CSSL National Guidelines / Lower Urinary Tract Symptoms

Lower Urinary Tract

Symptoms
(LUTS)

College of Surgeons of Sri Lanka

2007

Authors

Dr. Srinath Chandrasekera MBBS MS FRCS FEBU

Dr. Suren De Zylva MBBS MS FRCS FEBU

Dr. Ajith Malalasekera MBBS MS MRCS

Dr. Serosha Gunawardena MBBS MS FRCS D Urol.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Contents
Page

Introduction 03

Types of LUTS 05

Definitions 07

Patient evaluation 09

Management 19

References 20

Appendix -1 22
AUAA symptom index

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 CSSL National Guidelines / Lower Urinary Tract Symptoms
Introduction:
The purpose of this guideline is to help medical
practitioners recognize this clinical problem, enabling
them to make an initial assessment, request basic
investigations and be advised of indications for specialist
referral.
Lower Urinary Tact Symptoms (LUTS) is one of
the commonest urological complaints. These symptoms
are not organ or disease specific and may well occur in
the female. Therefore, the previously used term
“prostatism” is no longer considered appropriate. LUTS
is a grouping of 3 types of symptoms which can be
classified as follows.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Table 1 Lower urinary tract symptoms

Filling / storage Voiding Post micturition

(irritative) (obstructive)
Urgency • Hesitancy • Feeling of
Frequency • Poor steam incomplete
Urge incontinence • Intermittency evacuation
Nocturia • Need to strain
Nocturnal enuresis* • Terminal
(in the adult) dribbling of
urine
• Dysuria*
• Thin stream*

* These symptoms are not listed in the document by the

standardisation sub-committee of the international continence
society [1,2]. However given the frequency of occurrence in clinical
practice in Sri Lanka the authors find it appropriate to include them
as above.

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

Type of LUTS

Filling type LUTS

These symptoms arise mainly during the filling

phase of the bladder and therefore called “filling” or
“irritative” symptoms. Some of the causes which give
rise to these symptoms are listed below.

• Urinary tract infections

• Inappropriate hydration, dietary and or social
habits.
(Excessive fluid intake leading to frequency
and nocturia, excessive consumption of
caffeine containing drink, smoking etc)
• Bladder stone(s)
• Bladder cancer (especially carcinoma in-situ)
• Bladder outflow obstruction (Due to
secondary changes occurring in the bladder)
• Interstitial and non bacterial cystitis
• Neurogenic bladder disorders
(Parkinson’s disease, Cerebrovascular
accidents, Spinal cord injuries and tumours
Neurogenic bladder disorders etc.)
• Drugs (Diuretics, anti-cholinergics, anti-
depressants,Nifidepine etc)

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Voiding type LUTS

Voiding symptoms occur typically due to bladder

outflow obstruction which may be due to

• Benign prostatic obstruction

• Prostate cancer

• Urethral stricture

• Meatal stenosis

• A poorly contracting detrusor muscle

(detrusor failure, detrusor sphincter

dyssynergia etc) may also cause these

symptoms.

The following points are worthy of note.

• The severity of LUTS can be measured by various

validated questionnaires such as the
International Prostate Symptom Score (IPSS),
American Urological Association (AUA) (see
appendix-1) symptom score. However the use
of these tools is limited in Sri Lanka due to
the unavailability if validated versions.

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

• The commonest cause of LUTS in the >50

year males is benign prostatic hyperplasia.
However even with prostate cancer, LUTS
is perhaps the commonest mode of
presentation in Sri Lanka.

Definitions

• Increased daytime frequency - Self explanatory

• Nocturia- Waking at night one or more times to
void urine
• Urgency- Sudden compelling desire to pass urine
which is difficult to postpone.
• Urge incontinence- Involuntary leakage of urine
accompanied or immediately preceded by
urgency
• Nocturnal enuresis- the complaint of loss of urine
occurring during sleep.
• Poor stream- A slow stream; reduced urine flow
rate
• Hesitancy- Difficulty in initiating micturition
after the individual is ready to pass urine

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

• Intermittency- Urine flow stops and starts on one

or more occasions during voiding
• Terminal dribbling- Prolonged final part of
micturition when the flow has slowed to a trickle
or dribble
• Straining- Muscular effort to initiate , maintain or
improve urinary stream
• Dysuria- Burning type discomfort during
micturition
• Thin stream- self explanatory
• Feeling of Incomplete Emptying - self
explanatory.

