Lower Urinary Tract Symptoms (LUTS)

LUTS can occur during bladder filling (storage), emptying (voiding), post urination or any combination of the three. Symptoms are therefore generally grouped into voiding (“obstructive”) symptoms or storage symptoms.

Voiding symptoms

• Hesitancy – a longer wait than usual for the stream of urine to begin.
• Decreased urinary stream.
• Straining to pass urine.
• Post-micturition dribble – dribbling after urination has finished.
• Intermittency – a stop/start stream of urine.
• Dysuria – discomfort on passing urine (often burning or stinging in nature).
• A feeling of incomplete emptying – a feeling that you still need to pass urine again even though you have just tried to empty your bladder.

Storage symptoms

• Lower abdominal discomfort (tummy pain) – often constant in nature.
• Urgency – feeling an urgent need to urinate.
• Frequency – a short interval between episodes of needing to urinate.
• Nocturia – excessive passage of urine at night.
• Incontinence – a loss of bladder control (including stress incontinence and urge incontinence also known as detrusor instability).

Contact your doctor urgently if you pass blood in your urine or are unable to pass urine for 6 – 12 hours.

LUTS in men are most commonly due to benign prostatic enlargement, whereas in women they are most commonly caused by urinary tract infection. Whilst the majority of lower urinary tract symptoms are not indicative of serious disease, it is important to exclude more serious causes when LUTS persist.

Men:

• Benign Prostate Hypertrophy (BPH) – an age-related enlargement of the prostate.
• Prostate Cancer.
• Inflammation/ infection of the prostate gland (prostatitis).
• Urinary Tract Infections (UTI’s).
• Abnormal function of the: prostate, urethra, bladder or sphincters (e.g. over-active bladder/detrusor instability).
• Bladder Stones.
• Bladder Cancer.
• Diabetes (Type 1 and Type 2).
• Neurological Diseases. Such as Parkinson’s disease, Multiple Sclerosis or Stroke.

Women:

• Menopause.
• Urinary Tract Infections (UTI’s).
• Abnormal function of the: uterus, urethra, bladder or sphincters (e.g. fibroids or over-active bladder/detrusor instability).
• Bladder Stones.
• Bladder Cancer.
• Diabetes (Type 1 and Type 2).
• Neurological Diseases. Such as Parkinson’s disease, Multiple Sclerosis or Stroke.

Certain medications are known to exacerbate LUTS. Those with an anticholinergic action (such as the antidepressants Amitriptylline and Paroxetine) can exacerbate voiding symptoms and even lead to complete urinary retention. By the same token, these medications can be helpful in addressing the storage symptoms found in conditions such as overactive bladder (e.g. oxybutynin, solifenacin, tolterodine & fesoterodine).

Some older antihistamines (e.g. diphenhydramine/Benadryl) and several bronchodilators used for chronic lung disease (e.g. ipratropium/Atrovent & tiotropium/Spiriva), are also known to exacerbate LUTS.

Drugs such as calcium channel blockers (used to control blood pressure and certain heart conditions), diuretics (water tablets), and SSRIs (antidepressants) can cause night-time polyuria (need to urinate frequently, passing large amounts of urine each time). Night sedatives can reduce the awareness of need to urinate (potentially leading to incontinence).

It is important that you discuss any concerns that you may have about the possible side-effects of prescribed medication with a doctor before making any changes or stopping them.

General measures:

• Weight reduction can result in an improvement in symptoms.
• Stop smoking as this is associated with increased risk of incontinence.
• Consider changing what you are drinking. Alcoholic, fizzy and caffeine-containing drinks can all make LUTS worse. You should stop drinking these to see if this improves your symptoms.
• Reduce drinking in the evening. You should try to drink as little as possible after 4 pm if you are having night-time symptoms.
• Try to anticipate times when urinary frequency and urgency are likely to be most inconvenient and reduce the amount that you drink beforehand.
• Do not drink more than 2 litres of fluid per day.
• Too low a fluid intake may cause constipation which can also provoke incontinence.
• Avoid artificial sweeteners as these can act as bladder stimulants.
• If urgency is a symptom, attempt to hold on for as long as possible before going.
• Avoid using the toilet ‘just in case’.
• Pelvic floor exercises to strengthen the pelvic floor are useful in cases of stress incontinence or post-micturition dribble.

