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Continence Coach: LUTS and OAB in Men: Gender Matters
Because pregnancy and childbirth are leading risk factors for urinary incontinence (UI), the majority of studies focus on women. But healthcare providers need to be equally as conscious of problems with bladder control and other lower urinary tract symptoms (LUTS) more typical in men. LUTS include voiding problems (eg, weak or slow stream), intermittency, hesitancy, straining, retention, and incomplete emptying. Men do not encounter symptoms of leakage or stress urinary incontinence (SUI) and pelvic floor dysfunction to the extent that women do, especially at younger ages. However, men are just as likely to have overactive bladder (OAB) — ie, urinary urgency (the sudden desire to urinate without warning), with or without urge incontinence, usually accompanied by symptoms of urinary frequency and nocturia.1 When predictors of variability in UI and OAB symptoms have been studied longitudinally, researchers found that age is the strongest predictor of OAB symptoms in men.2 OAB in men carries an economic cost estimated at $1.8 billion (significant but not nearly as consequential as the comparative price tag of $7.2 billion for women3). The landmark epidemiological study on prevalence in the US established that 17% of women and men 40 years of age and older had symptoms of OAB several times a week or more; based on US Census data at the time, this percentage was translated into 33 million adults.4 When researchers further studied symptoms in both men and women, they found that urinary urgency had a greater negative effect on health-related quality of life than incontinence, frequency, or nocturia.5 OAB in the presence of other LUTS has an even stronger impact.6
Clinicians often have difficulty distinguishing between LUTS and OAB in men because of the presence of the prostate. By age 60, as many as half of all men experience symptoms of benign (no cancer or infection) prostatic hyperplasia (BPH) or enlarged prostate, while 90% will report symptoms by age 85.7 However, fearing the condition could signal cancer, men may be reluctant to speak to a physician about LUTS.
Differential Diagnoses
LUTS. LUTS is more commonly associated with an enlarged prostate, a gland that naturally increases in size as men age. The prostate gland is located just below the bladder where the bladder connects to the urethra, the body’s outlet for urine. As the gland enlarges, it can press against the urethra, blocking the flow of urine and semen. The obstruction may cause irritating symptoms or be asymptomatic for some men. Symptom severity can be evaluated through a series of questions about urination habits; a digital rectal exam to feel for enlargement through the wall of the rectum at the anus is also routinely performed. A urinalysis helps rule out infections.
Two groups of prescription drugs are used to alleviate enlarged prostate symptoms — alpha-blockers and 5-alpha reductase inhibitors. They are frequently used in combination to relax the smooth muscles around the bladder neck to improve urine flow and to inhibit the production of the hormone associated with prostate gland growth.8 In the past year, Jalyn® (GlaxoSmithKline, Philadelphia, PA), a combination treatment using dutasteride (Avodart®) and tamsulosin (Flomax®) for lower urinary tract symptoms suggestive of BPH has received US Food and Drug Administration (FDA) clearance. If drug therapy is not effective, minimally invasive options such as controlled energy to relieve obstruction are available. Transurethral microwave energy is the most widely type used to eliminate prostatic tissue. It is performed as an outpatient procedure with local anesthesia. Photo-selective laser vaporization is another option and is growing in popularity because it is successful and carries a reduced risk of bleeding. An earlier generation of laser treatment heated and coagulated tissue. Transurethral needle ablation delivers low level radio frequency energy to shrink the tissue.
Surgically removing tissue growth may help severe and persistent symptoms. The co-mingling of LUTS and OAB in men has been studied extensively — one of the many OAB drugs often is prescribed before resorting to more invasive measures for BPH to mitigate symptoms of urinary urgency and frequency. Treating OAB and/or BPH with drugs requires a lifelong commitment.
OAB. If OAB is suspected, with or without confirmation of an enlarged prostate, symptoms often can be improved using behavioral modifications. Dietary changes that eliminate caffeine, alcohol, and artificial sweeteners are a must. Fluid management with adequate water intake should be monitored and be appropriate to a person’s body mass, climate, and level of physical activity. Fluid management also will help prevent constipation, which can aggravate or initiate symptoms that mimic OAB. Pelvic muscle training is an essential tool for managing sudden contractions of the bladder. Nurses can be instrumental in coaching a patient in such matters, as well as in bladder retraining.
In addition to behavioral strategies and medications for OAB, other nonsurgical treatments include percutaneous tibial nerve stimulation (PTNS), a proven therapeutic option for persons with OAB with or without incontinence. Results of a multicenter, double-blind, randomized, sham-controlled trial9 published in 2010 provide level I evidence that PTNS therapy is safe and effective in treating OAB symptoms in men and women. When conservative treatments are ineffective, implanted sacral nerve stimulation (Interstim®, Medtronic, Inc.) is an option. Since its FDA approval in 1997, more than 75,000 implants have been performed worldwide, demonstrating success in two-thirds of all patients with urinary urgency and frequency.
Don’t leave men off your radar screen. Remain watchful for symptoms of OAB and enlarged prostate. There are many options and pathways for restoring quality of life and freedom.
The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.
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