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DownloadThis information is for men who are troubled by lower urinary tract symptoms (LUTS).
Healthcare professionals use the words ‘Lower urinary tract symptoms’ (or LUTS) to describe the problems they believe are related to the working of the bladder (which holds urine) and the urethra (the tube from the bladder to outside) through which urine passes when we urinate.
There are many causes of these symptoms and we will investigate to find out the cause.
Prostatic enlargement secondary to benign prostatic hyperplasia (BPH) is a major cause of LUTS, as a result of obstruction at the exit of the bladder.
Other urological conditions such as a tight or enlarged bladder neck, an overactive bladder, or a narrowing in the urethra known as a ‘stricture’ may cause similar symptoms.
Not all LUTS are caused by a urological condition and other possibilities could involve heart, kidney or nervous system abnormalities.
The prostate is a small gland, about the size of a walnut, which lies just below the bladder and is only present in men.
One of the main functions of the prostate is to squeeze fluid into the urethra as sperm move through during ejaculation. This fluid contains nutrients for the sperm, activates them and has other roles in sexual reproduction. The prostate provides much of the volume of the ejaculate.
Lower urinary tract symptoms (LUTS) are a very common problem that affects men as they get older. In Europe 14 per cent of men in their forties experience symptoms and this increases to 40 per cent in men over sixty.
One cause of obstruction can be from the prostate gland enlarging. As men age their prostate becomes enlarged and this condition is known as benign prostatic hyperplasia (BPH) the exact cause of which is unknown. The condition is associated with hormonal changes that occur as men age.
The testes produce the male hormone testosterone, which is converted to a more active form dihydrotestosterone (DHT). High levels of dihydrotestosterone are produced in the cells of the prostate and cause prostate growth ‘hyperplasia’ (enlargement). How and why levels of DHT increase remains a subject of research.
As the prostate gland grows it can squeeze the urethra and the neck of the bladder can be tight or enlarge.
These can make it more difficult for the urine to flow freely and the bladder works harder to force urine through the narrowed urethra. This leads to the bladder wall becoming thicker and more sensitive, and makes it more difficult for the bladder to empty completely.
LUTS can be divided into two groups according to its symptoms:
Those that occur during the filling of the bladder known as ‘storage symptoms’ and those that describe the way the urine is passed, known as ‘voiding symptoms’.
The main storage symptoms are:
The main voiding symptoms are:
These different types of dribble have different causes and therefore different types of treatment.
The causes of Nocturia may include:
BPH is rarely life threatening, however if left untreated it can lead to irreversible bladder or kidney damage.
The bladder can become stretched and little pockets form in the bladder wall – known as diverticular, these may hold stale urine, which can then become infected.
Back pressure may also be exerted onto the kidneys as the bladder is unable to empty, it becomes swollen causing a rise in pressure and the urine can be transmitted back up to the kidneys.
Some men find they are suddenly unable to pass urine to empty their bladder and have severe pain and discomfort in the lower abdomen; this is referred to as Acute Urinary Retention (AUR).
If this situation occurs you need to attend a hospital’s emergency department to have a catheter inserted. A catheter is a slim plastic tube that is gently passed through the urethra to drain urine away.
Other symptoms that can develop over time include Urinary Tract Infections (UTI’s) bladder stones and incontinence.
Your GP or consultant will refer you to a Prostate Assessment Clinic or a Lower Urinary Tract Symptoms (LUTS) clinic for an assessment. There you will be seen by a specialist nurse or a doctor, either at the Princess Royal Hospital or at the Royal Sussex County Hospital.
During the assessment a number of tests may be performed, these may include;
Prostate Specific Antigen (PSA) is a substance produced in the prostate gland and detected in the blood therefore a blood test can be taken to measure the levels.
It is normal for men to have low levels of PSA in their blood; however, prostate cancer or benign (not cancerous) conditions can increase PSA levels. As men age, both benign prostate conditions and prostate cancer become more frequent.
The most common benign prostate conditions are prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH) (enlargement of the prostate). There is no evidence that prostatitis or BPH cause cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.
PSA levels alone do not give doctors enough information to distinguish between benign prostate conditions and cancer.
However, PSA is not a specific test for cancer, and before you have the test you need to have discussed the implications of the results with your GP, doctor or nurse specialist.
If you have symptoms of bladder irritation, where you are going to the toilet very frequently or with some urgency, you may be asked to have an investigation called Urodynamics.
This frequency and urgency is sometimes due to the bladder muscle having to work harder to get the urine past the prostate gland, and as a result the bladder continues to squeeze or spasm intermittently giving you the feeling that you need to empty your bladder frequently.