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

Patient evaluation

History

A complete urological history must be taken and

all patients examined. Following are some of the salient
points.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

• Presence or absence of all the symptoms listed in

table 1 should be documented
(eg; Nocturia x3, Frequency x 8, no hesitancy)
• Duration of symptoms.
• Associated symptoms such as dysuria, fever,
haematuria, pain, loss of appetite, loss of weight
• Degree of bother (note: in the absence of a
questionnaire “mild, moderate and severe” may
suffice)
• Dietary habits e.g.: fluid intake, caffeine intake,
smoking.
• Occupation e.g.: Dye, rubber industry etc
• Past history of urological or nephrological
disease. e.g. Urolithiasis, UTI, prostate cancer.
• Medications

Physical examination

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

• General examination - pallor, oedema, fever,

vital signs etc
• Abdominal-Palpable bladder, tender and or
enlarged kidneys
• Genital examination - meatal stenosis, and
digital rectal examination is mandatory in
male patients

Note: With benign enlargement the prostate gland is

uniformly and symmetrically enlarged with preservation of
normal anatomical features such as the median groove. The
mucosa is mobile over the gland. Nodularity, obliteration of
the median groove, hardness or distortion of symmetry is
suggestive of malignant change requiring specialist urological
evaluation. Digital examination of the prostate is known to be
examiner dependant.

Investigations

• All patients should have a urine analysis. This

is a mandatory test for any patient presenting
with a urological complaint.

• Further investigations will be influenced by

the clinical scenario. Following tests are
recommended especially for those with
bothersome or persistent

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Urine culture and antibiotic sensitivity test. (before

antibiotics are commenced)
Ultrasound scan of the genito-urinary tract with
measurement of post void residual urine
KUB X ray
Serum creatinine
Fasting and postprandial blood glucose (for those
with filling type LUTS only)

• Following tests are optional especially in

particular clinical settings. (These may well
be done at a specialist level)

Urine flowmetry
PSA (in males over 50 years of age).
Frequency volume chart

Further evaluation of patients with filling type LUTS

• The commonest cause of filling type LUTS is

urinary tract infection. However it must be
emphasized that more sinister causes may present
similarly as indicated above. The presence of pus

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CSSL National Guidelines / Lower Urinary Tract Symptoms
cells in urine only indicates inflammation and is
NOT confirmatory of urinary tract infection. A
urine culture and ABST must be done for
definitive diagnosis with the exception of pre-
menopausal sexually active females presenting
with the first episode of UTI (honeymoon
cystitis). Here the doctor may prescribe a urinary
antiseptic without ABST provided the patient is
otherwise healthy and afebrile. In other instances
where urine culture and ABST is requested, the
doctor may commence antibiotic therapy on
clinical grounds pending results of the culture
and ABST.

• In the absence of a culture positive UTI, with an

abnormal UFR or other investigations or if
symptoms persist, such patients should be
referred for specialist urological evaluation. All
other forms of urinary tract infections are deemed
complicated and needs specialist urological
evaluation.(Table 2)

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Table 2. Classification of UTI [3]

Uncomplicated UTI Complicated UTI

• Acute cystitis in pre- Infection associated with a

menopausal, non- condition, such as structural or
pregnant women who functional abnormalities of the
are otherwise normal. genitourinary tract or the presence
• Acute uncomplicated of an underlying disease, which
pyelonephritis in pre- increases the risks of acquiring an
menopausal, non- infection or of failing therapy.
pregnant women who E.g.
are otherwise normal. • The presence of an indwelling
• Recurrent catheter, stent or splint
(uncomplicated) UTIs (urethral, ureteral, renal) or the
in post-menopausal use of intermittent bladder
women catheterization
• UTIs in pregnancy* • A post-void residual urine of >
• Acute uncomplicated 100 mL
UTIs in young men • An obstructive uropathy of any
• Asymptomatic aetiology, e.g. bladder outlet
bacteriuria obstruction (including
neurogenic urinary bladder),
stones and tumour