Benign Prostatic Hypertrophy (BPH) in men:

• Saw Palmetto

No saw palmetto product has been conclusively shown to be effective for BPH.

• Prostatic Specific Antigen (PSA)

The PSA test is a blood test to help detect prostate cancer. However, it is not perfect and will not find all prostate cancers.

The test, which can be done at a GP surgery, measures the level of prostate-specific antigen (PSA) in your blood. PSA is a protein made only by the prostate gland. Some of it leaks into your blood, but how much depends on your age and the health of your prostate.

There is currently no national screening programme for prostate cancer in the UK because the PSA test is not always accurate.

Before deciding to have the PSA test, you may want to talk to a GP and practice nurse, as well as your partner or a friend or family member.

You have a higher risk of prostate cancer if you:

• have a family history of prostate cancer.
• are of black ethnic origin.
• are overweight or obese.

The National Institute for Health & Care Excellence (NICE CG97) recommends men with LUTS should be offered information, advice, and time to decide if they wish to have PSA testing if:

• Their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement (BPE) or
• Their prostate feels abnormal on examination or
• They are concerned about prostate cancer

It is essential that patients are thoroughly counselled on the meaning and uncertainties surrounding PSA levels to avoid unnecessary worry.

Urinary tract infections in women:

UTIs are more commonly referred to as cystitis if the bladder is specifically involved. They are usually caused when bacteria that live harmlessly in the bowel, or on the skin, get into the bladder through the urethra (the tube that releases urine from the body) and start to multiply. These infections are far more common in women than in men, as the urethral opening is so close to the anus in women.

The most common definition for recurrent urinary tract infections is having at least two UTIs in six months or three or more in a year.

• Stay hydrated

Drink at least 1.2 litres of water (six to eight glasses) a day, or two litres if you currently have symptoms (assuming you have no medical problems that require fluid restriction).

Reduce fizzy drinks, fruit juice, caffeine, and alcohol (and avoid entirely if you currently have a UTI).

• Pay attention to personal hygiene and toilet habits

Ensure you empty your bladder entirely after urination, wipe from front to back, and avoid constipation.

Avoid intimate wash products and wipes that can disrupt the normal microflora. Just wash with water or a gentle emollient.

• If symptoms are associated with sexual intercourse

Avoid use of spermicides, and flavoured condoms and lubricants; use an organic, pH-balanced, water-based lubricant; empty the bladder immediately after sex.

Menopausal women often find that topical vaginal oestrogen helps prevent UTIs and makes sexual intercourse more comfortable.

• Dietary advice

Keep your urine acidic by taking regular vitamin C and consuming foods and probiotics containing lactobacillus. A probiotic applied directly to the vulva/vagina to help restore the normal flora can be helpful. The evidence for the benefits of cranberry juice and extract is variable, mainly because there are so many different juices and tablets. The problem with the juice is that you may have to drink a lot which increases sugar intake to unhealthy levels. Another dietary tip is D-mannose which is a naturally occurring sugar and can be bought from health food shops. Recent clinical trials demonstrate promising results regarding the potential benefits of taking D-mannose in both acute urinary tract infections and in reducing recurrent urinary tract infections in women.

Similar symptoms to those of a UTI can be caused by other conditions such as sexually transmitted infections (chlamydia and gonorrhoea in particular), bacterial vaginosis, vaginal thrush, vulvodynia, lichen sclerosus, endometriosis, bladder cancer, overactive bladder, and interstitial cystitis. Your local sexual health clinic can test for many of these conditions, including UTIs.

Interstitial cystitis (IC), also known as painful bladder syndrome, is a chronic, non-infectious condition of the urinary bladder that causes frequency and urgency of urination and pelvic pain. It is often difficult for clinicians to diagnose and treat, but it is crucial that IC is not mistaken for recurrent cystitis, as antibiotics are not an appropriate treatment.

