Head To Head

Should we treat lower urinary tract symptoms without a definitive diagnosis? No

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6058 (Published 01 December 2011) Cite this as: BMJ 2011;343:d6058
  1. Julian R Shah, consultant urological surgeon
  1. 1 Institute of Urology and University College London Hospitals, London, UK
  1. pjrshah{at}hotmail.com

Paul Abrams (doi:10.1136/bmj.d6038) argues that invasive investigations are unnecessary and impractical for most patients with lower urinary tract symptoms, but Julian Shah thinks they are essential for successful treatment

The term “lower urinary tract symptoms” (LUTS) was coined to cover the variety of symptoms that affect the bladder. The symptoms may be storage or emptying symptoms or both. It was initially introduced because of the potential difficulty with terms such as “prostatism,” which described bladder symptoms in older men that were thought to be due to prostatic enlargement. Unfortunately, the term has been extended to apply to any patient, male or female, young or old, with urinary symptoms. The other arguably misleading term that has come into common parlance is “overactive bladder.” Both these terms are non-specific, non-diagnostic descriptions of symptom complexes. Yet their widespread use can easily lead to treatment being decided without any knowledge of the underlying condition.

From a clinical point of view, the term prostatism is more useful. Although it is also non-specific, it applied to a specific patient group—older men with prostatic enlargement with symptoms usually caused, but not always, by obstruction. But even this cannot be used to determine treatment without urodynamic studies.

Prostatic enlargement is the most common cause of lower urinary tract symptoms in older men,1 and the most effective treatment is surgery. Nevertheless, a large case series of 3830 patients with LUTS showed that symptoms are not always caused by bladder outflow obstruction2 and urodynamic studies are necessary for diagnosis. This particularly applies to specific patient groups such as young men,3 diabetic patients,4 those who have had a stroke,5 and men with small prostates.6

But what about other patients with symptoms of bladder dysfunction? In some patients the symptoms may be short term and could be due to an acute condition such as prostatitis or urinary infection. The diagnosis in these circumstances may be easier. However, for patients with chronic symptoms, the cause could be a condition that could last a lifetime, such as an unstable bladder, and this can only be determined definitively with urodynamics. Furthermore, not all men with prostatic obstruction require surgery. Urodynamics may, for example, show poor bladder contractility due to chronic bladder distension, which is best treated by intermittent self catheterisation rather than surgery if there is significant retained urine.7

Need for firm evidence

Objective evidence should be obtained in all men with voiding problems, such as slow stream or hesitancy. Non-invasive tests include free urine flowmetry and ultrasound residual urine measurement.8 A non-invasive penile cuff test can show the pressure-flow relation and help make a diagnosis.9 However, urodynamic studies, which also show the relation between pressure and flow (with x ray screening of the bladder outlet, when available) still remains the gold standard for diagnosis of obstruction.10 Numerous studies show that non-invasive tests are not able to diagnose obstruction sufficiently accurately to enable surgical intervention, with only 26% of men being obstructed when symptom scores and non-invasive tests are used to predict obstruction.11 A recent review by Parsons et al concluded there is “insufficient evidence to justify replacement of invasive voiding cystometry.”12

A primary diagnosis by appropriate urodynamic testing can provide an understanding of the patient’s condition and direct long term management. The benefit of a correct diagnosis is that the outcome from surgery is likely to be better, and if surgery is deferred in favour of conservative management at least this is with a knowledge of bladder function. The risk of retention in an obstructed man is 2% a year, and this prediction is useful in long term management, especially in younger men.

This approach is preferable to the treatment of symptoms without a definitive diagnosis. Symptoms are generally not resolved by “best guess” medical management. A systematic review has shown that 43% to 83% of patients discontinue medical treatment within 30 days.13 Such treatment could be argued to be a serious waste of resource. If we cannot provide long term benefit for patients with LUTS what is the point of short term treatment? Surely, this is an unsatisfactory way of treating patients unless they are clearly told that the treatment is an experiment. It could be argued that because many patients with untreated bladder outflow obstruction do not deteriorate in the long term, making a diagnosis is critical to providing them with the necessary reassurance they need. If obstruction is not present there would be no purpose in advising unnecessary treatment based on symptoms alone.14 15

So how should we approach the problem? We should continue to debate the relevance of terminology. It is interesting how terms come into parlance because of the enthusiasm of a particular group only to be replaced later when such enthusiasm wanes or evidence shows that the terminology is misleading.

LUTS should not be treated without a clear diagnosis. Knowledge of the underlying cause will enable appropriate management, improve the likelihood of compliance with treatment or allow selection for surgical intervention, and provide a better clinical outcome.

Notes

Cite this as: BMJ 2011;343:d6058

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; JS has received financial support from Astellas, Pfizer, Coloplast, and Genesis for lectures and travel support. 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