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

• Vesicoureteric reflux or other

functional abnormalities
• Urinary tract modifications,
such as an ileal loop or pouch
• Chemical or radiation injuries
of the uroepithelium
• Peri- and post-operative UTI
• Renal insufficiency and
transplantation, diabetes
mellitus and immunodeficiency

* The European association of Urology Guidelines indicate

pregnancy associated UTI as a risk factor for complication.
This is possibly best treated as “complicated” in a Sri Lankan
clinical setting.

• Patients with mild symptoms and normal

investigations may be managed at community
level by family physicians. However in the case
of males over 50 years at least one specialist
urological consultation is strongly recommended.

• If nocturia is the only symptom, the

family/community physicians may try advising
the patients to reduce fluid intake after 6pm or a
few hours before bedtime. Such patients will
benefit from excluding diabetes mellitus and
congestive cardiac failure.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

• All patients with abnormal laboratory tests (with

the exception of honeymoon cystitis) or
persistent symptoms should be referred for
specialist urological opinion.

Further evaluation of patients with voiding type LUTS

• The commonest cause of these symptoms in

males >50 years is benign prostatic hyperplasia.
As mentioned before in Sri Lanka where
screening for prostate cancer is not available
LUTS may the commonest mode of presentation
for those with prostate cancer as well.

• Prostate Specific Antigen PSA may be used after

consent of the patient to further evaluate the risks
of prostate cancer. PSA is NOT a substitute for
DRE as 10-15% patients with locally advanced or
metastatic prostate cancer may present with a
normal PSA [unpublished data].

• PSA is a surrogate marker for prostate cancer and

may be elevated due to other causes (Table3).
Inappropriate use of PSA may lead to erroneous
diagnosis of prostate cancer leading to undue
anxiety and investigations.

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

Table 3. Causes for elevated PSA

Causes for elevated PSA

• Large benign prostatic hyperplasia
• Prostate cancer
Causes for spurious elevation of PSA
• UTI, prostatitis
• Acute urinary retention
• Catheterization
• Urinary tract instrumentation (cystoscopy etc)
(in these instances estimation of PSA should
be differed for 4-6 weeks )

Normal PSA
The conventional normal range for PSA is
regarded as 0-4 ng/mL. However this is a
controversial topic and even ‘normal’ PSA
values could be associated with prostate
cancer.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Table 4. PSA values and predictive value for prostate

cancer [4]
Positive predictive
PSA ng/mL
value for cancer
0-1 2.8-5%
1-2.5 10.5-14%
2.5-4 22-30%
4-10 41%
> 10 69%

PSA = prostate-specific antigen.

• In uncomplicated BPH (symptomatic due to

benign prostatic obstruction without further
complications) urine analysis and culture should
be normal. Such patients may be managed at
community level [5,6]. However at least one
specialist urological consultation in patients over
50 years in encouraged.

• Ultrasonography of the genitourinary system is

useful in detecting post voidal residual urine as
well as dilated upper urinary tracts which may
occur due to high pressure chronic urinary
retention (obstructive uropathy). Serum

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CSSL National Guidelines / Lower Urinary Tract Symptoms
creatinine is useful to evaluate renal function as
obstructive uropathy can result in renal
impairment.

• In younger males, urethral stricture disease or

meatal stenosis needs to be considered. Younger
patients (less than 50 years), those with
neurological symptoms, those with previous
urinary tract disease or surgery should be referred
for specialist review. Sudden onset deterioration
of stream or acute urinary retention may be
precipitated in this group due to bladder neck
stones.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Management
LUTS suitable for community based
management

• LUTS caused by uncomplicated cystitis in

sexually active pre-menopausal females.

• LUTS in postmenopausal females

Indications for specialist referral

• Men > 50 years

• Abnormal DRE

• Nocturnal enuresis in adults

• Persistent or progressive symptoms

• Abnormal PSA or other laboratory tests

• LUTS associated with fever, chills or rigors

(this may be an emergency requiring
immediate hospitalization and specialist
attention)

• Associated haematuria or constitutional

symptoms.

