Lower urinary tract symptoms (LUTS)

A plethora of terms have been coined to describe the symptom complex traditionally associated with prostatic obstruction due to BPH. 

The classic prostatic symptoms of hesitancy, poor flow, frequency, urgency, nocturia, and terminal dribbling have, in the past, been termed prostatism or simply BPH symptoms. One sometimes hears these symptoms being described as due to BPO (benign prostatic obstruction) or BPE (benign prostatic enlargement) or, more recently, LUTS/BPH. However, these classic symptoms of prostatic disease bear little relationship to prostate size, urinary flow rate, residual urine volume or indeed uro-dynamic evidence of bladder outlet obstruction.

 Furthermore, age-matched men and women have similar prostate symptom scores, but women obviously have no prostate. We therefore no longer use the expression prostatism to describe the symptom complex of hesitancy, poor flow, etc. Instead we call such symptoms lower urinary tract symptoms (LUTS) which is purely a descriptive term avoiding any implication about the possible underlying cause of these symptoms.

The new terminology of  LUTS is useful because it reminds the uro-logist to consider possible alternative causes of symptoms, which may have absolutely nothing to do with prostatic obstruction, and it reminds us to avoid operating on an organ, such as the prostate, when the cause of the symptoms may lie elsewhere.

Baseline symptoms can be measured using a symptom index. The most widely used is the International Prostate Symptom Score (IPSS), a modified version of the AUA Symptom Index.

International prostate symptom score (IPSS) Name:                                                                                                    Date: Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your score Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 0 1 2 3 4 5 Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5 Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? 0 1 2 3 4 5 Urgency Over the last month, how difficult have you found it to postpone urination? 0 1 2 3 4 5 Weak stream Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5 Straining Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5 None 1 time 2 times 3 times 4 times 5 times or more Your score Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5 Total IPSS score Quality of life due to urinary symptoms Delighted Pleased Mostly satisfied Mixed – about equally satisfied and dissatisfied Mostly dissatisfied Unhappy Terrible If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? 0 1 2 3 4 5 6 Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

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Other causes of LUTS

In broad terms, LUTS can be due to pathology in the prostate, the bladder, the urethra, other pelvic organs (uterus, rectum) or due to neurological disease affecting the nerves that innervate the bladder. These pathologies can include benign enlargement of the prostate causing bladder outflow obstruction (‘BPE’ causing ‘BOO’) and infective, inflammatory, and neoplastic conditions of the bladder, prostate, or urethra. While LUTS are, in general, relatively non-specific for particular pathologies, the context in which they occur (i.e. associated symptoms) can indicate their cause. For example:

• LUTS in association with macroscopic haematuria or with dipstick or microscopic haematuria suggests a possibility of bladder cancer. This is more likely if urinary frequency, urgency, and ‘bladder’ pain (suprapubic pain) are prominent. Carcinoma in situ of the bladder—a non-invasive but potentially very aggressive form of bladder cancer which very often progresses to muscle invasive or metastatic cancer—classically presents in this way.
• Recent onset of bedwetting in an elderly man is often due to high-pressure chronic retention. Visual inspection of the abdomen may show marked distension due to a grossly enlarged bladder. The diagnosis of chronic retention is confirmed by palpating the enlarged, tense bladder, which is dull to percussion, and by drainage of a large volume (often well in excess of 2L) following catheterization.
• Rarely, LUTS can be due to neurological disease causing spinal cord or cauda equina compression or to pelvic or sacral tumours. Associated symptoms include back pain, sciatica, ejaculatory disturbances, and sensory disturbances in the legs, feet, and perineum. In these rare cases, loss of pericoccygeal or perineal sensation (sacral nerve roots 2–4) indicates an interruption to the sensory innervation of the bladder and a MRI scan will confirm the clinical suspicion that there is a neurological problem.