QuestionSBA
QuestionChoice
Tamsulosin is an alpha-blocker, usually used first line in treating BPH. However, here the patient has postural hypotension and so a 5-alpha reductase inhibitor would be preferable
32944
b
Tamsulosin
QuestionChoice
Doxazosin is an alpha-blocker. It is less selective than tamsulosin and so is only used when these selective effects are preferable, for example in a patient with hypertension
32945
c
Doxazosin
QuestionChoice
Fenofibrate is prescribed for patients with hyperlipidaemia or hypertriglyceridaemia
32947
e
Fenofibrate
QuestionChoice
Finasteride is a 5-alpha reductase inhibitor. Usually these are prescribed 2nd-line after alpha-blockers. However, in this case the patient has postural hypotension and therefore, alpha-blockers are relatively contraindicated because of their potential adverse effects on the patients blood pressure
32943
a
Finasteride
QuestionChoice
Alfuzosin is an alpha-blocker. It is less selective than tamsulosin and so is only used when these selective effects are preferable, for example in a patient with hypertension
32946
d
Alfuzosin
QuestionComment
good q
25988
User
subscriber
Kinin Polyps
QuestionComment
i prefer really, not to not to speak
61882
User
subscriber
Gabriel Magalhaes
Concept
Chapter
# Summary

Lower Urinary Tract Symptoms (LUTS) encompass a wide range of symptoms related to issues with voiding, storage, and post-micturition. These symptoms are often the result of underlying pathologies affecting the bladder, prostate, or urethra, or due to neurological causes. Key signs and symptoms are categorised under voiding and storage symptoms. Investigations often include urinalysis, DRE, bladder diary, and urodynamics. Management strategies vary depending on the cause and often involve a combination of medical and surgical interventions.

# Definition

Lower Urinary Tract Symptoms (LUTS) refer to a group of symptoms that occur as a result of abnormal storage, voiding, or post-micturition function of the bladder, prostate (in men), or urethra.

# Aetiology

The commonest cause of LUTS are UTIs, which result in storage symptoms (below), and dysuria, haematuria and sometimes systemic upset.

LUTS  can be due to:

- **Neurological causes**: Lesions at the higher functional centres or tracts that control micturition and continence
- **Bladder causes**: Bladder underactivity or detrusor underactivity, where the bladder cannot generate sufficient pressures to overcome resistance downstream.
- **Prostate causes**: An increase in prostate size, due to benign prostatic hyperplasia (BPH) or prostate cancer, can narrow the prostatic urethra and increase the resistance in the lumen.
- **Other mass effect causes**: Including ovarian masses in women, which could be malignant or non-malignant (e.g. fibroids).
- **Urethral causes**: Urethral strictures, which are the narrowing of the urethra due to congenital or traumatic causes.


# Signs and Symptoms

**Voiding Symptoms**

- Weak or intermittent urinary stream
- Straining
- Hesitancy
- Terminal dribbling
- Incomplete emptying

**Storage Symptoms**

- Urgency
- Frequency
- Urgency incontinence
- Nocturia

# Differential Diagnosis

The key differentials for LUTS include:

- **Bladder outlet obstruction**: Characterised by weak or intermittent urinary stream, straining, hesitancy, terminal dribbling, incomplete emptying, and sometimes urgency and frequency.
- **Overactive bladder syndrome**: Typically presents with urgency, increased daytime frequency, nocturia, and may also include urgency incontinence.
- **Prostatitis**: Symptoms can include voiding and storage symptoms, but often accompanied by discomfort or pain in the pelvic region.
- **Bladder cancer**: Hematuria is the most common symptom but it may also present with LUTS.
- **Urethral stricture**: Symptoms can include diminished force of the urinary stream, straining, spraying of urine, and incomplete emptying.

# Investigations

Key investigations for LUTS include:

- Urinalysis
- Digital Rectal Examination (DRE)
- Bladder diary
- Urodynamics

The most definitive tests available to determine the aetiology of both voiding dysfunction and LUTS are urodynamic studies which comprise a filling and storage phase, and a voiding phase.

# Management

Management of LUTS  depends on the underlying cause, which can be deduced from the investigations above. See dedicated sections on UTI, BPH, urinary incontinence and bladder cancer for more information.

# NICE Guidelines

[NICE CKS - Lower Urinary Tract Conditions](https://www.nice.org.uk/guidance/conditions-and-diseases/urological-conditions/lower-urinary-tract-symptoms)
760
793
Lower urinary tract symptoms (LUTS)
Topic
22
Urology
6589
Finasteride is a 5-alpha reductase inhibitor used to treat benign prostatic hypertrophy, particularly in patients with contraindications to alpha-blockers.
A 65-year-old man presents to his GP with increased frequency. He has noticed that he has been getting up during the night to urinate more often. He reports having a poor stream, and having to try and force urine out because he often has a feeling of incomplete voiding. He has a past medical history of type 2 diabetes mellitus, obesity and postural hypotension. On digital rectal examination, the prostate was noted to be enlarged and smooth. A diagnosis of benign prostatic hypertrophy was made.

Which medication should the GP start this patient on?
a