by public health posters associating LUTS with a Symptoms Storage vs. voiding vs. postmicturition Duration Severity: i.e. incontinence episodes Degree of bother Which symptom is most bothersome Any treatment previously trialled Impact on quality of life Any precipitating factors Fluid intake Volume Type of fluid intake Urinary colour Timing of fluids, especially late evening Drug history Diuretics, herbal formulations, illicit drug use (especially ketamine) Co-morbidities Previous surgery: penile, prostatic or rectal (e.g. for inflammatory bowel disease) Previous trauma Neurological disorders Cardio-respiratory disease: heart failure, sleep apnoea BXO is the commonest identifiable cause of penile strictures in young and middle aged adults TABLE 2. EXAMINATION AND ADJUNCTS IN PATIENTS PRESENTING WITH LUTS Examination Abdomen Urinary retention Surgical scars External genitalia Phimosis Meatal stenosis Balanitis xerotica obliterans Penile cancer Digital rectal examination Anal tone Prostate: size, irregularity, tenderness, bogginess Rectal mass Adjuncts Urinalysis Urinary tract infection Diabetes Proteinuria Haematuria Frequency volume chart Should be completed over 3 consecutive days Diagnose nocturnal polyuria IPSS: for men considering treatment | November/December 2013 | 25 MEN’S HEALTH possible diagnosis of prostate cancer. These men can often be reassured and discharged. However, it is important not to miss important bothersome symptoms and underlying pathology. Assessment would ideally comprise a focused history and examination with relevant tests, as shown in Tables 1 and 2. In patients with urinary retention or clinical signs of renal impairment or failure, renal function tests should be requested. The value or otherwise of checking the patient’s PSA is controversial. Current NICE guidance suggests this may be offered in an adequately counselled man with LUTS suggestive of bladder outlet obstruction, if the prostate is abnormal on digital rectal examination (DRE) or the patient is concerned about prostate cancer.2 The PSA may be used as a surrogate for prostate volume;10 a prostate volume of greater than 30mL is associated with a 3 times greater risk of acute urinary retention (AUR) and BPH-related surgery.10 The PSA thresholds for volumes greater than 30ml are: 1.3ng/mL for ages 50-59 1.5ng/mL for ages 60-69 The value or otherwise of checking the patient’s PSA is controversial Lifestyle modifications are an important adjunct and include the following: Fluid reduction at specific times especially late in the evenings Avoidance of stimulants: caffeine, alcohol, fizzy drinks Distraction techniques: penile squeeze, breathing exercises, perineal pressure, mental distraction techniques Bladder retraining and pelvic floor exercises Review of medications and optimisation of drug timings Weight reduction if obese Treatment of constipation Abnormal PSA Urethral milking There is no PSA below which the risk of prostate cancer is zero. The PSA is expected to rise with age and the use of age specific PSA ranges (see below) as a basis for referral to secondary care is recommended. The PSA may be elevated by BPH, prostatitis, UTI or recent instrumentation of the urinary tract.11 It is also advisable to repeat the PSA after a reasonable interval and send mid-stream urine to exclude an asymptomatic UTI. A normal PSA which is rising significantly may be a third indication for referral. A PSA velocity of greater than 0.75ng/ml/year or a PSA doubling time less than 3 years indicates a significant PSA rise.11 Age (years) PSA (ng/ml) 40-49 ≤2.5 50-59 ≤3.5 60-69 ≤4.5 >69 ≤6.5 Conservative management1 There is good evidence to suggest that men with mild, low bothersome symptoms may be reassured and managed conservatively. In addition, self-management reduces symptoms and their progression. The key aspects of self-management are: Patient education Reassurance that their symptoms are not caused by cancer Periodic monitoring 26 | November/December 2013 | Adequate fluid intake: ensure urine is a light straw colour; 1500ml/day should be adequate Initial treatment1 The options for men who have failed conservative management include α-adrenergic blockers (e.g. tamsulosin, alfuzosin), muscarinic receptor antagonists (e.g. solifenacin), 5α-reductase inhibitors (e.g. finasteride, dutasteride) and the novel β3 adrenoceptor agonist, mirabegron. Men with predominantly voiding symptoms may be managed with α-adrenergic blockers while those with mainly storage symptoms are typically managed with muscarinic receptor antagonists. Anti-muscarinics are associated with significant side effects, such as dry mouth, constipation and reflux, which are at least partly responsible for their low patient compliance. Patients should be warned that they may need to try several different types of antimuscarinics at different doses before finding the most efficacious drug and dose. The dose at which patients develop a dry mouth is likely to be the most efficacious. There is a theoretical risk of causing urinary retention in the presence of significant bladder outlet obstruction with the use of anti-muscarinics. In the community, men should be warned about this potential risk, and caution should be exercised if the prostate volume is large, or there are mixed voiding and storage symptoms or a history of retention. The new β3 agonist mirabegron (Betmiga) is licensed for use in patients with symptoms of overactive bladder syndrome or storage symptoms. The results from trials of this and other β3 agonists are very encouraging, with a better side effect profile MEN’S HEALTH compared to anti-muscarinics.12 However, real life experience with this drug is still awaited. Men with mixed symptoms may be treated with both α-adrenergic blockers and anti muscarinics. Men with risk factors for BPH progression could be treated with dual therapy with 5α-reductase inhibitors and α-adrenergic blockers, although most of these do not apply to this age group. The side effects of sexual dysfunction must be balanced with the degree of symptom bother. Criteria for referral include: side effects, reassurance and the use of lifestyle modifications. Older men often expect to experience LUTS, while younger men may present with concerns that it may signify cancer. Benign causes of LUTS are more common; however there will be a small cohort who may have significant underlying pathology such as cancer. The key to successful management of these men is in their initial assessment and the majority can be adequately managed in the community. Failed medical management References Abnormal DRE/PSA 1 European Association of Urology guidelines 2012. 2 NICE clinical guidelines 97 – Lower urinary tract symptoms. 3 Irwin D, Milson I, Hunskaar S, et al. Euro Urol 2006;50:1306-15. 4 Jacobsen SJ, Girman CJ, Guess HA, et al. J Urol 1996;155:595-600. 5 Wang CC, Shei Dei Yang S, Chen Y, et al. Euro Urol 2003;43:386-90. 6 Toh K-L, NG C-K. Int J Urol 2006;13:520-3. 7 Mundy AR, Andrich DE. BJU Int 2010;107:6-27. 8 Chu PS, Ma WK, Wong SC, et al. BJU Int 2008;102:1616-22. 9 Wood D, Cottrell A, Baker SC, et al. BJU Int 2011;107:1881-4. 10 Marberger MJ, Andersen JT, Nickel JC, et al. Euro Urol 2000;38:563-8. 11 Arya M, Shergill, et al. Viva practice for the FRCS (Urol) examination. Complications: renal failure, recurrent/persistent UTI, urinary retention Visible haematuria Painful LUTS: bladder carcinomas, ketamine bladder syndrome, bladder stone(s) Non-visible haematuria in the absence of UTI in men aged ≥50 years Conclusion Young men with LUTS may be managed in a similar way to older men. However, careful consideration must be given to issues such as minimising treatment New BJFM website now live! Go to www.bjfm.co.uk today to: Find articles of interest quickly using our simple search; search by author or topic Understand more about a special interest area using our dedicated channels Catch up with what’s new Give us your views by commenting on articles you’ve read in the journal Share content with colleagues. | November/December 2013 | 27