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Management of Male Lower Urinary Tract Symptoms History:
Usually due to benign prostatic enlargement, bladder neck stenosis, urethral
stricture or poor detrusor contractility.
Causes include urinary tract infection, bladder calculi, urothelial
carcinoma, and overactive bladder
History should also include attention to contributing
factors for nocturia - including diabetes, CCF, sleep apnoea and diuretics –
and retention including certain medications. Further assess symptoms and the impact on quality of life
with the International Prostate Symptom Score.
This tool describes symptoms as mild (0-7), moderate (8-19) or severe
(20 +). May help determine management Examination:
Investigations:
Management:
Monitor regularly – repeat assessment of
symptoms, IPSS, examination +/- PSA after six months then annually
o
Prazosin (Minipres) – PBS listed §
SE: postural hypotension, palpitations, oedema,
nausea, headache, blurred vision o
Tamsulosin (Flomaxtra) – Repatriation only,
otherwise private §
SE: (better due greater selectivity) postural
hypotension, syncope, retrograde ejaculation, erectile dysfunction o
Alfuzosin, Terazosin o
5α reductase inhibitors – especially for
prostatic enlargement > 30-40ml §
Especially for obstructive symptoms §
Block conversion of testosterone to
dihydrotestosterone §
Induce prostatic epithelial cell apoptosis §
Reduce prostate size §
Effective over six – twelve months §
Reduce long term risk of urinary retention §
Check PSA first §
Follow up
at twelve weeks, six months then annually o
Finasteride (Proscar) – Repatriation only §
SE: erectile dysfunction, reduced libido,
reduced ejaculate volume, breast tenderness or enlargement o
Dutasteride (Avodart) – Authority via urologist
if already on α blocker § SE: impotence, altered libido, ejaculatory disorders o
Combination (Tamsulosin + Dutasteride = Duodart)
– Authority §
More effective than monotherapy if monotherapy inadequate
o
Antimuscarinics §
Especially for storage disorders §
C/I with high post void residual volumes – risk
acute urinary retention §
SE: impaired cognitive function – cautious use
in elderly o
Phytotherapy eg Saw Palmetto §
Minimal SE but variable concentrations,
co-ingredients and efficacy §
Not PBS §
Not better than placebo, Finasteride or Tamsulosin §
International guidelines currently NOT
supportive ·
Surgical
treatment – especially for severe symptoms o
Transurethral
Resection of the Prostate (TURP) (Gold Standard) especially prostates 30 –
80ml o
Transurethral
Incision of the Prostate (TUIP) especially prostates < 30ml o
Open
prostatectomy or TURP for prostates > 80ml o
Other options Other indications for specialist referral include complex symptoms,
deterioration of severity of symptoms, severe interference with quality of
life, no response to treatment, post void residual > 100ml References/Useful Resources:
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