Urodynamics involves having a fine catheter in you bladder and a second fine catheter measuring the pressure of your tummy muscle just inside the back passage. The pressures in your bladder and tummy are measured as your bladder fills and empties.
If you have severe irritative symptoms such as frequency, urgency, passing small volumes. Urine infections, or blood detected in your urine you will require a flexible cystoscopy.
The procedure is called a flexible cystoscopy, because a flexible instrument known as a cystoscope is used, which is inserted via the urethra and allows us to examine the urethra and inside of your bladder.
It can also be used to assess the size of the prostate gland. It is performed using a local anaesthetic gel, the procedure takes approximately 10 – 15 minutes and you will be able to go home shortly after the procedure has finished.
You should be able to resume normal activities, eg. driving or work, straight away.
The aim of treatment is to improve the flow of urine, reduce symptoms and provide a better quality of life.
Three main treatment options are available:
1. Watchful waiting and self management;
This is suitable for men with mild symptoms who may wish to try a period of watchful waiting as a first course of action. Many men are quite happy to live with their symptoms once they have been reassured that they do not have prostate cancer. There are a number of things that men can try which may help reduce the severity of their symptoms. Below are some of these lifestyle changes that some men have found helpful:
Try one suggestion at a time to find out which lifestyle change is making a difference or not.
2. Medical Management
Medical management is most beneficial in people who have moderate symptoms, rather than mild or severe. Medical management involves using drugs to improve symptoms. These drug treatments are not a ‘cure’ and need to be taken for a long time.
There are two types of drug available. These are classed as:
Alpha-blockers
Alpha-blockers have been shown to increase urine flow-rates and improve symptoms associated with BPH and a tight bladder neck.
They work by causing the smooth muscle in the prostate and bladder neck to relax, which in turn relieves the obstruction and therefore increases the ability for urine to flow.
Types:
The common alpha-blockers used are Alfuzosin, Doxazosin, Indoramin and Tamsulosin. Improvement in symptoms is usually noticeable within a couple of weeks. If no improvement is noticed after a few months then it may be worth you stopping these and considering an alternative treatment.
Side effects:
The most common side effects from alpha-blockers may include headaches, tiredness, and dizziness in 10 –15 percent of patients. These are caused because this group of drugs also relax the blood vessels so that blood passes through them more easily which in turn lowers blood pressure.
A less common side effect is retrograde ejaculation which is when the semen goes back into the bladder when ejaculation occurs. This is not harmful, the next time you pass urine it may be cloudy.
5 alpha reductase inhibitors Unlike alpha-blockers, 5 alpha reductase inhibitors can potentially slow the progression of BPH. This is because they work by interfering with the production of the enzyme (dihydrotestosterone), which is needed for the prostate to grow.
As a result the volume of the prostate reduces by about 25 per cent after six months, which relieves the obstruction (caused by a narrowed urethra) and the associated symptoms.
These tablets work better in men with larger prostates and shrinking may reverse the problem. Recent studies have shown that fewer patients then need operations for their prostate or experience the sudden inability to pass urine (acute retention).
Types:
There are two 5 alpha reductase drugs available, these are Finasteride and Dutasteride. It can take up to 6 months before you see improvement in your symptoms.
Side effects:
Most of the side effects which can occur are usually reversed on stopping the treatment, but potential side effects include a loss of libido (sex drive), nipple and breast tenderness, erectile dysfunction and a reduction in the amount of ejaculate. However on the whole these drugs are well tolerated.
Combination therapy
Your doctor or nurse specialist may suggest a combination therapy of both an alpha-blocker and a 5 alpha reductase.
Herbal remedies
These have been used in parts of Europe for many years and are becoming more popular in the UK. Many men who take herbal remedies say that their symptoms improve but no long-term studies have been performed on these plant extracts. One such example of plant extract is Saw Palmetto. These can be bought from a chemist or health food shop and are not available on prescription.
3. Surgical Techniques
Over recent years new surgical techniques have been developed, however the most common is a TUR(P) Trans Urethral Resection of Prostate. This is an operation to create a larger channel through the prostate gland. This will prevent or relieve obstruction to the flow of urine.
When the prostate is not enlarged but is obstructive and narrow, a cut may be made into the neck of the bladder to improve the flow of urine. This is known as a bladder neck incision (Transurethral incision of the prostate).
It is only possible to differentiate between these causes of obstruction at the time of the operation.
No prostate tissue needs to be removed in this procedure. The results are often as effective as a TURP and with lower incidences of side-effects, however this is only suitable for men with small sized prostates.
An instrument (resectoscope) is inserted via the urethra and through the prostate gland, into the bladder.
It has a telescope and light guide, which allows the urologist to see inside the bladder and prostate.
