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

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.