Lower urinary tract symptoms are common in older men and many more are seeking help. Recent guidance will support GP management, says Professor Roger Kirby
Benign prostatic hyperplasia (BPH) is a common condition affecting approximately 50% of men between 50 and 60 years and more than 80% of men over 80.1 Analysis of the General Practice Research Database reveals lower urinary tract symptoms (LUTS) suggestive of BPH in 3.5% of men in their late 40s and in 35% in their late 80s.2
LUTS, an enlarged prostate and bladder outlet obstruction are the three main BPH characteristics of which patients may experience one or more. Further symptoms are listed in Box 1 (below).
|Box 1: Symptoms of benign prostatic hyperplasia|
If BPH is left untreated, acute or chronic urinary retention may develop and hospital admission, catheterisation and eventually prostate surgery will often be required.
The need for a guideline
BPH has traditionally been managed in secondary care, with primary care involvement largely dependent on the GP’s knowledge and confidence. Increasing availability of medical treatments for BPH, however, has meant that the condition can now be managed effectively and safely in primary care.
The British Association of Urological Surgeons (BAUS) has therefore rewritten its secondary care guideline on management of male lower urinary tract symptoms, which was developed in 1997, for use in primary care.3
Increased awareness of prostate disease and its symptoms has led more men to seek advice from their GP – the main worry for many men complaining of LUTS will be prostate cancer. However, there are other concerns; BPH can affect quality of life and cause complications involving acute urinary retention leading to hospitalisation and surgery.
The evidence base
The new BAUS guideline for men with lower urinary tract symptoms is grounded in evidence-based medicine. It has been produced by a multidisciplinary working group, consisting of five consultant urologists, two GPs, a nurse, a patient and a medical facilitator.
Major guidelines, such as those from the American Urological Association, the European Association of Urology and BAUS, were reviewed, along with the supporting literature.
For men presenting with LUTS, GPs need to provide reassurance, lifestyle advice and a review of their other medication or therapies. The BAUS guideline includes an easy to follow algorithm (Figure 1, below), which can be personalised to individual patients, to help the GP to identify and meet their treatment needs. The algorithm prompts the GP to ask questions such as "Are the symptoms bothersome?” and "Do you need to get up during the night to pass water?”
|Figure 1: Algorithm for the management of patients with lower urinary tract symptoms|
|Reproduced from Primary Care Management of Male Lower Urinary Tract Symptoms (LUTS) by kind permission of the British Association of Urological Surgeons|
BAUS recommends several investigations and defines which patients should be referred to a urologist (Table 1, below).
|Table 1: Recommended investigations and reasons for referral|
|Investigations recommended on presentation||Reasons for referral to a urologist|
|History and International Prostate Symptom Score (IPSS) assessment: 0-7 = mild; 8-19 = moderate; >=20 = severe||Severe lower urinary tract symptoms
Recurrent urinary infection
|Digital rectal examination (DRE)||Abnormal DRE|
|Prostate specific antigen (PSA) test
Age-related cut off values:
50-59 years: >3 ng/ml
60-69 years: >4 ng/ml
>=70 years: >5 ng/ml
|Elevated PSA (>4.0 ng/ml)|
Although their reliability is debated, digital rectal examination (DRE) and prostate specific antigen (PSA) tests can be an early indicator of cancer,4 as well as help to determine the size of the prostate. This is important as the size of the prostate and how much the patient is bothered by symptoms are the two main determining factors when making a treatment choice.
Watchful waiting and lifestyle advice is the first-line approach for patients who are not overly bothered by their symptoms. Patients can be advised about fluid intake and avoiding caffeine, the need to monitor symptom deterioration and the potential risk of acute urinary retention.
The guideline advises that follow up should be every 3-6 months, and changes in symptom severity or PSA levels should prompt a management review.
Two categories of drug therapy are available for medical management: alpha blockers and the 5-alpha reductase inhibitors:
- alpha blockers such as doxazosin GITS, tamsulosin and alfuzosin act on the alpha-adrenergic nerve supply in the smooth muscle of the prostate and proximal urethra to increase peak urine flow rate. Rapid symptom improvement (usually within 2-3 weeks) can be expected in 60% of patients and is maintained in the long term.5
- 5-alpha reductase inhibitors such as finasteride and dutasteride reduce plasma dihydrotestosterone levels, which can lead to a reduction in the size of the prostate.6
The guideline recommends that if the patient has bothersome symptoms, the prostate is small and the PSA is <1.4 ng/ml, a selective alpha blocker is an accepted first-line treatment. If the prostate is large on clinical examination and/or the PSA is >1.4 ng/ml, a 5-alpha reductase inhibitor is recommended.
The guideline recommends that if the prostate is large and the patient has bothersome symptoms, consideration should be given to combining an alpha blocker and a 5-alpha reductase inhibitor.
New data from a landmark study show that combination treatment can slow disease progression. The Medical Therapy for Prostatic Symptoms (MTOPS) study was conducted over four and a half years to determine whether combined treatment with an alpha blocker (doxazosin) and a 5-alpha reductase inhibitor (finasteride or dutasteride) would be more effective than either drug alone.7
The results of this study revealed a greater delay in clinical progression of BPH with a combination of doxazosin and finasteride than with either drug alone (risk reduction relative to placebo: doxazosin 39%, finasteride 34%, combination therapy 67%).7 In the light of this evidence, combination therapy should be considered for a patient with a larger prostate or high PSA (>1.4 ng/ml), who has bothersome symptoms. These patients should then be reviewed every 3-6 months.7
BPH is a common condition that can often be managed effectively in primary care. The BAUS guideline will help the GP to initiate treatment and refer patients where appropriate. The algorithm outlines necessary investigations such as PSA and DRE and recommendations for the selection of appropriate treatments. Watchful waiting is recommended for patients with a small prostate and no bothersome symptoms. The guideline suggests patients with bothersome symptoms should be treated with an alpha blocker and if the prostate is large or PSA elevated (>1.4 ng/ml), combination therapy with a 5-alpha reductase inhibitor is recommended.
Primary care management of male lower urinary tract symptoms (LUTS) has been produced as an interactive algorithm and is available on CD ROM or via the BAUS website: www.baus.org.uk and has been published in the BJUI (Vol 93: p. 985-90).
- Berry SJ, Coffey DS,Walsh PC, Ewing LL.The development of human benign prostatic hyperplasia with age. J Urol 1984; 132: 474-9.
- Logie JW, Clifford GM, Farmer RD, Meesen BP. Lower urinary tract symptoms suggestive of benign prostatic obstruction - Triumph: the role of general practice databases. Eur Urol 2001 39(Suppl 3): 42-7.
- Speakman M, Kirby RS, Joyce A et al. Guideline for the primary care management of male lower urinary tract symptoms. BJUI 2004; 93: 985.
- Prostate Enlargement: Benign Prostatic Hyperplasia. National Kidney and Urological Diseases Information Clearinghouse, May 1998. NIH Publication No.98-3012. http://www.kidney.niddk.nih.gov/kudiseases/pubs/prostate/
- Djavan B, Marberger M.A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. Eur Urol 1999; 36:1-13.
- Nickel JC, Fradet Y, Boake RC et al. Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomized controlled trial (the PROSPECT study) PROscar Safety Plus Efficacy Canadian Two year Study. CMAJ 1996; 155: 1251-9.
- McConnell JD, Roehrborn CG, Bautista OM et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Eng J Med 2003; 349: 2387-98.
Click here for a checklist to aid implementation of the British Association of Urological Surgeons guideline Primary Care Managment of Male Lower Urinary Tract Symptoms (LUTS) to print out and keep