Urinary retention
Recurrent urinary infections
Renal impairment (from obstructive nephropathy)
Bladder stones
A: Urinalysis/urine microscopy and culture, serum creatinine and PSA, and residual urine assessment (Table 5.2). All tests were within normal limits except elevated post-void residual of 100 ml (Fig. 5.1).
Table 5.2
Safety tests for patients with LUTS
Urinalysis/urine microscopy and culture |
Serum creatinine |
Prostate specific antigen (PSA) |
Post- void residual urine (ultrasound/bladder scan) |
Fig. 5.1
Ultrasound image of bladder showing elevated residual urine and prostatomegaly with prominent intravesical protrusion of the prostate (arrows)
Q: What is the likely cause of this patient’s symptoms?
A: Bladder outlet obstruction from benign prostatic enlargement (previously called benign prostatic hyperplasia or BPH) resulting in an overactive bladder in addition to poor urinary flow. In men presenting with LUTS, the main diagnostic dilemma is between overactive bladder or bladder outlet obstruction. Empirical therapy is justified in the absence of complicated LUTS if the patient is bothered by the symptoms (see Chap. 3 International Prostate Symptom Score- IPSS)
Q: How should the patient be treated?
A: In patients who are not bothered or mildly bothered by their symptoms, conservative measures (see Chap. 4) especially aimed at managing the OAB symptoms can be tried. For those failing conservative measures, medical therapy (generally with an alpha-blocker) is often considered first line bearing in mind the potential ongoing cost of medications and side effects. (Fig. 5.2, Table 5.3).
Fig. 5.2
Medical therapy for LUTS – mechanisms of action: Alpha blocker causes relaxation of smooth muscle of bladder neck and prostate (left). 5-alpha-reductase inhibitor reduces the size of the prostatic adenoma (right)
Table 5.3
Medications for LUTS (due to BPH)
Class of medication | Common examples | Mechanism of action | Prescribing points |
|---|---|---|---|
Alpha-adrenergic blockers | Prazosin, terazosin, alfuzosin, tamsulosin, silodosin | Relax smooth muscle in bladder neck and prostate | Effective regardless of prostate size. Clinical response within days to 4 weeks |
Side effects – tiredness, headache, nasal congestion, dizziness | |||
Need to dose-titrate nonselective agents (e.g., prazosin) | |||
Uroselective alpha-blockers have less effect on BP and may be better tolerated
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