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 CSSL National Guidelines / Lower Urinary Tract Symptoms

References

1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier

P, Ulmsten U, van Kerrebroeck P, Victor A, Wein

A: The standardization of terminology of lower

urinary tract function: report from the

stadardisation sub-committee of the international

continence society, Neurourol Urodynam 2002;

21: 167-78.

2. Sand Peter K., Dmochowski M.D. Roger.

Analysis of the standardisation of terminology of

lower urinary tract dysfunction: report from the

standardisation sub-committee of the

International Continence Society. Neurourol

Urodynam 21: 167-78, 2002)

3. Naber KG, Bergman B, Bishop MC, Bjerklund-

Johansen TE, Botto H, Lobel B, Jinenez Cruz F,

Selvaggi FP; Urinary Tract Infection (UTI)

Working Group of the Health Care Office (HCO)

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

of the European Association of Urology (EAU).

EAU guidelines for the management of urinary

and male genital tract infections. Eur Urol. 2001

Nov;40(5):576-88.

4. Aus G, Abbou CC, Bolla M, Heidenreich A,

Schmid HP, van Poppel H, Wolff J, Zattoni F;

European Association of Urology. EAU

guidelines on prostate cancer. Eur Urol. 2005

Oct;48(4):546-51.

5. Madersbacher S, Alivizatos G, Nordling J, Sanz

CR, Emberton M, de la Rosette JJ. EAU 2004

guidelines on assessment, therapy and follow-up

of men with lower urinary tract symptoms

suggestive of benign prostatic obstruction (BPH

guidelines). Eur Urol. 2004 Nov;46(5):547-54.

6. de la Rosette JJ, Alivizatos G, Madersbacher S,

Perachino M, Thomas D, Desgrandchamps F, de

Wildt M; European Association of Urology. EAU

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 CSSL National Guidelines / Lower Urinary Tract Symptoms
Guidelines on benign prostatic hyperplasia

(BPH). Eur Urol. 2001 Sep;40(3):256-63.

7. Abeygunasekera AM, Nirupika H, Bulegoda H.

Acute urinary retention in the 15-50 year age

group. Sri Lanka Journal of Urology

2002:3(1);10-12.

This document is aimed to serve as a guide for

Sri Lanka doctors. It is a consensus document and
not a comprehensive guide for specialist management.

APPENDIX – 1 The American Urological

Association symptom index for benign prostatic
hyperplasia

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Almost always
More than half
About half the
Less than half

Your score
Less than 1
Not at all

time in 5

the time

the time
time
Incomplete
emptying
Over the past month,
how often have you
had a sensation of not 0 1 2 3 4 5
emptying your
bladder completely
after you finish
urinating?
Frequency
Over the past month,
how often have you
had to urinate again 0 1 2 3 4 5
less than two hours
after you finished
urinating?
Intermittency
Over the past month,
how often have you
found you stopped 0 1 2 3 4 5
and started again
several times when
you urinated?
Urgency
Over the last month,
how difficult have 0 1 2 3 4 5
you found it to
postpone urination?
Weak stream
Over the past month, 0 1 2 3 4 5
how often have you

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 CSSL National Guidelines / Lower Urinary Tract Symptoms
had a weak urinary
stream?
Straining
Over the past month,
how often have you 0 1 2 3 4 5
had to push or strain
to begin urination?

5 times or more
Your score
2 times
3 times
4 times
1 time
None

Nocturia
Over the past month, many
times did you most typically
get up to urinate from the time
you went to bed until the time
0 1 2 3 4 5
you got up in the morning?

Total IPSS score

Total score: 0-7 Mildly symptomatic; 8-19 moderately

symptomatic; 20-35 severely symptomatic.

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 Lower Urinary Tract Symptoms / CSSL National Guidelines

Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC,

Holtgrewe HL, Mebust WK, Cockett AT. The American
Urological Association symptom index for benign
prostatic hyperplasia. The Measurement Committee of
the American Urological Association. J Urol. 1992
Nov;148(5):1549-57.

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