There are several available questionnaires which are validated in a variety of languages. They are usually sensitive to changes in symptoms and therefore can be used to monitor responses to treatment. The most widely used questionnaire is the International Prostate Symptom Score (IPSS). This eight-item questionnaire has seven symptom and one quality of life (QoL) questions. The symptom questions assess four voiding and three storage symptoms for the previous month (see Fig. 9.1). The response options range from ‘not at all’ (0 points) to ‘almost always’ (5 points). The minimum score is 0 and the maximum score 35. The symptom severity is determined based on the basis of the total symptom scores as:

The QoL scores range from 0 to 6. The main limitation of the IPSS is the lack of assessment of incontinence. This means that LUTS severity may be underestimated.

This validated questionnaire resulted from the ICS-BPH study. This 11-item questionnaire assesses a large spectrum of LUTS and bother scores for individual symptoms.

These are useful adjuncts in providing information about patients’ drinking and voiding habits. A bladder diary records volumes voided and their times, incontinence episodes, pad usage, fluid intake and degree of urgency. Information about fluid intake allows counselling regarding fluid reduction at specific times of the day and avoidance of stimulants. The diary may also be used to diagnose nocturnal polyuria (nocturnal urine production >20 % in young individuals and >33 % in elderly of the total 24-h urine production) or 24-h polyuria (24-h urine production >40 ml/kg bodyweight). Frequent small-volume voids may indicate OAB. The time between voids may be utilised in counselling in bladder training techniques. Lastly, the maximum volume voided may be useful when performing invasive urodynamics in guiding volumes to which the patient’s bladder can be filled. This also provides information about bladder capacity.

Bright et al. have recently illustrated that the validated ICIQ-bladder diary is as reliable when completed over 3 days versus 4 days. They recommend the 3-day version.

This is an inexpensive tool to exclude underlying pathologies such as diabetes, UTI, renal disease or urogenital malignancy. The European Association of Urology (EAU) expert panel recommends its use, although there is no strong evidence for its use in LUTS.

The serum PSA concentration may be used as a surrogate for prostate volume. A prostate volume >30 mL is associated with 3 times greater risk of acute urinary retention (AUR) and BPO-related surgery. The PSA thresholds for volumes greater than 30 mL are:

Recent studies have also used PSA to predict the likelihood of BPO; a PSA >4 ng/mL was shown to have an 89 % chance of being associated with BPO. The EAU currently recommends that the PSA should only be measured if it will change the patient’s management or in those at risk of disease progression.

There is a very low risk of renal impairment in men with LUTS, less than 1 % in the Medical Therapy of Prostatic Symptoms Study (MTOPS). However, renal impairment is associated with an increased risk of complications following TURP.

The EAU recommends renal function should be checked if:

There are a variety of available formulae for calculating PVR, usually varying in the multiplication factor used in the formula. A high PVR was found to be associated with an increased risk of symptom progression in both MTOPS and ALTRESS. A significant PVR may be associated with BOO/BPO and/or DUA. EAU recommendation: PVR measurement should be part of routine assessment.

This is a non-invasive urodynamic test which produces a visual representative of the strength of urinary flow. It evaluates the function of the lower urinary tract. It is a quick test which may be easily performed and interpreted in the office.

The key parameters of the test are:

Ideally, uroflowmetry should be performed twice to maximise the reliability of the results, especially when flow parameters are pathological, and the voided volume should exceed 150 mL. The flow pattern may provide suggestions regarding a diagnosis:

A normal flow trace is bell shaped with Q _max attained with 3–10 s. Q _max may be affected by age, voided volume, bladder contractility and urethral resistance. The values give an indication of probability of BOO/BPO (Table 9.3). Q _max >15 mL/s can exclude BOO/BPO in 97 % of patients and is associated with a poorer outcome after TURP; therefore, Q _max >15 mL/s is one of the indications for performing invasive urodynamics prior to prostate surgery in symptomatic patients.

