Dr Jon Rees offers tips on diagnosing and managing common prostate conditions in primary care

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Read this article to learn more about:

  • the importance of classifying lower urinary tract symptoms
  • how to recognise chronic prostatitis
  • red-flag symptoms that require prompt referral.

 

Understand the difference between storage, voiding, and post-micturition symptoms

The classification of lower urinary tract symptoms (LUTS) into storage, voiding, and post-micturition symptoms is not just an academic exercise, it is key to the diagnosis and management of urinary symptoms.1

Lower urinary tract symptoms may be classified as:
  • storage
    • urgency
    • urgency urinary incontinence
    • frequency of micturition
    • nocturia
  • voiding
    • slow stream
    • hesitancy
    • intermittency
    • terminal dribble
    • straining
  • post-micturition
    • sensation of incomplete emptying
    • post-micturition dribble.

Men with symptomatic benign prostate enlargement will typically present with a mixed picture, often with voiding, storage, and sometimes post-micturition symptoms.

Isolated storage symptoms, with little or no accompanying voiding symptoms, are most commonly due to an overactive bladder; however, this cause can often be overlooked and the symptoms instead blamed on the prostate. Storage symptoms may also be due to other pathology, for example, urinary tract infection or bladder cancer (usually in association with haematuria).1

Voiding symptoms do not necessarily indicate benign prostatic enlargement, and can be caused by urethral strictures, a tight phimosis of the foreskin, or weakness of detrusor contraction.

A full assessment helps in making a diagnosis and avoids the assumption that LUTS in all men are due to benign prostatic hyperplasia.1

When required, medical therapy can be targeted according to the symptom profile.

Lifestyle advice and reassurance are vital when managing LUTS

Lifestyle advice is a vital part of successful LUTS management, and factors such as the volume, type, and timing of fluid intake are often neglected.1 The best way to assess these factors is to encourage all men presenting with urinary symptoms to complete a 3–day bladder diary (or frequency volume chart).2,3 Reducing evening fluid intake may help with nocturia, and decreasing consumption of caffeinated (and to a lesser extent) carbonated, and alcoholic drinks may improve storage symptoms.1 There is also good evidence that losing weight and increasing exercise can help improve urinary symptoms.4

It is important also to reassure men that LUTS are a common part of ageing and do not always need treatment; 90% of men aged over 65 years will have to pass urine once a night, and over 50% will have to pass urine twice a night.2 This knowledge can be reassuring to men and may help them live with their symptoms without necessarily requiring long-term medication.

Be aware that most men with LUTS are worried about prostate cancer

Most men presenting with LUTS have some degree of concern about prostate cancer. For those who are concerned (as well as those with LUTS suggestive of bladder outflow obstruction due to benign prostate enlargement, or those found to have an abnormal prostate upon examination), NICE Clinical Guideline 97 recommends discussion of prostate-specific antigen (PSA) testing.3 Thus, a discussion about pros and cons of PSA testing should form an integral part of a LUTS assessment.

Public Health England has developed several resources on PSA testing, including information for GPs on how to advise men about the PSA test for prostate cancer, and information aimed at well men aged over 50 years who are considering a PSA test; see: gov.uk/guidance/prostate-cancerrisk-management-programme-overview

Find out which LUTS are causing the most bother to the patient

The vast majority of men who consult about LUTS should be managed according to the bother that their symptoms cause. Just because a symptom is present it does not mean that it will require treatment; some symptoms may actually have little effect on the patient’s quality of life.

There is good evidence to show that storage symptoms tend to cause the most bother to patients.5 This is entirely understandable, as nocturia, urgency, and frequency are clearly more likely to cause problems with, for example, sleep disturbance, interruption of social activities, and disruption of long journeys.

Typically, treatment of LUTS due to benign prostate enlargement begins with an alpha blocker, such as tamsulosin, which will often improve the voiding symptoms; however, it often has a lesser impact on bothersome storage LUTS. Understanding which symptoms the patient wants to improve the most will help determine whether initial therapy has been successful, or whether the addition of, for instance, an antimuscarinic drug is required.1

Chronic prostatitis is not uncommon—learn to recognise the symptoms

Prostatitis is under-recognised, and not all men will present with the classic symptom of perineal discomfort or pain. Chronic prostatitis should be considered an aspect of chronic pelvic pain syndrome, and therefore the discomfort can vary in site. Suprapubic, penile, testicular, lower back, inguinal region/groin, and rectal pain can all be manifestations of the syndrome. Sexual dysfunction symptoms are also common, and include discomfort on ejaculation, loss of libido, and erectile dysfunction. Men with chronic prostatitis will often have LUTS including storage, voiding, and post-micturition symptoms. As with many other chronic pain conditions, chronic prostatitis can have a significant impact on mental health, and both anxiety and depression are common psychosocial symptoms.6

Investigation of chronic prostatitis is simple

Complex tests are not required to diagnose chronic prostatitis in primary care. All men should have digital rectal examination (this will often reproduce the discomfort of the condition, which can help confirm the diagnosis) to exclude a palpable prostate cancer, which occasionally presents with symptoms overlapping those of chronic prostatitis. A dipstick analysis of the patient’s urine should be performed and sent for culture if infection is suspected. Testing for sexually transmitted infection, particularly chlamydia, should be considered for all sexually active men. A PSA test should be discussed with the patient, though remember that during an acute flare of prostatitis, PSA levels can be elevated, so avoid testing until symptoms have settled.6

Take a symptom-based approach when managing chronic prostatitis

Very few men with chronic prostatitis/chronic pelvic pain syndrome show any evidence of infection as a cause, but despite this many receive recurrent courses of antibiotics, particularly quinolones, to treat their symptoms. While it is reasonable to prescribe a single prolonged course of antibiotics to men presenting with LUTS in primary care (particularly if the symptoms are <1 year in duration), it is important to move away from antibiotics as the mainstay of treatment.

