© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
17
Apractical primary care approach to lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH-LUTS)
completion. For some males this may involve taking a
little extra time to void or sitting on the toilet as opposed
to standing. An example of poor urinaryhygienemaybe
found in the work place when a patient is given limited
time at the toilet and is not able to void to completion.
15
A review of the patient’s medical and surgical
history may offer a clue as to the cause of the LUTS or
an associated relationship. For example, the polyuria
of the poorly controlled diabetic may increase the
voiding frequency enough that the symptoms become
markedly more bothersome. Similarly, the patient
with congestive heart failure may find that nighttime
output and urinary frequency is increased as a result of
having elevated their legs in bed, allowing more fluid
to reabsorption in the periphery. Sleep apnea has been
associatedwith nocturnal diuresis aswell as antidiuretic
hormone deficiency. These symptoms may worsen
as the condition progresses. The effects of decreased
cognition or mobility may limit the patient’s access
to the bathroom, thereby making the symptoms more
noticeable. The provider may also want to take note of
comorbid conditions such as erectile dysfunction (ED)
and vascular disease, as those are risk factors for BPH.
There are several medications that can affect urinary
production and elimination. Polyuria associatedwith a
diuretic could increase output. The alpha agonist effect
of a cold medication may tighten the prostatic urethra
enough to obstruct flow, and the antimuscarinic effect of
multiple medications may contribute to impairment of
bladder contractility. Medication induced constipation
may exacerbate LUTS. It is important to examine the
temporal relationship between when the medication
regimen was started and when the symptoms began
or became worse.
TABLE 4.
Indications for referral
History of recurrent UTIs or other infection
Microscopic or gross hematuria
Prior genitourinary surgery
Elevated PSA
Abnormal prostate exam (nodules)
Suspicion of neurologic cause of symptoms
Findings or suspicion of urinary retention
Meatal stenosis
History of genitourinary trauma
Uncertain diagnosis
Desire to see a specialist
UTIs = urinary tract infections
PSA = prostate-specific antigen
The physical examination should be focused. It
is necessary to check the abdomen for masses or a
distended bladder. Abrief neurological examination is
needed to evaluate a patient’s mental and ambulatory
status as well as neuromuscular function as these can
affect toileting. The PCP should conduct a thorough
examination of the genitalia. Meatal stenosis or a
phimotic foreskin can mimic the enlarged prostate by
impeding flow. Adigital rectal examination (DRE) can
provide information about the anal sphincter tone as
well as prostate size, shape and consistency.
10
BPH
usually results in a smooth, enlarged prostate which
is not tender to palpation.
16
The gland may have a
rubbery consistency, similar to the thenar eminence of
the hand, and has often lost the median furrow.
17
In
contrast, a nodular firm prostate raises the suspicion
of carcinoma and a tender, possibly indurated, gland
may indicate infection (prostatitis).
17,18
The PCP should
keep inmind that the DRE does offer a basic idea about
the size, shape and consistency of the gland, but it is
only an estimate. This can often lead the physician to
underestimate prostate size as the digital exam cannot
assess the full length or anterior portion of the gland.
19
In addition, size alone does not correlatewith symptom
severity because obstruction is dependent on growth
and dynamic changes within the prostatic urethra.
20
The physical examination, as just reviewed, describes
what should be included in the basic evaluation of LUTS
in themale. However, much of thismay have beendone
at prior visits with the PCP, so that re-examination (i.e.
prostate exam) may not be necessary if it is up to date.
The required laboratory tests are minimal. A
urinalysis performed by dipstick or microscopic
examination is strongly recommended to check for
blood, protein, glucose or any signs of infection. This
may prompt treatment or referral. Although hematuria
or pyuria are not always found in conditions such as
bladder cancer, stones or infection, a normal urinalysis
makes these diagnoses less likely.
21
It is not adequate to
use the urinalysis to rule out the possibility of diabetes
as the serum blood sugar must be over 180 mg/dL
before glucose is spilled into the urine.
12
Consequently, a
dipstick urinalysis may fail to pick up on intermittently
high sugars or patients with mild diabetes. Therefore,
although this is not part of the American Urological
Association (AUA) guidelines, there is a good argument
for testing blood sugar, either random or fasting.
12,21
Assessment of renal function by measurement of
electrolytes, blood urea nitrogen (BUN) and creatinine
are useful in screening for chronic renal insufficiency
in patients with a high post void residual (PVR)
bladder volume.
22
However, they are not universally
recommended in the initial evaluation of LUTS.
21,23-25
