Lower Urinary Tract Symptoms in men. How to diagnose and treat them correctly? LUTS. 14
Lower urinary tract symptoms in men are common after age 40. How to diagnose and treat LUTS? Weak urinary bladder, enlarged prostate, decreased kidney function cause lower urinary tract symptoms. Dr. Anton Titov, MD. 40% of men 40 years of age or older experience lower urinary tract symptoms (LUTS). They go to see urologist or general practitioner. What is a typical diagnostic path and diagnostic tests to identify the cause of lower urinary tract symptoms? Dr. Mark Emberton, MD. So lower urinary tract symptoms are extremely common. They are multifactorial. And I think lower urinary tract symptoms arise from a broad basis. Some of it is the nervous system deteriorating. I’ll start from the top. Obviously, if you have a cognitive dysfunction, you might not be aware when your bladder is filling. You might not be aware of the sense, the urge to urinate. We know that some neurological degenerative diseases affect the way the urinary bladder functions. And if you have a spinal cord injury, your bladder becomes much more active. And then we focus on your kidneys. As you age the kidneys are less able to concentrate urine at night. This means that if you drink in the evening tea or wine or beer, you’re more likely to get up at night to urinate. You might see a patient who reports that he’s getting up three times a night now to urinate. Whereas 10 years ago he wouldn’t get up at night at all. And much of that is this inability of kidneys to concentrate urine. There is substance called ADH that is secreted from the kidneys. And then we get down to the urinary bladder. The bladder wall thickens. It becomes more unstable. Urinary bladder wall fills with scar tissue. It develops hernias over time. And so urinary bladder loses its oomph. When you want urinary bladder muscle to contract, it doesn’t contract as well as it did. Dr. Mark Emberton, MD. And then you’ve got the enlarging prostate. Then maybe you’ve got obesity, which changes the shape of the lower urinary tract. All these things can affect the two functions. One is to store the urine in the bladder at low pressure. The second function is to expel it efficiently in one go. And the key to the lower urinary tract symptoms diagnosis is to find out this. Which of those two processes dominate? They are usually shared. So it’s very rare to find somebody with lower urinary tract symptoms who just has an outlet problem. Dr. Anton Titov, MD. And the tests try and discriminate between those two causes of lower urinary tract symptoms. So what I tend to do is make sure that there’s no complicated aspect to this, no urological problems, no sign of infection, no sign of blood in the urine. That happens in very very few patients, 2%. And the rest of patients have uncomplicated lower urinary tract symptoms. Dr. Mark Emberton, MD. Then I tend to do two tests. One diagnostic test is to establish how well the bladder empties. That’s an ultrasound test. Then I do another test. I ask the patient to keep a diary over three days. This gives me some idea of their functional capacity. How the bladder works over a day and a night. It is really important how much urine a patient puts out in the 24-hour period. And it was quite amazing. I saw patient yesterday who swore to me that he wasn’t drinking too much water. And yet he was producing 5,5 liters of urine per day. So most of us pass at best 400-500 milliliters of urine. So he was passing 5 liters a day. So he was having to urinate half a liter 10 times a day. And remember he’s asleep for a third of the day or half the day. So he was urinating on the hour every hour. All he needed to do is to drink less, because his bladder was working perfectly and emptied very well. Dr. Mark Emberton, MD. So these two diagnostic tests give you an extraordinary insight into lower urinary tract symptoms. Then you direct your therapy at the bladder, at the prostate, at the individual. And normally we can get away without using any drugs. We have to understand what’s going on. We have to use lifestyle changes to improve lower urinary tract symptoms. And then sometimes we might need to calm the urinary bladder down with medication. Sometimes we might need to relax the prostate with medicine. Sometimes we might need to shrink the prostate down with medicine. That will solve lower urinary tract symptoms in the majority of patients. In those patients that are left, who cannot urinate at all, who have bladders that are wrecked and are very weak, we might need to operate. And everything we can really do is to remove or reduce the urinary bladder exit resistance. We have to make it easier for the urinary bladder to empty. And that is successful in 70-80-90% of patients, depending on how good their urinary bladder function is. Dr. Anton Titov, MD. Professor Emberton, thank you very much for this very detailed and very fascinating conversation about prostate cancer and other issues in urology. We hope it will be very useful for our viewers around the world. Thank you very much! It’s been a really great pleasure to discuss prostate cancer and lower urinary tract symptoms with you! You’re very knowledgeable. Why are you so knowledgeable?
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