Lower Urinary Tract Symptoms—LUTS

Lower urinary tract symptoms (LUTSs) are classified as storage symptoms (previously referred to as irritative symptoms) or voiding symptoms (previously referred to as obstructive symptoms). From a functional standpoint, LUTS can be most easily understood as a result of either a failure to store or a failure to empty. This functional classification is not perfect because there is some symptom overlap, but it is a good start to establishing an etiologic cause. The single best way to appreciate a patient’s LUTS is to ask them to keep a voiding diary for 1 to 2 days. It forces the patient to focus on the details of their symptoms and results in a far more accurate history that can frequently avoid unnecessary and costly invasive procedures. The patient should make a record of all fluid intake (time, type, and quantity) and every voiding episode (time and volume).

STORAGE (IRRITATIVE) SYMPTOMS

Storage (irritative) symptoms (e.g., frequency, nocturia, urgency, incontinence, and bladder pain) are common presenting complaints that herald a failure of the bladder to store urine and can point to several different urologic diseases. Storage symptoms tend to be the most bothersome to the patient, particularly nocturia.

Frequency describes the need to urinate more often than usual. If polyuria (large urine volume) is excluded, then the patient has a functionally reduced bladder capacity by virtue of decreased compliance, residual urine, or irritation or pain on stretching. Causes include infection, tumor, stone, outlet obstruction, neurogenic bladder, or foreign body. Frequency is best recorded in terms of how many hours between voiding.

Nocturia describes the act of awakening at night to urinate and has a pathophysiology similar to frequency. Ask how many times the patient awakes from sleep to urinate and how much he or she drinks before retiring. Nocturia one to two times per night is inconsequential if the patient drinks a few cups of coffee before bed. It is helpful to ask the patient what time they go to bed and get up in the morning. Although most patients are in bed
for 6 to 8 hours, occasionally elderly patients will be spending 12 or more hours in bed and that can easily explain their nocturia.

Urgency describes the patient’s sensation to urinate immediately if an “accident” is to be avoided. Urgency most often accompanies infection, bladder outlet obstruction (BOO), or neurogenic bladder.

Incontinence is the involuntary loss of urine and is the ultimate sign of storage failure. Incontinence is frequently associated with urgency, frequency, or nocturia and should be distinguished by the different types (see Chapter 5).

Pain with storage is generally located in the suprapubic area and is a result of bladder distention. It is distinguished from the more common pain with voiding referred to as dysuria, which is also a classic irritative symptom that is categorized as a voiding symptom (see section “Voiding (Obstructive) Symptoms” below).

VOIDING (OBSTRUCTIVE) SYMPTOMS

Voiding (obstructive) symptoms include hesitancy, straining to void, poor stream, intermittency, dysuria, feeling of incomplete emptying, terminal or postmicturition dribbling, and lastly the ultimate sign of a failure to empty, urinary retention. A poor, slow, or weak stream is the complaint most directly associated with BOO. Other complaints include decreased force of stream, hesitancy in voiding, or difficulty starting the stream. Patients also complain of decreased caliber or narrowing of the stream, which may be split or interrupted. These are all symptoms of increased outlet resistance to urine flow in the urethra or bladder neck. Voiding symptoms, except for dysuria, occur primarily in males. Prostatic enlargement is the most common cause; however, other causes include urethral stricture, bladder neck contracture, and cancer of the prostate or urethra.

Dysuria describes a burning or painful sensation on urination, which is usually felt in the urethra. It is most commonly a symptom of urinary tract infection (UTI).