A key feature of IC is pain during filling of the bladder, relieved by passing urine, whereas UTIs are often worse when passing urine. Interstitial cystitis can flare suddenly, often after sexual activity, with a relapsing and remitting course. It is a diagnosis of exclusion and not usually made in one visit to the doctor. If you think you may have IC, consult your GP, and contact the Interstitial Cystitis Association and Bladder Health UK for advice and support.

Urinary tract symptoms in men can have several causes, including conditions such as prostate cancer that need prompt treatment. If you are a man having problems with urination, it is important to consult your doctor.

Mild cystitis in women will usually resolve with increased fluid intake and over-the-counter pain relief, but if symptoms persist for more than two days – or include a fever, loin pain and/or nausea and vomiting – it is important to consult your GP (a urine sample may help confirm diagnosis and determine which antibiotic will work best, if one is necessary).You may require further investigations or referral to a specialist if you have frequent UTIs, the infection spreads to your kidneys, or you see blood in your urine.

Contact your doctor urgently if you pass blood in your urine or are unable to pass urine for 6 – 12 hours.

The tests you have will depend on your symptoms. Your doctor may want to examine your tummy (abdomen) and genitalia. In men a prostate examination may be required (performed by inserting a gloved finger into the anus) and in women a vaginal examination may be suggested.

The most common tests performed include:

• A urine dipstick test for infection, sugar (glucose) and blood.
• A urine test to send to the hospital to confirm the dipstick findings.
• A blood test for glucose to rule out diabetes.
• In men a PSA test may be suggested (see above)

You may have an ultrasound scan on your bladder and urinary tract.

You may be referred to a specialist nurse or consultant (urologist) for tests on your urinary system (urodynamic tests). Urodynamic studies test the working of the bladder and are used to see how the urinary system and pelvic floor work.

You may be asked to keep a diary. In your diary make a note of the times you pass urine and the amount (volume) that you pass each time. Also, make a note of the times you leak urine (are incontinent).

If you have unexplained blood in your urine, you will be referred urgently to a urologist for further tests.

Women:

The treatment for LUTS in women will depend on the underlying cause. Often, no specific cause is found and so there is no specific treatment.

Some women find that their symptoms come and go and do not cause them a great deal of bother or distress. But if your LUTS do interfere with your normal life, you should consult your doctor for advice.

You may be offered help at a special continence clinic which can advise about pelvic floor exercises and ways of coping with incontinence. Specialist incontinence nurses can also advise about pads and catheters.

Medicines can be effective in helping symptoms of an overactive bladder if there is not enough improvement with bladder training alone. These medicines work by blocking certain nerve impulses to the bladder which relax the bladder muscle, so increasing the bladder capacity. These medications are called antimuscarinics (or anticholinergics). There are several different types and many different brand names. They include oxybutynin, solifenacin and tolterodine.

HRT can help menopausal symptoms including vaginal dryness and discomfort when you urinate.

An operation may be required to repair or boost your pelvic floor in some cases.

You may be referred to a specialist if your symptoms do not improve after self-help measures and treatment from your doctor.

Men:

The treatment for your LUTS will depend upon the underlying cause and how much your symptoms are bothering you and interfering with the quality of your life.

If you have an enlarged prostate, then you may be offered a medicine to shrink your prostate (5-alpha reductase inhibitors) or to relax the muscles in both the prostate and the base of the bladder (alpha-blockers).

Alternatively, an operation to remove some of your prostate may be recommended. You can read more about the treatments for BPH here.

Medicines can also be effective to improve symptoms of an overactive bladder and storage symptoms. These medications are called antimuscarinics (or anticholinergics). There are several different types and many different brand names. They include oxybutynin, solifenacin and tolterodine. They can also improve symptoms of passing urine in the night.

If you are experiencing problems with incontinence, then you may benefit from using a small tube (a urinary catheter) to drain the urine from your bladder. Many men use catheters just to empty their bladders, so they do not have a catheter in all the time. However, some men may need to have long-term catheters. This will be discussed with you in more detail by your doctor if you are likely to benefit from this.

You may be referred to a specialist, especially if your symptoms have not improved with some of the self-help measures or with some medication. You may also be referred if you need further tests.

If you have been referred for a specialist opinion your details will be reviewed, and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

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If a hospital assessment and/or treatment is clinically recommended your information will be sent to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

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