Management of Lower Urinary Tract Symptoms in Men

Lower urinary tract symptoms (LUTS) like urinary frequency, urgency, hesitancy and nocturia are common issues that affect men, especially as they age. The first line of treatment is often focused on behavioral modifications and patient education. When symptoms persist, medications like alpha blockers, antimuscarinics and Desmopressin can provide relief. This article summarizes an expert discussion on managing LUTS in men.

Behavioral Modifications and Patient Education

Making changes to fluid intake habits is often the first recommendation for managing LUTS. This includes:

Regulating Total Fluid Intake

• Reducing overall fluid intake can decrease urinary frequency and urgency. The kidneys maintain fluid homeostasis, so increased intake leads to increased output.

Timing of Fluid Intake

• Avoiding excess fluid intake in the evening and nighttime can help reduce nocturia (waking at night to urinate).
• Similarly, avoiding drinking right before bedtime and after nighttime urination can help.

Monitoring Caffeine and Natural Diuretics

• Caffeine and some natural fluids have diuretic effects, meaning they increase urine production. Limiting these, especially in the evenings, may help.

Using a Voiding Diary

• Having patients track timing and volume of their fluid intake and urination episodes can help identify targets for modification.

Education About Normal Changes with Age

• Nocturia tends to increase with age due to attenuation of nighttime anti-diuretic hormone levels and vascular changes. Explaining normal age-related changes can provide realistic expectations.

Management of Nocturia

Nocturia, or urinary frequency at night, is a common concern. Contributing factors include:

• Age-related hormone changes – Anti-diuretic hormone normally surges at night to reduce urine production. This effect decreases with age.
• Peripheral edema – Fluid shifts from the extremities to the vascular system at night can increase urine production. Wearing compression stockings in the evening may help.
• Sleep apnea – Fragmented sleep impacts anti-diuretic hormone regulation. Treating sleep apnea can reduce nocturia.

Pharmacologic Options

When behavioral approaches are insufficient to manage LUTS, medications can be considered. Some options include:

Alpha Blockers

• These relax smooth muscle in the prostate to improve urine flow. Side effects like orthostatic hypotension are uncommon with newer generation medications.

Antimuscarinics

• These reduce bladder contractility and may help with urgency and frequency symptoms. Side effects like dry mouth limit their use in elderly patients.

Desmopressin

• This synthetic anti-diuretic hormone reduces nighttime urine production. Hyponatremia is a potential side effect requiring monitoring.

Alpha Blockers

Alpha blockers like tamsulosin were originally developed as antihypertensives. They were noted to improve urinary flow as a side effect. Alpha blockers relax smooth muscle tissue in the prostate and prostate urethra. This is thought to enhance the diameter of the urethral channel and improve voiding.

The prostate smooth muscle also facilitates ejaculation. Early alpha blockers impacted semen emission. Newer 3rd and 4th generation medications like silodosin and alfuzosin are more prostate-selective and have less impact on ejaculation.

Alpha blockers are considered first-line pharmacologic therapy for LUTS in men. They provide symptomatic relief and improved urinary flow with minimal side effects.

Antimuscarinics

Antimuscarinics like oxybutynin block acetylcholine receptors in the bladder smooth muscle. This reduces bladder contractility. They may be used to treat urgency, frequency and urge incontinence symptoms.

However, antimuscarinics have more bothersome side effects like dry mouth and constipation. Their use is limited in elderly patients due to risks like confusion and urinary retention. They are not considered first-line medications for LUTS.

Desmopressin

Desmopressin is a synthetic version of the anti-diuretic hormone vasopressin. It reduces urine production by increasing water reabsorption in the kidneys.

Low dose desmopressin (0.1-0.4 mg) taken at bedtime can significantly reduce nighttime urine production and nocturia. This provides a targeted approach to address a common LUTS complaint.

The main side effect is hyponatremia caused by retaining too much water. Sodium levels need to be monitored, especially in older patients. Still, short-term use of desmopressin for nocturia is considered safe and effective.

Urinary Infections Impact Quality of Life As Men Age

LUTS can significantly impact quality of life as men age. Behavioral changes and patient education should be tried first. When pharmacologic treatment is indicated, alpha blockers are usually the initial medication choice for men due to their efficacy and favorable side effect profile. Other agents like antimuscarinics and desmopressin have narrower roles for specific LUTS issues. A multi-modal approach combining behavioral changes and medications can provide optimal symptom relief.