This invasive test involves the insertion of intravesical and rectal catheters which allows for simultaneous bladder filling, vesical and rectal pressure measurements and the calculation of detrusor pressure. The test consists of filling and voiding phases. It allows for the diagnosis of bladder detrusor overactivity (DO) during filling and BOO and/or DUA during voiding which may significantly affect management. BOO and DUA may be determined using the bladder outflow obstruction index (BOOI, previously known as the Abrams-Griffiths number) and bladder contractility index (BCI), respectively (Fig. 9.2). BOO is characterised by increased detrusor pressure and reduced flow, while DUA is characterised by reduced detrusor pressure and flow during the voiding phase. The importance of establishing a UDS diagnosis is that in men with ‘clinical’ BOO, 57–61 % may have DO, 29 % BOO and 11 % DUA. The prevalence of DUA in men with LUTS ranges between 11 and 40 %. A study by Cannon et al. revealed that there are no UDS or symptomatic gains from TURP in men shown to have DUA. Lastly, the other advantage of invasive UDS prior to surgery is in determining the presence of preoperative DO which, after bladder outlet surgery, may result in DO incontinence. This allows for better patient counselling prior to surgery (Table 9.4).

The origin of LUTS in adult men, as described above, is multifactorial and shifted away from the prostate (BPH, BPE or BPO). Although the prostate may be responsible for LUTS in some men, different organs or structures can also cause or contribute to LUTS in others, for example, the urinary bladder, pelvic floor, central or peripheral nervous system and even the kidney in case of nocturia due to nocturnal polyuria. It is sometimes difficult or even impossible to detect the primary origin of LUTS in individual patients. Therefore, symptomatic therapy of LUTS with conservative treatment modalities, regardless the exact cause, should always be the first and an essential part of the treatment in all patients without absolute indications for surgery. Conservative treatment modalities consist of:

Conservative treatment has shown to significantly reduce LUTS to a greater extent than standard care when three self-management sessions were offered. Approximately 64 % of men do well with conservative treatment over a period of 5 years. Conservative treatment has level 1b evidence (randomised-controlled trials, RCTs), and the EAU guidelines on male LUTS recommend this treatment approach for patients with mild (to moderate) symptoms in the absence of complicated LUTS, absolute indications for surgical treatment or parameters of disease progression. Physicians should always offer conservative treatment prior or concurrent to drug treatment (grade of recommendation A).

If symptom relief has been insufficient with conservative treatment modalities alone and the patient still suffers of LUTS, drug treatment can be added. There are currently five different drug classes available which have been licensed for the treatment of male LUTS and can be used either alone or in combination:

Approved drug classes, drugs within the different classes, the key pharmacokinetic features and recommended daily doses are listed in Table 9.7. This chapter focuses only on the drugs which have been analysed by the NICE, EAU and AUA guidelines.

In some European countries, phytotherapy is also popular and has a market share as high as 50 % of the national male LUTS market. However, plant extracts are a heterogeneous group of drugs, not universally available, and can contain different concentrations of active ingredients when comparing the extract of different producers and even different brands of the same producer. Additionally, it has yet not been clarified which active ingredient is responsible for LUTS improvement. Phytotherapy was excluded from the NICE, EAU and AUA guidelines due to methodological reasons but may be a viable treatment option for some men with mild to moderate LUTS who refuse using chemical drugs. Therefore, phytotherapy could be used to support conservative treatment.

The prescription of one drug of the above-mentioned five chemical drug classes depends on baseline values determined during systematic assessment of the patient and is largely dependent on the type of symptom (storage, voiding, storage + voiding or nocturnal polyuria), concomitant erectile dysfunction, prostate volume and the patient’s willingness to use the drug long term. The flow diagram (Fig. 9.3) illustrates the evidence-based drug treatment of male LUTS with key results of the initial diagnostic tests, as described in the EAU guidelines on male LUTS in the year 2013.