Courtesy Dr. Camille Vaughan
Dr. Loai Albarqouni
The researchers reviewed the literature and analyzed eight randomized controlled trials enrolling a total of 1,006 men, who were experiencing lower urinary tract symptoms, according to the paper published in the Annals of Family Medicine. The self-management techniques practiced by patients as part of the trials included adjusting the timing of when patients drank fluids, reducing or eliminating caffeine and alcohol, adjusting the schedules of or replacing medications for other conditions, adjusting patients’ habits for urinating, and performing pelvic floor exercises for better performance of muscles controlling urination.
“Self-management interventions for lower urinary tract symptoms should be considered as a cheap and safe alternative to drug interventions with unfavorable safety profiles,” said study author Loai Albarqouni, MD, MSc, PhD, a post-doctoral fellow at Bond University in Australia.
Self-management yielded better results than usual care
Some of the symptoms experienced by participants in the trials included increased frequency of urination, urgency of urination, urination hesitancy, and dribbling. The researchers excluded research involving men with LUTS attributed to infections, those with prostate cancer, men who had undergone prostate surgery, and men with neurologic conditions.
Self-management techniques, which frequently included watchful waiting, significantly reduced symptom severity, compared with usual care in two of the trials, which included a total of 350 participants. Symptom severity was measured using the International Prostate Symptom Score (IPSS), with a mean difference of 7.44 points in favor of self-management (95% confidence interval, –8.82 to –6.06). A drop of 3 points on the IPSS scale is considered clinically meaningful.
The researchers found no difference in symptom severity at 6-12 weeks between self-management and drug therapy in their analysis of four trials that compared these approaches. Self-management resulted in better results in terms of waking at night because of the need to urinate, but there was no difference in the number of times urinating per day.
In two of the studies, investigators examined a combined self-management and drug therapy approach, compared with drug therapy by itself. In one of these studies, which included 133 participants, using the combination of treatments resulted in significantly lower symptom severity, compared with using drug therapy alone at 6 weeks, on the IPSS, with a mean difference of 2.30 (95% CI, –4.11 to –0.49).
One study involving men with involuntary loss of urine immediately after urination compared utilizing counseling, pelvic floor exercises, and urethral milking to work urine through the urethra. Pelvic floor exercise was the most effective at reducing urine loss.
Study author Dr. Albarqouni said better tools for physician education could help with implementing these strategies more effectively.
Analysis draws more attention to self-management approaches for men
Outside experts said that, while self-management approaches for these symptoms have long been recognized for women, this analysis draws more attention to the growing use of self-management approaches for men. They noted that hurdles, such as time constraints and physician education on proper technique, remain.
Dr. Camille Vaughan
“Evidence suggests that the regular use of nondrug interventions is suboptimal for various reasons, including the inadequate reporting of the details of the interventions in the literature,” Dr. Albarqouni said.
Camille Vaughan, MD, MS, assistant professor of medicine at Emory University, where she has researched lower urinary tract symptoms, said advising patients on self-care is common in her practice, but should be more widely adopted in primary care.
Many patients don’t want to add to drugs that are often already a long list of medications, for fear of side effects and interactions, she said.
“If there are behavioral-based approaches that are appropriate, they’re often really interested in those strategies,” she said.
Barriers include the time it takes to teach patients these strategies and the confidence of the physicians themselves to instruct patients correctly, Dr. Vaughan said. Some physicians might be interested in the self-management approach for their patients, but “may not feel like they have all of the information at hand to share with patients,” she added.
“I think there are several decades of work showing the benefit of these types of strategies in women,” she said. “It’s relatively recent for men.” The analysis is a useful summary, she said.
“I think this should be really encouraging for providers and patients alike, because it’s highlighting the benefits of behavior and lifestyle-based strategies. A lot of these issues are going to impact men as they age,” she added.
High-quality data on self-management techniques have been limited
Scott Bauer, MD, MS, assistant professor of medicine at the University of California, San Francisco, and general internist at the San Francisco VA Medical Center, said he often prescribes self-management but has often had to review primary data from smaller trials and adapt that information to his own practice.
Dr. Scott Bauer
“I have felt like, for a long time, there’s been a lack of high-quality data and good synthesis of that data to really guide what I should specifically be recommending,” he said. “I’m very happy to see efforts to try to synthesize the data in a more comprehensive way and maybe work toward guidelines that can be applied more easily in clinical care.” It shows, he said, that “there is a decent amount of signal that should really be taken seriously both in a clinical context and for future research studies.”
Dr. Bauer noted that there is still a need to identify which patients are best suited for which approaches.
“We are very poor at diagnosing the specific etiology of LUTS – we don’t have great diagnostic tests or even phenotyping, and so that leaves clinicians with a very heterogeneous group of patients who all have the same syndrome of symptoms,” he explained. “But we don’t have much to guide us in terms of identifying who would benefit most from self-management overall, who would benefit from specific self-management techniques, and who would benefit from medication to target very specific mechanisms.”
Dr. Vaughan reported receiving funding from the Department of Veterans Affairs and National institutes of Health for research related to urinary symptom management, and that her spouse is an employee of Kimberly-Clark, which makes adult care products. Dr. Albarqouni and Dr. Bauer reported no relevant financial disclosures.