Instead, a symptom-based approach should be taken. Pain should be managed with simple analgesics (avoiding opiates if possible); however, non-steroidal anti-inflammatories should only be used to treat an acute flare.6 If the pain is considered to be neuropathic in origin, an early introduction of anti-neuropathic agents such as amitriptyline or gabapentin is recommended. Urinary symptoms and sexual dysfunction should be managed in their own right, following the usual care pathways. Anxiety and depression may require counselling, cognitive therapies, or medication.6

PSA is a marker of prostate cancer risk, not a diagnostic tool

A normal PSA level does not entirely exclude the possibility of prostate cancer, just as most men with a mildly raised PSA do not have prostate cancer. High PSA results (usually below 100 ng/ml) can be observed, for example, after a urinary tract infection (UTI), or due to prostatitis. Only when the PSA result is very high (i.e. over 100 ng/ml), can a diagnosis of prostate cancer be made confidently.

Remember to consider other risk factors for prostate cancer when interpreting PSA results; a strong family history is clearly concerning, and African-Caribbean men are at greater risk of prostate cancer than Caucasian men.7

Consider the impact of long-term hormonal therapy on overall health

Gonadotrophin releasing hormone (GnRH) agonists such as goserelin, triptorelin, and leuprorelin are used for ‘hormonal treatment’ of advanced prostate cancer, and are sometimes required in the long term. As well as the well-known side-effects such as hot flushes and fatigue, these injections can also cause problems with bone health, increased cardiovascular risk, and are sometimes associated with a decline in cognitive function. Increased exercise has been shown to improve the outcomes of men on long-term hormone therapy, thus exercise should be discussed and recommended to all men on these treatments.8

Prostate Cancer UK has created a webpage with information on the most common side-effects of hormone therapy.

10  When to refer men with prostate problems

Most LUTS (whether due to benign prostate enlargement or other causes) can be managed by the GP with basic assessment and symptom-based management; however, there are a number of red flags that usually indicate a requirement for referral (see Box 1, below).3

Box 1: Red flags that suggest referral is required for men with prostate problems1

Men should be referred for specialist assessment if they have lower urinary tract symptoms complicated by:

  • recurrent or persistent urinary tract infection
  • retention
  • nocturnal enuresis (a marker for possible high pressure chronic retention of urine)
  • haematuria (visible or non-visible)
  • previous or suspected urinary retention
  • renal impairment that is suspected to be secondary to lower urinary tract dysfunction
  • pain with voiding
  • suspected urological cancer

Early referral is recommended for men presenting with severe symptoms of chronic prostatitis, or if there is any diagnostic uncertainty. Referral may be to a urologist (ideally with a sub-specialist interest in prostatitis), a pain physician, or a sexual health clinic, depending on local expertise.6

Referral criteria for suspected prostate cancer are included in NICE Guideline 12 Suspected cancer: recognition and referral.9 This states:‘refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age-specific range.’ Before doing this, it is important to ensure that the test was not taken during or shortly after a UTI (as this can cause transient elevation of PSA levels). If there is any doubt, the PSA should be rechecked 4–6 weeks after resolution of a UTI.6

References

  1. Rees J, Bultitude M, Challacombe B. Clinical review: The management of lower urinary tract symptoms in men. BMJ 2014; 348: g3861.
  2. Blanker M, Bohnen A, Groeneveld F et al. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. J Urol 2000; 164  (4): 1201–1205.
  3. NICE. Lower urinary tract symptoms in men: management. Clinical Guideline 97. NICE, 2015. Available at: www.nice.org.uk/cg97
  4. Parsons K, Kashefi C. Physical activity, benign prostatic hyperplasia, and lower urinary tract symptoms. Eur Urol 2008; 53: 1228–1235.
  5. Agarwal A, Eryuzlu L, Cartwright R et al. What is the most bothersome lower urinary tract symptom? Individual- and population-level perspectives for both men and women. Eur Urol 2014; 65 (6): 1211–1217.
  6. Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJUI Int 2015; 116 (4): 509–525.
  7. Prostate Cancer UK. A black man’s risk.prostatecanceruk.org/prostate-information/are-you-at-risk/a-black-mans-risk (accessed 3 May 2016).
  8. Jefferies E, Bahl A, Hounsome L et al. Cardiovascular and skeletal events in men treated with ADT for advanced prostate cancer: survivorship issues. Trends in urology, 2003; 3 (6): 32–36.
  9. NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: www.nice.org.uk/ng12