The resectoscope uses a wire loop to remove areas of tissue from the prostate that are blocking the urethra and allows blood vessels to be sealed (cauterised) to reduce the risk of bleeding afterwards.
TURP is performed under anaesthetic. This may involve a general anaesthetic or a spinal anaesthetic (awake but numb from the waist down).
This will be discussed with you beforehand. You should expect to stay in hospital for between two – four days, the procedure is minimally invasive and does not involve any external cuts.
All patients require a draining tube (catheter) to drain urine from the bladder after the operation.
TURP normally takes between 30 – 40 minutes to perform, although having an anaesthetic makes this time longer. The whole procedure takes about 60 minutes.
Any operation and anaesthetic carry risks, these are generally small and not doing the operation may carry a greater risk. Risks of anaesthetic can be discussed with the anaesthetist who will be looking after you during the procedure .
Retrograde ejaculation, this occurs in nearly all men after TURP, i.e. rather than sperm being ejaculated out through the penis during sexual climax, the sperm pass back into the bladder and are passed out in the urine. This will reduce the ability to have children, but is not a means of contraception.
Urinary catheter, it is sometimes necessary for men to be sent home with a catheter for a few weeks after the operation to allow the prostate to heal or rest the bladder for a period of time.
During this operation we will also look inside the bladder. Sometimes, we find bladder growths and stones, which may be treated during this operation.
Impotence, there is a reported risk (approximately 7-10%) of impotence after the operation.
If this is a problem, treatments are available e.g. Viagra, vacuum devices.
Most men notice improvement in their symptoms within 6 weeks of the operation. However, in a few men it can take several months to notice an improvement in their symptoms.
Regrowth of the prostate gland, because only the areas of prostate gland that are causing the obstruction are removed then the remaining gland may regrow and need a further operation, a number of years later.
TURP is usually performed for non-cancerous (benign) growth of the prostate gland, however tissue removed during the operation is sent for analysis to confirm that the areas removed were benign.
The results of this analysis (histology) will be discussed with you at the outpatient’s appointment after the operation.
This is a relatively new technique and is very similar to the TURP. The instruments are passed via the urethra and through the prostate gland, into the bladder as with the TURP but instead of using a wire loop to remove the tissue from the prostate a powerful green laser is used to vaporise the prostate. The green light is selectively absorbed by the red prostate tissue hence ‘photoselective’.
PVP is performed under spinal or general anaesthetic.
You may have to stay in hospital between one to three days.
You will require a catheter to drain urine from the bladder after the operation. This will normally be removed late on the evening of the operation or early the following morning.
PVP normally takes between 30- 60 minutes, depending on the size of the prostate. Having the anaesthetic makes the total length of time for the procedure longer.
Any operation and anaesthetic carry risks, these are generally small and not doing the operation may carry a greater risk. Risks of anaesthetic can be discussed with the anaesthetist who will be looking after you during the procedure.
Retrograde ejaculation, this occurs in nearly all men after LUTS. Rather than sperm being ejaculated out through the penis during sexual climax, the sperm pass back into the bladder and are passed out in the urine. This will reduce the ability to have children, but is not a means of contraception.
Impotence, there is a reported risk (approximately 7-10%) of impotence after the operation. If this is a problem, treatments are available e.g. Viagra, Vacuum Devices.
Regrowth of the prostate gland, because only the areas of prostate gland that are causing the obstruction are removed then the remaining gland may regrow and need a further operation, a number of years later.
As this procedure is relatively new, we assume that evidence from the USA that shows the long term outcome to be similar to that of the TURP, will be applicable in this country also.
The urology staff caring for you have written this information leaflet to give you information on your symptoms. This should help you to be able to make an informed choice about your treatment. However, it does not cover every aspect of your care and we will be happy to answer any other questions or points of concern that you may have.
If you think of any questions you wish to discuss at your next visit to the urology department, please write them below (so that you don’t forget them).
Some useful telephone numbers:
The Urology Nursing Team 01444 441881 Extension. 65457.
Email uhsussex.urologyclinicalnursingteam@nhs.net
Ansty Ward 01444 441881 Extension. 68240/68241.
Urology Consultants:
Mr Coker’s secretary 01444 441881 Extension. 68043.
Mr Crawford’s secretary 01444 441881 Extension. 65962.
Mr Symes’ secretary 01273 696955 Extension. 67809.
Mr Larner’s secretary 01273 696955 Extension. 67808.
Mr Alanbuki’s secretary 01273 696955 Extension. 67810.
Mr Zakikhani’s secretary 01273 696955 Extension. 67810.
This information is intended for patients receiving care in Brighton & Hove or Haywards Heath.
The information here is for guidance purposes only and is in no way intended to replace professional clinical advice by a qualified practitioner.
Publication Date: May 2022
Review Date: February 2025
