Should we treat lower urinary tract symptoms without a definitive diagnosis? YesBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6038 (Published 01 December 2011) Cite this as: BMJ 2011;343:d6038
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This discussion regarding the treatment of lower urinary tract symptoms is both interesting and insightful. However, this discussion may be confusing to the non-urologist, especially General Practitioners who may follow the NICE guidelines on Lower Urinary Tract Symptoms (1).
These placed an emphasis on the assessment of patients’ symptoms including objective quantification by the IPPS score, physical examination aimed at the exclusion of urinary retention and meatal stenosis and assessment of prostate size and consistency.
This assessment should indirectly indicate whether symptoms are due to presumed bladder outflow obstruction, overactive bladder syndrome or nocturnal polyuria, followed by an initiation of an appropriate medical treatment. The treatment would need to be directed towards either the storage or voiding lower urinary tract symptoms that cause the highest degree of bother. Such an approach would allow a GP to make an initial diagnosis, with symptomatic resolution.
The overlap between a histological, functional and symptomatic diagnosis has been described previously (2). We suggest that the presence of two of these three domains are sufficient to indicate the need for treatment. Asymptomatic progression should be discussed with the patient because of the risk of renal dysfunction and loss of lower urinary tract function in the future (3).
Those who fail to respond are expected to undergo further assessment that would include urodynamic studies and cystoscopy, aimed at obtaining a more definitive diagnosis. We agree that establishing a diagnosis of either benign prostate hyperplasia or other causes of ‘prostatism’ is not always necessary before treatment can be initiated. This is because of the difficulty and potential complications that may arise in making such a diagnosis.
The question however is what constitutes a definitive diagnosis especially if some of our initial assessment yields contradictory information. Furthermore, how can our initial assessments of such patients be tailored to be more specific and less invasive.
1.NICE Guidance on Lower Urinary Tract Symptoms (CG97), National Institute of Clinical Excellence, May 2010.
2.Scand J Urol Nephrol. 1996 Aug;30(4):303-6. Benign prostatic hyperplasia. Does a correlation exist between prostatic morphology and irritative symptoms? Atan A, Horn T, Hansen F, Jakobsen H, Hald T.
3.Ther Adv Urol. 2012 Apr;4(2):77-83. Optimizing the management of benign prostatic hyperplasia. Elterman DS, Barkin J, Kaplan SA.
Competing interests: No competing interests