Lower Urinary Tract Symptoms (LUTS)

Introduction to LUTS for MCCQE1

Lower Urinary Tract Symptoms (LUTS) represent a common clinical presentation in primary care and urology, particularly among the aging male population in Canada. For the MCCQE1, candidates must demonstrate competence in differentiating between storage, voiding, and post-micturition symptoms, identifying underlying etiologies (most commonly Benign Prostatic Hyperplasia - BPH), and applying Canadian guidelines for management.

Understanding LUTS is crucial for the Medical Council of Canada Qualifying Examination Part I, as it touches upon multiple CanMEDS roles, including Medical Expert (diagnosis/management) and Health Advocate (quality of life and screening discussions).

Classification of LUTS

LUTS are clinically classified into three categories. Distinguishing these helps narrow the differential diagnosis.

Etiology and Differential Diagnosis

While BPH is the predominant cause in older men, the differential diagnosis is broad.

Common Causes

1. Benign Prostatic Hyperplasia (BPH): Histologic diagnosis leading to Benign Prostatic Obstruction (BPO).
2. Overactive Bladder (OAB): Urgency with/without urge incontinence, usually with frequency and nocturia.
3. Nocturnal Polyuria: Production of >33% of 24-hour urine output at night (common in CHF, OSA, diabetes).

Red Flag Etiologies (Must Rule Out)

• Prostate Cancer: May coexist with BPH.
• Bladder Cancer: Consider in patients with hematuria or irritative symptoms (Carcinoma in situ).
• Urethral Stricture: History of trauma or STI.
• Neurogenic Bladder: Parkinson’s, MS, Spinal cord injury.
• Urinary Tract Infection (UTI).

Clinical Evaluation

The goal is to determine the severity of symptoms, their impact on Quality of Life (QoL), and rule out serious pathology.

1. History

• Characterize Symptoms: Storage vs. Voiding.
• IPSS (International Prostate Symptom Score):
  • Mild: 0-7
  • Moderate: 8-19
  • Severe: 20-35
• Fluid Intake: Caffeine, alcohol, evening fluid intake.
• Medications: Diuretics, anticholinergics, decongestants (alpha-agonists can precipitate retention).

2. Physical Examination

3. Investigations

Management Strategies

Management is tailored to symptom severity (IPSS) and bother.

Conservative Management (Watchful Waiting)

Indicated for Mild symptoms (IPSS < 8) or moderate symptoms with low bother.

• Fluid restriction: Especially before bedtime.
• Avoidance: Caffeine and alcohol.
• Bladder retraining: For storage symptoms.
• Medication review: Adjust timing of diuretics.

Pharmacotherapy

Indicated for Moderate to Severe symptoms (IPSS ≥ 8) affecting QoL.

// Common Abbreviations
const BPH = "Benign Prostatic Hyperplasia";
const OAB = "Overactive Bladder";
const AUR = "Acute Urinary Retention";

A. Alpha-Blockers (e.g., Tamsulosin, Alfuzosin, Silodosin)

• Mechanism: Relax smooth muscle in the bladder neck and prostate capsule.
• Onset: Rapid (days to weeks).
• Side Effects: Dizziness, orthostatic hypotension, Retrograde Ejaculation (important counseling point), Intraoperative Floppy Iris Syndrome (IFIS - warn cataract surgeons).
• Canadian Context: First-line for moderate/severe LUTS.

B. 5-Alpha Reductase Inhibitors (5-ARIs) (e.g., Finasteride, Dutasteride)

• Mechanism: Blocks conversion of Testosterone to Dihydrotestosterone (DHT). Shrinks prostate volume.
• Indication: Large prostates (>30-40cc) or PSA >1.5 ng/mL.
• Onset: Slow (3-6 months for peak effect).
• Side Effects: Decreased libido, ED, gynecomastia.
• Key Note: Reduces PSA by approximately 50%. If PSA rises while on 5-ARI, it is highly suspicious for cancer.

C. Combination Therapy (CombAT)

• Alpha-blocker + 5-ARI.
• Indicated for patients with moderate/severe symptoms AND risk of progression (large prostate, high PSA).
• Superior to monotherapy in preventing Acute Urinary Retention (AUR) and surgery in high-risk patients.

