Lower Urinary Tract Symptoms

Lower urinary tract symptoms (LUTS) is a term used to describe a range of symptoms related to problems of the lower urinary tract including the bladder, prostate and urethra. LUTS affects both men and women, although usually for different reasons.

A uroflow and residual are usually performed as part of the initial assessment.

Micturition Cycle

These problems arise when there is a dysfunction of the micturition, or urination, cycle. There are essentially two phases of the cycle:

  • Storage – the bladder accommodates the volume of urine at low pressure. The outlet orpelvic floor remains closed so that continence is maintained. When the bladder is full, a signal is sent to the brain to void at an appropriate time.
  • Voiding – the pelvic floor relaxes and the bladder contracts so that all the urine empties out at low pressure.

Therefore, LUTS are broadly divided into storage (irritative) or voiding (obstructive) symptoms, although they do no reliably correlate with the cause of the problem.

The two most common causes of LUTS are bladder outflow obstruction (BOO) from an enlarged prostate and an overactive bladder (OAB).

Storage (irritative)
  • Urgency
  • Frequency
  • Nocturia – passing urine at night
  • Urge incontinence – leakage as unable to get to the toilet in time
Voiding (obstructive)
  • Hesitancy or difficulty starting
  • Slow stream
  • Intermittency or interrupted stream
  • Straining
  • Terminal dribbling
  • Sensation of incomplete emptying
  • Double voiding

Flexible Cystoscopy with Urodynamics

Sometimes it is unclear what the cause of the LUTS is due to, particularly in the presence of neurological conditions, previous surgery or failure to respond to initial treatment. In this situation, a flexible cystoscopy with urodynamics may be suggested to characterise the structure and function of the bladder.

Bladder Outflow Obstruction and Urinary Retention

Bladder outflow obstruction from an enlarged prostate is very common in men as they age, particularly over 50. The prostate slowly enlarges the longer it has been exposed to testosterone and therefore this problem is common in older men.

The enlarged prostate can obstruct the urethra running through it and push up into the bladder. Symptoms of an enlarged prostate do not increase your risk of prostate cancer, although it can be a cause for a PSA rise.

Treatment for an enlarged prostate is usually medication or an operation such as a transurethral resection of the prostate (TURP) to “rebore” a hole through the narrowed prostatic urethra.

Alpha blockers such as Tamsulosin or Prazocin relax the muscle at the bladder neck where the prostate joins the bladder and can be helpful in mild to moderate symptoms. Duodart contains Tamsulosin as well as Dutasteride. The Dutasteride shrinks the prostate in size over a period of months through a hormone pathway. The potential side effects include erectile dysfunction (impotence), loss of libido, decreased ejaculatory volume and breast growth (gynaecomastia).

An operation is usually discussed if medications do not adequately settle the symptoms or stop working with time. In some circumstances, there is a complication from the enlarged prostate such as retention, infections or kidney impairment, and in this situation an operation such as a TURP is offered.

A special electric knife is used to shave away the sides of the prostate to widen the urethra running through it.

Urinary retention is an extreme example of being unable to void. This usually requires a catheter to be inserted into the bladder to drain urine. It can be due to severe obstruction, a bladder that does not squeeze or a combination of both. A TURP is usually performed in cases due to obstruction.

Overactive Bladder Syndrome (OAB)

This is a set of symptoms characterised by frequency, urgency and nocturia, sometimes with associated urge incontinence. It is due to involuntary contractions or “spasm” of the bladder while it should be filling at low pressure or the storage phase of the micturition cycle.

Additional tests may be required such as imaging, a uroflow and residual, cystoscopy and urodynamics to confirm the problem and exclude anything else more sinister.

In most cases, an overactive bladder can be managed conservatively with bladder training and medications. Bladder training involves lifestyle changes such as modifying fluid intake to mostly water and avoiding bladder irritants such as caffeine, alcohol and fizzy drinks. Keeping a bladder diary can help with this and monitor improvement with the fluid changes. Deferment techniques are also taught to increase the interval between needing to pass urine.

Medications such as anticholinergics and Mirabegron (beta 3 agonist) can also help reduce the bladder contracting. Anticholinergics have the side effect of dry eyes and mouth, constipation and sometimes cognitive changes. Mirabegron has a theoretical risk of increasing blood pressure.

In very severe circumstances, injections of Botox directly into the bladder can be helpful. It also reduces the bladder contractions when bladder training and medications are not enough to settle the symptoms. In a small proportion of patients, the bladder can be “paralysed” so all patients offered this treatment must learn clean intermittent self catheterisation in the event they experience retention.

Nocturia

Nocturia literally means waking up at night to urinate. It usually accompanies other lower urinary tract symptoms. As an isolated problem however, it is usually related to producing too much urine overnight (nocturnal polyuria) and can be diagnosed on a bladder diary.

The cause is usually non-urological such as medical problems of the heart and lungs. Treatment involves correcting these other medical issues as well as lifestyle changes.

Clean intermittent self catheterisation (CISC)

This involves insertion of a thin plastic tube (catheter) through the urethra into the bladder to completely drain out urine.

It is commonly used for patients where their bladder does not adequately contract. There is no medication presently the helps the bladder squeeze so self catheterisation allows the bladder to artificially empty through the tube.

In some instances, it is used to prevent strictures from reforming.

Your surgeon and specialist continence nurse will advise how often CISC needs to be performed based on your circumstances. You will be initially shown a video about the technique and our specialist continence nurses have many decades of experience.

You will be directly observed to perform it competently and our nurse will help with ordering of the appropriate appliances, including completing forms for any government rebates to assist with purchase of the catheters and equipment.

Flixible Cystoscopy and Urodynamics

The test is performed under a local anaesthetic, and a fine flexible telescope (cystoscope) is passed through the urethra into the bladder to examine the “plumbing”. It will identify obstructing lesions suchas an enlarged prostate or stricture, and also confirm that the bladder lining, or urothelium, looks normal.

A fine tube connected to a pressure monitor is then inserted into the bladder and into the rectum so that pressure measurements can be obtained while the bladder fills slowly. When feel full, urinating into a special toilet measures the volume and flow rate.

This test will confirm if your bladder is stable during filling or whether it “spasms” and contracts when it should quiet. It will also tell if your bladder is able to consistently contract to completely empty your bladder and if there is any obstruction.

Transurethral Resection of Prostate (TURP)

The commonest operation performed for an enlarged prostate causing bladder outflow obstruction is the TURP. Given that the Newcastle region has a lot of mining, it is colloquially called a “re-bore”!

Usually under a spinal or general anaesthetic, a rigid cystoscopy is initially performed to directly visualise the urethra and bladder. Then, a special electric knife is used to shave off the sides of the prostate to widen the tube, or urethra, running through it. An irrigating catheter is then placed into the bladder usually for 1-2 nights before it is taken out in the morning for a trial of void to ensure that you can pass urine comfortably a few times.

There is visible blood in the urine for a few weeks, which may be prolonged if on blood thinners. The flow will be immediately improved when passing a large volume of urine. There is usually burning and stinging when voiding, and irritative symptoms such as frequency, urgency and nocturia for a few weeks to months after the procedure is common while the raw area of the prostate takes time to heal. It almost always settles down with time.

There is a very small risk of stress incontinence and dry orgasms are to be expected due to retrograde ejaculation as semen goes back into the bladder after the prostate is opened. Please tell your doctor if you are on any blood thinners as these may need to be stopped temporarily prior to the operation. It is usually reasonable to remain on low dose aspirin, such as Cartia.