Men and their urinary symptoms: an evidence-based approach to their management
Author: Hirst G.
From: Australian Continence journal 1999; 5(1):4-5.
There can be little doubt that news about ‘the prostate’ has been ‘flavour of the month’ for sometime. Hardly a week goes by without an article in the newsprint or on television about prostate cancer and the latest ‘this or that’ treatment to save men from a terrible fate. Many of us would prefer that the media’s attention to men’s health matters be more holistic. After all, for every man who dies of prostate cancer, 20 die of cardiovascular causes, five from strokes and three in accidents. Yet the focus seems firmly fixed on the prostate.
And this publicity touches a fertile audience. On one side of the coin is the fact that almost 40 per cent of men over 45 years of age notice some changes in their urinary function. Or, to ‘medicalise’ this prevalence, almost half the men in the community have some lower urinary tract symptoms. In keeping with modern parlance, the nature of these changes is reduced to the medical acronym ‘LUTS’ thereby enshrining them as changes of significance. And this despite the fact that, until recently, most men have not sought medical advice about them. Indeed, whether they are truly symptom reflective of come underlying disease or just a function of the ageing process is open o a debate that could almost be considered an exercise in semantics.
But there is another reason why the community is susceptible to this media barrage. It is the other side of the coin, so to speak. We in the medical community have for a long time educated people to consider that changes in normal bodily functions may indicate some serious underlying disease process. And, of course, this is true for many conditions.
It is therefore not reasonable for men, but more frequently their partners, to draw the same conclusion from a change in a man’s urinary function.
Do these changes represent the first symptom of prostate cancer? Whether for this or other reasons, more and more men are presenting to their general practitioners regarding their LUTS.
With many conditions there has been a significant shift in our understanding of their underlying causes, leading to better management. In the cause of LUTS, the situation has been a little different. Until the very recent past, these symptoms have gone under a variety of names such as ‘BPH’ for benign prostatic hyperlasia’ (or ‘hypertrophy’!) or ‘prostatism’. This naturally implied that it was the benign changes in the prostate, and principally the gland’s enlargement, that were responsible for the symptoms. It is now evident that the picture is far from being so clear and that a number of different factors, including changes in the prostate, may be responsible. What is abundantly obvious is that, for age-matched cohorts of men and women, the prevalence of LUTS is similar, suggesting that at lease one aetiological factor may be simply an aging of the lower urinary tract.
With — or maybe because of — this change in our understanding of the possible cause of LUTS in mean has come a whole new range of interventions with cause of this, it seemed propitious to subject the evaluation and management of men with LUTS to the scrutiny of an evidence based approach and develop clinical practice guidelines.
The medical groups most closely aligned with the management of these men are the Urological Society of Australasia and the Royal Australian College of General Practitioners. Both gave their support and so an NHMRC Working Party was convened to consider the evidence and develop the guidelines. This process commenced in November 1995 and the NHMRC approved the final documents in December 1996. In April 1997 the Clinical practice Guidelines for the Management of Uncomplicated Lower Urinary Tract Symptoms in Men were launched, together with two companion documents: ‘Is it my prostate, Doc?’, a general practitioner version, and ‘To pee or not to pee’, a consumer’s guide.
The guidelines first consider the possible underlying cause of LUTS and identify their uncertain nature. The histological process of benign prostatic hyperplasia, which is almost ubiquitous in the aging man, is undoubtedly involved. While it has always been considered that the symptoms were largely related to the actual size of the prostate, this no longer appears to be the case. There seems to be little or no correlation between the volume of the gland and the severity of a man’s symptoms.
It is more likely that the smooth muscle stroma arising from the process of benign prostatic enlargement and the configuration of the enlarged portion of the gland play a significant role in producing the symptoms. What is clear is that LUTS in men is caused by multiple factors, including changes in bladder function.
Given that many men are presenting because they are concerned that their LUTS, no matter how minor, might represent some significant underlying pathology, the guidelines closely examined the evidence regarding this. There appears to be little risk that LUTS of any severity suggests a mean may suffer a serious health threat. Thus, the guidelines recommend that few investigations are needed when a man first presents with uncomplicated symptoms.
Indeed, it seems likely that many men present mainly because they are concerned about the possibility that they may have prostate cancer. There is at present no evidence that there is a higher incidence of early and potentially curable prostate cancer in men with LUTS as compared to a similar cohort without any symptoms. Intuitively this is as one might expect, given that potentially curable prostate cancer must be of a small volume and usually arises in the posterior portion of the prostate. Because of these findings, and the fact that there is as yet no evidence that screening for prostate cancer reduces the mortality of the disease, the guidelines do not recommend the routine screening of men with LUTS for prostate cancer.