D. Anticholinergics / Beta-3 Agonists

• Used for predominant storage symptoms (OAB component).
• Use with caution in patients with high PVR (risk of retention).

Surgical Management

Indicated for:

• Refractory to medical therapy.
• Recurrent AUR.
• Recurrent UTIs.
• Bladder stones.
• Renal failure due to obstruction.
• Gross hematuria refractory to meds.

Procedures:

• TURP (Transurethral Resection of the Prostate): Gold standard.
• Laser Therapy (HoLEP, PVP): Often used for patients on anticoagulation.

Canadian Guidelines (CUA)

The Canadian Urological Association (CUA) Guidelines on Male LUTS/BPH (2018/2022 updates) emphasize:

1. Choosing Wisely Canada: Don’t order a creatinine or upper tract imaging (ultrasound/CT) for uncomplicated LUTS with normal urinalysis.
2. PSA Screening: Should not be done without discussing potential risks and benefits (false positives, over-diagnosis).
3. Referral: Timely referral for patients with red flags or failed medical therapy.

Key Points to Remember for MCCQE1

• Alpha-blockers provide symptomatic relief but do not change the natural history of the disease (do not shrink prostate).
• 5-ARIs reduce prostate size and do alter natural history (reduce risk of AUR and surgery).
• Always check Urinalysis to rule out infection or hematuria before diagnosing BPH.
• Retrograde ejaculation is a common side effect of Tamsulosin; counsel young sexually active men.
• In a patient taking Finasteride, a “normal” PSA of 2.0 ng/mL is effectively 4.0 ng/mL (multiply by 2).

Sample Question

Question

A 68-year-old male presents to your family practice clinic complaining of a 6-month history of hesitancy, weak urinary stream, and nocturia (waking 3 times per night). He denies dysuria or hematuria. He has no history of prostate cancer in his family. His past medical history is significant for hypertension.

Physical Examination:

• Abdomen: Soft, non-tender, no palpable bladder.
• DRE: Smooth, enlarged prostate (approx. 40g), non-tender, no nodules, normal anal tone.

Initial Investigations:

• Urinalysis: Unremarkable.
• PSA: 1.8 ng/mL.

He reports that the symptoms are bothersome and interfere with his sleep. He wishes to start treatment.

Which one of the following is the most appropriate initial pharmacotherapy?

• A. Finasteride
• B. Oxybutynin
• C. Tamsulosin
• D. Ciprofloxacin
• E. Furosemide

Explanation

The correct answer is:

• C. Tamsulosin

Explanation: This patient presents with classic Lower Urinary Tract Symptoms (LUTS) suggestive of Benign Prostatic Hyperplasia (BPH). He has botherome voiding symptoms (hesitancy, weak stream) and storage symptoms (nocturia).

• Option C (Tamsulosin): An alpha-1 blocker is the first-line pharmacotherapy for bothersome LUTS. It has a rapid onset of action (days) and works by relaxing the smooth muscle of the bladder neck and prostate. It addresses the patient’s immediate need for symptom relief.
• Option A (Finasteride): A 5-alpha reductase inhibitor is indicated for patients with large prostates to prevent progression. While his prostate is enlarged (40g), Finasteride takes 3-6 months to work. It is often used in combination with alpha-blockers but is less ideal as a sole initial agent for immediate symptom relief compared to alpha-blockers.
• Option B (Oxybutynin): An anticholinergic used for Overactive Bladder (OAB). While he has nocturia, his predominant symptoms are obstructive (voiding). Using an anticholinergic alone in a patient with untreated obstruction could precipitate urinary retention.
• Option D (Ciprofloxacin): Antibiotics are indicated for prostatitis or UTI. This patient has no dysuria, no tenderness on DRE, and a normal urinalysis.
• Option E (Furosemide): A loop diuretic would likely worsen his urgency and frequency/nocturia.

References

1. Canadian Urological Association (CUA). (2018). Guideline on Male Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia (MLUTS/BPH). Link to CUA Guidelines 
2. Medical Council of Canada. (2023). MCCQE Part I Objectives: Urology.
3. Nickel, J. C., et al. (2018). 2018 Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH). Can Urol Assoc J, 12(10), 303-12.
4. Toronto Notes. (2023). Urology Chapter.
5. Choosing Wisely Canada. Urology Recommendations. https://choosingwiselycanada.org/urology/