Head To Head

Should we treat lower urinary tract symptoms without a definitive diagnosis? Yes

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6038 (Published 01 December 2011) Cite this as: BMJ 2011;343:d6038
  1. Paul Abrams, professor of urology
  1. 1Bristol Urological Institute, Southmead Hospital, Bristol BS10 5NB, UK
  1. paul_abrams{at}bui.ac.uk

Paul Abrams argues that invasive investigations are unnecessary and impractical for most patients with lower urinary tract symptoms, but Julian Shah (doi:10.1136/bmj.d6058) thinks they are essential for successful treatment

Lower urinary tract symptoms (LUTS) are common in the general population, their main causes (including overactive bladder and benign prostatic obstruction) are not life threatening, definitive diagnosis is invasive, and initial management is safe. Initial treatment of the symptoms without a definitive diagnosis is therefore sensible and avoids unnecessary secondary care.

Defining the problem

Around 1.8 billion men and women worldwide have LUTS, and the numbers are increasing rapidly as the population ages.1 The term was introduced in 1994 to escape the “prostate-centric” approach of doctors to lower urinary tract symptoms in men, which led to many men having unnecessary prostate surgery when their symptoms had other causes.2 Later, the International Continence Society divided symptoms into three categories: storage LUTS, including the symptoms of overactive bladder (urgency, urgency urinary incontinence, frequency, and nocturia) and stress urinary incontinence; voiding LUTS, including slow stream and hesitancy; and post-micturition LUTS, such as a feeling of incomplete emptying and post-micturition dribble.3

LUTS affect patients in many ways.4 5 Although symptoms can be bothersome and interfere with quality of life,4 5 not all patients are troubled enough to seek treatment. However, there is undoubtedly considerable unmet need, and some data show that many patients have failed to get treatment, even when they would be happy to accept it.

Urodynamic studies are needed to determine the underlying causes of LUTS. Such studies require the passage of a urethral catheter and are therefore uncomfortable for patients as well as expensive. Given the large numbers of people with LUTS who seek medical care, treatment without a definitive diagnosis is the only practical way of managing most patients. Furthermore, my experience is that patients are unlikely to agree to an invasive, uncomfortable investigation if the management they are offered is simple, safe, and relatively inexpensive. Successive international consultations have recommended that urodynamic studies are used only if invasive treatments are being considered.6 7 Most patients with symptoms that interfere with their quality of life can be managed by a combination of lifestyle interventions, behaviour modification, and drugs.

Conservative treatment

A definitive diagnosis is not needed to start many of the simple interventions that benefit patients with LUTS. Lifestyle modifications include measures such as manipulation of fluid and food intake. Many patients drink far more fluids than they need, partly because of publicity of the false perception that we need to drink 2 litres of water a day. It has been shown that restricting fluid intake improves symptoms of overactive bladder.8 There is also evidence that stopping caffeine helps many people with overactive bladder, possibly because caffeine is a mild diuretic and also a direct smooth muscle stimulant.9

Overactive bladder with or without urgency incontinence is improved by pelvic floor exercises because contraction of the pelvic floor increases urethral closure pressure, thereby maintaining the pressure gradient essential for continence. Furthermore, contracting the pelvic floor inhibits the detrusor contractions that are responsible for the symptoms of overactive bladder. Overactive bladder is also improved by bladder training—that is, by asking the patient to void every one hour initially and, if that controls their urgency and incontinence, then increasing their inter-void intervals by 15 minutes, at intervals of two to three days, until the patient can void safely, without bothersome symptoms, at socially acceptable intervals.

Prostatic obstruction, and its associated symptoms, can be partly relieved by α adrenergic blocking drugs and 5α reductase inhibitors. Overactive bladder may be improved by antimuscarinic drugs and nocturia by judicious use of desmopressin.

LUTS are not dangerous, for the most part, although certain symptoms should alert clinicians to the need for further investigation. These include haematuria, dysuria, and new onset nocturnal incontinence, and signs such as an enlarged bladder. However, even conditions like prostatic obstruction, which were previously thought to be potentially dangerous and to need early treatment, have been shown in longitudinal studies to be relatively benign and show little progression.10 11

Best management

The treatments for LUTS mentioned above are low risk and, for the most part, low cost. Hence, neither the National Institute for Health and Clinical Excellence’s guidelines on incontinence12 nor its guidance on male LUTS13 recommend seeking a definitive diagnosis before treatment of symptoms in men or women.

In future the aim should be to teach men and women self care as initial management. This would require the production of psychometrically validated self care packages, which are safe to use and clearly indicate when medical care should be sought. All doctors can continue to treat LUTS without a diagnosis. If symptoms remain bothersome, referral for a urodynamic diagnosis is mandatory if the patient wishes to consider invasive treatments.

Notes

Cite this as: BMJ 2011;343:d6038

Footnotes

  • Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares no support from any organisation for the submitted work. PA has received consultancy fees from Astellas, Novartis, ONO, Pfizer, and Ferring; fees from Pfizer for expert testimony; lecture fees from Astellas, Novartis, and Pfizer; and travel support from Astellas and Pfizer to attend meetings. His department has received a grant for a research study from Verathon. He has no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References