This recommendation is in keeping with that by the NHMRC’s Australian Health Technology Advisory Committee. Naturally, the decision as to whether a man should ultimately be screen with a PSA test must remain his, but the guidelines recommend that he be strongly encouraged to understand the implications of this screening process before agreeing to undergo it.
The practitioner’s goal in the management of a man with LUTS should be to improve his quality of life, as this relates to his symptoms, while this frequently translates into a similar improvement in the severity of his symptoms, there is not necessarily a direct relationship between this severity and the man’s perception of how bothered he is by them. It is the severity of his bother that he wants improved.
In an era of scientific evaluation, the urological community has sought reliable tests with which to predict the outcome of their interventions to manage men with LUTS. Measurements such as urine flow rate and post-void residual urine volumes have been widely used for this purpose. Because these and other non-invasive tests have no been reproducible or significantly predictive, the currently accepted ‘gold standard’ as been the outcome of a pressure-flow urodynamic study. The guidelines identified that none of these urodynamic parameter provide sufficient prediction of the outcome of surgical intervention for LUTS to allow a man to make an informed decision as to whether to undergo an operation.
The best predictor of the outcome of treatment for LUTS is the severity of bother a man perceives his LUTS to be causing him. It is therefore possible to advise a man who is not particularly bothered by his LUTS that he does not need to worry about them. Changes in lifestyle are often helpful in minimising the inconvenience cased by the symptoms.
The guidelines also identified that such a man does not required any particular follow-up. While the probability that the severity of his symptoms will increase in the next 5 years in 20 per cent, conversely, there is a 30 per cent chance that they will improve. In 50 per cent of men there is no perceptible change in how bothered they are by their symptoms over this five-year period.
Where a man is moderately bothered and wishes to consider treatment, pharmacological intervention may be his first choice. Alpha adrenergic booking agents such as prazosin (Minipress, Pressin) and terazosin (Hytrin) can provide some improvement in up to 60 per cent of men and anticholinergic agents may also be of some benefit.
Obviously, such conservative approaches to management lie in the domain of the general practitioner. The guide ‘Is it my prostate, Dos?’ is accompanied by an easy-to-use, A4, laminated life-out page which provides synopsis of the guidelines and a flow chart for the management of men with LUTS.
For men who are severely bothered or who fail, or do not want to consider, the medication, surgical intervention provides the prospect of considerable symptomatic improvement. The well-established procedures of transurethral resection of the prostate (TURP) and transurediral incision of the prostate (TUIP) each offer a similar 80 per cent chance of significant improvement, with the benefits depending on the size of the gland.
Although both these procedures have a relatively low morbidity profile and complication rate, newer and less invasive procedures are being developed in an effort to further reduce the morbidity of treating these men. Most rely on heating the prostate by a variety of means, including lasers, microwaves and radiowaves. We must await the long –term outcome, where these approaches have been randomised against TURP and TUIP, before they can be considered as superseding the established surgical treatments.
We live in an era of medico-legal uncertainty, one in which, rightly or wrongly, the community seems ever more litigious. Many practitioners feel they are between the proverbial ‘devil’ and the ‘deep blue sea’. The guidelines may support a conservative approach, particularly if the symptoms are not severe, but the man is fearful. Does he have a serious underlying disorder? Worse, does he have cancer? Under these circumstances, reassurance can be difficult and certainly very time consuming. Perhaps it is easier just to respond to the man’s and the doctor’s anxiety and do some tests, offer treatment?
In the end, only the man and his doctor can decide on the correct approach to any particular problem. The answer to specific problems may lie outside the scope of the guidelines. It would, however, be nice if the guidelines and their recommendations – based as they are on the available scientific evidence – could assist both parties in their decision-making.
The value of evidence-based guidelines in the defence of medical decisions is yet to be tested in the Australian courts. One can only conclude that following the recommendations does not guarantee protection from successful litigation.
The reality, however, is that the recommendations of these evidence-based guidelines very closely approximate those developed in both the United States and the United Kingdom. One could assume that they reflect high quality and inter-nationally acceptable best practice. As such, one can only hope that the legal profession will regard them in the same light as do their medical colleagues.
by GEOFFREY HIRST
FRACS, Urologist, Mater Hospitals
Brisbane, Queensland
Chair, NHMRC Working Party
Clinical Practice Guidelines for the
Management of Uncomplicated Lower
Urinary Tract Symptoms in Men