Lower Urinary Tract Symptoms in Men: A Review

Importance: Up to 40% of men older than 50 years have lower urinary tract symptoms, including urinary urgency, nocturia, and weak urinary stream, due to disorders of the bladder and prostate. These symptoms negatively affect quality of life and may be associated with urinary retention, which can cause kidney insufficiency, bladder calculi, hematuria, and urinary tract infections.

Observations: In men, lower urinary tract symptoms can be caused by bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), an overactive bladder detrusor (a syndrome of urinary urgency and frequency), or both. Behavioral therapy, including pelvic floor physical therapy, timed voiding (voiding at specific intervals), and fluid restriction, can improve symptoms. Medications including α-blockers (such as tamsulosin), 5α-reductase inhibitors (such as finasteride), and phosphodiesterase 5 inhibitors (such as tadalafil) improve lower urinary tract symptoms (mean improvement, 3-10 points on the International Prostate Symptom Score [IPSS], which ranges from 0-35, with higher scores indicating greater severity) and can prevent symptom worsening measured by increased IPSS greater than or equal to 4 points or development of secondary sequelae, such as urinary retention. Combination therapies are more effective than monotherapy. For example, α-blockade (eg, tamsulosin) combined with 5α-reductase inhibition (eg, finasteride) lowers progression risk to less than 10% compared with 10% to 15% with monotherapy. Treatment for overactive bladder detrusor, including anticholinergics (eg, trospium) and β3 agonists (eg, mirabegron), reduces voiding frequency by 2 to 4 times per day and reduces episodes of urinary incontinence by 10 to 20 times per week. Surgery (eg, transurethral resection of the prostate, holmium laser enucleation of the prostate) and minimally invasive surgery are highly effective for refractory or complicated cases of BPH, defined as persistent symptoms despite behavioral and pharmacologic therapy, and these therapies can improve IPSS by 10 to 15 points. Minimally invasive procedures, such as water vapor therapy (endoscopic injection of steam into BPH tissue) and prostatic urethral lift (endoscopic insertion of nonabsorbable suture implants that mechanically open the urethra), have lower complication rates of incontinence (0%-8%), erectile dysfunction (0%-3%), and retrograde ejaculation (0%-3%) but are associated with increased need for surgical retreatment (3.4%-21%) compared with transurethral resection of the prostate (5%) and holmium laser enucleation of the prostate (3.3%).

Conclusions and relevance: Lower urinary tract symptoms, defined as urinary urgency, nocturia, or weak stream, are common among men and are usually caused by BPH, overactive bladder detrusor, or both. First-line therapy consists of behavioral intervention, such as pelvic floor physical therapy and timed voiding, as well as pharmacologic therapy, including α-adrenergic blockers (tamsulosin), 5α-reductase inhibitors (finasteride), phosphodiesterase inhibitors (tadalafil), anticholinergics (trospium), and β3 agonists (mirabegron).

Author/s:

John T Wei, Casey A Dauw, Casey N Brodsky

Non-Surgical Management of Urinary Incontinence

Alex Haga — Tue, 25 Feb 2025 17:42:11 +0000

Date Added:

February 25, 2025

Journal/Publication:

The Journal of the American Board of Family Medicine

Publication Date:

September 1, 2024

Issue:

Volume:

Pages:

909-918

URL:

Non-Surgical Management of Urinary Incontinence

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.3122/jabfm.2023.230471R1

Keywords

urinary incontinence

incontinence

stress urinary incontinence

MeSH

urinary tract infections

A review of the non-surgical management of urinary incontinence. James W. Mold, MD, MPH

Free full text

View

Urinary incontinence management varies depending on the type of incontinence and severity of symptoms. Types of incontinence include stress (SUI), urge or overactive bladder (OAB), mixed, neurogenic, and overflow incontinence. First-line treatment for OAB and SUI is nonpharmacologic management. Behavioral therapy is first-line treatment for urge incontinence. Vaginal mechanical devices (cones, pessaries, and urethral plugs), pelvic floor muscle training, and electroacupuncture are recommended as first-line treatment for women with SUI. Biofeedback and electric muscle stimulation can be adjunctive therapy for SUI. Antimuscarinics and β-3 agonists can be used as adjective therapy for those with OAB who do not improve with behavioral therapy. β-3 agonists have less anticholinergic side effects compared with antimuscarinics for OAB. Adverse medication effects can often lead to discontinuation due to poor tolerability. Third-line therapies are for those who fail conservative and pharmacologic therapies and lack high-grade evidence. Neuromodulation, neurotoxin injections, vaginal laser therapy, and acupuncture are third-line in OAB management. Pharmacologic management with α-1-blockers is recommended as first-line treatment for moderate to severe overflow incontinence from BPH. 5-α reductase inhibitors can be used as an adjunct medication in those with refractory overflow incontinence symptoms and a PSA ≥ 1.5 mg/dL. Clean intermittent catheterization is first-line therapy for neurogenic bladder but can increase risk of catheter-associated urinary tract infection. Clinicians should assess type of incontinence, patient goals, side effect profile, and tolerability to determine an individualized treatment plan for each patient.

Author/s:

Ranna Al-Dossari, Monica Kalra, Julie Adkison, Bich-May Nguyen