Assess magnitude of symptoms

 


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When a man presents with LUTS, Dr. Hall says he first tries to gauge how bothersome the problem is. “I ask whether he’s had to make alterations in his lifestyle. Does he make it a point not to drink anything when he goes out? Does he carry a container in the car?” Dr. Hall also wants to rule out medical problems, such as bladder stones, bleeding, infection, urinary retention, and kidney problems. If none are present, he says, it’s a lifestyle issue. “I then may tell patients that as long as their PSA levels are within normal range, it’s unlikely that they’ll get significantly worse. In such cases, some men will choose to defer treatment.”

 

Dr. Paterson says all patients should receive an AUA symptom score, which includes a quality-of-life index. The index can be found online at http://www.prostatecancer.org/tools%20/forms/aua_symptom_form.pdf. Some patients may have a relatively high symptom score but not be that bothered, while others can have low scores but be very bothered, he says.

 

“To some extent this has to do with a man’s stage of life. A busy executive who has to urinate three times each night may be more bothered than a retiree. If a patient has BPH, the urologist could ask, ‘Can you live with the symptoms the way they are now?’ If the answer is yes, active surveillance may be an appropriate strategy.”

 

Patients who want OAB symptom relief can be placed on an anticholinergic. “There are now five different pills and a patch,” notes Dr. Hall. “Patients who are already taking a lot of medication may prefer a patch. If patients are taking anticholinergics, though, you have to monitor them to be sure they aren’t in retention.”

 

In the past, Dr. Hall continues, “it was considered a major faux pas to put the average man with urinary problems on meds to treat OAB. But some studies show you can treat men with OAB meds for mild-to-moderate LUTS, and that treating patients with PDE-5 [phosphodiesterase-5] inhibitors may improve urinary function.”

 

Following evaluation, most patients with obstructive symptoms are put on alpha blockers, which is the standard of care, says Dr. Hall. “If a patient has elevated PSA in addition to symptoms, but no evidence of cancer, it’s reasonable to take this route. I generally put average patients with relatively small prostate glands (30 grams) on an al-pha blocker. If a patient has a prostate over 50 cc, putting him on a 5-alpha-reductase inhibitor, finasteride (Proscar) or dutasteride (Avodart), will not only improve symptoms, but reduce the likelihood of urinary retention, especially if the patient has an elevated PSA level in the absence of cancer.”

 

“These days some urologists are putting these patients on anticholinergics. Before we do that on a large scale though, I think we need more and bigger studies. Lots of family doctors treat men with LUTS and are not ready to put patients on anticholinergics because we don’t yet know if they’re safe and effective long-term.”

 

Dr. Paterson says it’s important to check a urine cytology in patients with irritative voiding symptoms, and many urologists will then proceed to cystoscopy in this patient group. He also takes a thorough dietary history. “Dietary change is something we need to stress more: avoiding or limiting caffeinated beverages, acidic and spicy foods, and alcohol,” he says. “We also need to tell male patients to do Kegel exercises and discuss fluid restriction.” Only then does he bring up pharmacologic therapy. “If a patient has obstructive, irritative, or mixed voiding symptoms, and no absolute need for surgery, you can start with an alpha blocker and see how he does.”