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Lower Urinary Tract Symptoms

What Is Prostatitis?

Author/s: 
Rebecca Voelker

Prostatitis involves infection, inflammation, or pain in the prostate gland and affects about 9% of men during their lifetime.

What Is Acute Bacterial Prostatitis?
Acute bacterial prostatitis is a urinary tract infection that involves the prostate.1 Patients with acute prostatitis typically have fever, chills, pelvic pain, sudden onset of frequent urination, and pain or burning during urination. Some patients cannot empty their bladder adequately (urinary retention).

Risk factors include medical procedures such as cystoscopy, urethral catheterization, prostate biopsy, urinary obstruction such as benign prostatic hyperplasia and strictures, anal intercourse without condom use, immunosuppression, and certain neurological disorders such as multiple sclerosis, stroke, and spinal cord injury. Digital rectal examination often reveals prostate swelling and tenderness. The diagnosis of acute bacterial prostatitis is made based on symptoms, urinalysis, and urine culture. First-line treatment is 2 to 4 weeks of antibiotics. Men with urinary retention due to a swollen prostate should have a urinary catheter placed to relieve discomfort and to drain the infected urine.

What Is Chronic Bacterial Prostatitis?
Chronic bacterial prostatitis is a persistent bacterial infection of the prostate despite antibiotic therapy. Patients typically do not have fever or chills, and between episodes of infection they may have no symptoms or have persistent pelvic pain and/or lower urinary tract symptoms.

Risk factors include age 50 years or older, prior acute bacterial prostatitis, urethral surgery or catheterization, anal intercourse without condom use, and genitourinary tuberculosis. The diagnosis is made when multiple urine culture samples grow the same bacterial strain during episodes of urinary tract infection. First-line treatment for chronic bacterial prostatitis is at least 4 weeks of oral antibiotics such as ciprofloxacin or levofloxacin.

Keywords 
Prostatitis Humans pelvic pain male Urinary Tract Urinary Retention Prostatic Hyperplasia

Testosterone Treatment in Middle-Aged and Older Men with Hypogonadism

Author/s: 
Shalender Bhasin, Peter J Snyder

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In clinical trials involving middle-aged and older men with hypogonadism, testosterone treatment led to improved sexual activity and libido, correction of anemia, and modestly improved energy, mood, and walking ability. (The following key points also refer to findings from clinical trials involving this patient population.)
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Testosterone treatment did not improve cognition in men without a previously diagnosed cognitive disorder and did not prevent progression to diabetes in men with prediabetes or improve glycemic control in those with diabetes.
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Testosterone treatment did not increase the risk of major cardiovascular events among men with preexisting cardiovascular disease.
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Testosterone treatment did not increase the risk of prostate cancer or acute urinary retention and did not worsen lower urinary tract symptoms.
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Testosterone treatment was associated with an increased risk of clinical fractures and pulmonary embolism.
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The decision to administer testosterone treatment in a man with hypogonadism should be based on the severity of the hypogonadism and an assessment of the potential benefits and risks of treatment.

Keywords 
testosterone hypogonadism Libido anemia pulmonary embolism

Lower Urinary Tract Symptoms in Men: A Review

Author/s: 
John T Wei, Casey A Dauw, Casey N Brodsky

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).

Keywords 
prostate Lower Urinary Tract Symptoms
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