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Let's talk about Lower Urinary Tract Symptoms (LUTS)

I previously posted “WHY DOES THE PROSTATE CAUSE URINARY SYMPTOMS” – I would now like to discuss the treatment options for men with lower urinary tract symptoms (LUTS) caused by benign prostatic hypertrophy (BPH), otherwise known as an enlarged prostate. LUTS can include urinary frequency or urgency, weak stream, trouble starting stream, nighttime urination (nocturia), or even painful urination.
I’m feeling a bit wordy so this will be in 2 parts.
First, a few REALLY important concepts:
1) LUTS are VERY RARELY a presenting symptom of prostate cancer. LUTS are generally due to BENIGN prostate growth. Generally, early prostate cancer causes no symptoms at all. So when you begin to have LUTS, do not panic. It is almost certainly not from prostate cancer—of course a man can have LUTS and prostate cancer, but they arise independently in the vast majority of cases.
2) Having a big prostate is NOT a health problem in many cases. Prostates come in all sizes, much like feet. Of course feet don’t grow every day until you die like a prostate does. So there’s that. However, BPH often causes no significant lifestyle issues. Seeing a urologist for an enlarged prostate that is causing no bothersome symptoms is a sort of like seeing a podiatrist for big feet.
3) Even men who have symptoms from BPH often do not NEED intervention. In most cases, symptoms from BPH cause LIFESTYLE issues rather than LIFE-THREATENING issues. In general, deciding how aggressive to be for BPH symptoms should be the decision of the patient, based upon the degree of bother and the patient’s thoughts about options such as lifestyle modifications, medications, supplements, or surgeries. Some men choose to simply live with their symptoms, and in many cases this is okay. Some may choose medications over lifestyle modification. Some would rather jump to surgery and avoid medications.
To some degree, you have to pick your poison. For instance, if I have a pot of coffee in front of me in the morning I may drink the whole thing. And I’m gonna pee 5 times before lunch because of it. It may be urgent. That’s what caffeine does. It’s a nuisance, but not dangerous. And I would rather have my coffee than pee less frequently. Furthermore, it’s not enough of a bother to move on to other treatments. I’m a big fan of not overtreating symptoms that are not bothersome or dangerous, because of course ALL interventions have some risk and side effects.
Along those lines, a man may say he gets up 5 times a night to pee, but goes right back to sleep and is not bothered by it. He may choose no BPH intervention, which is a perfectly reasonable choice (although I would suspect that he may have obstructive sleep apnea). Conversely, a man may say he gets up twice a night, but it is a major issue because he is tired at work and is really bothered. I would recommend a more aggressive approach for the second man despite objectively lesser symptoms.
4) WHEN IS IT ACTUALLY A LIFE-THREATENING PROBLEM TO HAVE BPH? If a man has significant difficulty emptying his bladder such that his bladder remains relatively full after urinating, urine can back up to the kidneys potentially causing renal failure. Furthermore, the stagnant urine withing the bladder is more likely to become infected. It is not uncommon for this to progress to the point where the man cannot pee at all, and ends up in the ER in terrible pain and in need of a catheter. Acute urinary retention a miserable experience, and is the only time that a man actually thanks us for putting a tube in his penis.
This is the reason that AT THE MEN’S CENTER WE DO A BLADDER SCAN (ULTRASOUND) ON EVERY NEW PATIENT TO CHECK HIS POST-VOID RESIDUAL (PVR), which is simply the amount of urine left in the bladder after voiding. Ballpark, a PVR greater than 300mL may merit some intervention and should be followed closely.

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