Bruce Sperry is a General Surgery and Urologic Physician Assistant, Morgan Garcia is a Pharmacist, Catherine Bandeko is a Health System Specialist, and Steven Summers is an Attending Physician; all at the Veterans Affairs Salt Lake City Health Care System in Utah. Darshan Patel is an Assistant Professor of Urology at the University of California San Diego Health and the VA San Diego Healthcare System in La Jolla, California. Steven Summers is also an Assistant Professor of Urology at the University of Utah in Salt Lake City.
Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
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Background: Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are common clinical encounters for most primary care practitioners (PCPs). More than 50% of men aged > 50 years will develop significant lower urinary tract symptoms. Managing these symptoms can be complicated and requires an informed discussion between the PCP and the patient. This article provides a comprehensive review for PCPs regarding the evaluation and management of LUTS in men and when to consider a urology referral.
Observations: Over the past 3 decades, medications have become the most common BPH and LUTS therapy, but recently, newer minimally invasive surgeries have challenged this paradigm. PCPs are in a unique position to help many patients who present with early stage LUTS.
Conclusions: A clear understanding of the available treatment options will help PCPs counsel patients appropriately about lifestyle modification, medications, and surgical treatment options for their symptoms.
Lower urinary tract symptoms (LUTS)are common and tend to increase in frequency with age. Managing LUTS can be complicated, requires an informed discussion between the primary care practitioner (PCP) and patient, and is best achieved by a thorough understanding of the many medical and surgical options available. Over the past 3 decades, medications have become the most common therapy; but recently, newer minimally invasive surgeries have challenged this paradigm. This article provides a comprehensive review for PCPs regarding the evaluation and management of LUTS in men and when to consider a urology referral.
Benign prostatic hyperplasia (BPH) and LUTS are common clinical encounters for most PCPs. About 50% of men will develop LUTS associated with BPH, and symptoms associated with these conditions increase as men age.1,2 Studies have estimated that 90% of men aged 45 to 80 years demonstrate some symptoms of LUTS.3 Strong genetic influence seems to suggest heritability, but BPH also occurs in sporadic forms and is heavily influenced by androgens.4
BPH is a histologic diagnosis, whereas LUTS consists of complex symptomatology related to both static or dynamic components.1 The enlarged prostate gland obstructs the urethra, simultaneously causing an increase in muscle tone and resistance at the bladder neck and prostatic urethra, leading to increased resistance to urine flow. As a result, there is a thickening of the detrusor muscles in the bladder wall and an overall decreased compliance. Urine becomes stored under increased pressure. These changes result in a weak or intermittent urine stream, incomplete emptying of the bladder, postvoid dribble, hesitancy, and irritative symptoms, such as urgency, frequency, and nocturia.
For many patients, BPH associated with LUTS is a quality of life (QOL) issue. The stigma associated with these symptoms often leads to delays in patients seeking care. Many patients do not seek treatment until symptoms have become so severe that changes in bladder health are often irreversible. Early intervention can dramatically improve a patient’s QOL. Also, early intervention has the potential to reduce overall health care expenditures. BPH-related spending exceeds $1 billion each year in the Medicare program alone.5
PCPs are in a unique position to help many patients who present with early-stage LUTS. Given the substantial impact this disease has on QOL, early recognition of symptoms and prompt treatment play a major role. Paramount to this effort is awareness and understanding of various treatments, their advantages, and adverse effects (AEs). This article highlights evidence-based evaluation and treatment of BPH/LUTS for PCPs who treat veterans and recommendations as to when to refer a patient to a urologist.
Evaluation of LUTS and BPH
Evaluation begins with a thorough medical history and physical examination. Particular attention should focus on ruling out other causes of LUTS, such as a urinary tract infection (UTI), acute prostatitis, malignancy, bladder dysfunction, neurogenic bladder, and other obstructive pathology, such as urethral stricture disease. The differential diagnosis of LUTS includes BPH, UTI, bladder neck obstruction, urethral stricture, bladder stones, polydipsia, overactive bladder (OAB), nocturnal polyuria, neurologic disease, genitourinary malignancy, renal failure, and acute/chronic urinary retention.6
