Effective management of male lower urinary tract symptoms in primary care

Lower urinary tract symptoms (LUTS) constitute a substantial burden on males due to their high prevalence (up to 30% of males aged >65 years)¹ and significant impact on quality of life.² Prevalence and severity of LUTS increase with age; therefore, the burden on the NHS and primary care (where most males with LUTS are managed) is expected to grow, alongside population ageing. Yet a comparatively small proportion of affected males seek advice or treatment for their symptoms; reported as between 19% and 24% in studies conducted in Europe and the US.^3,4 There is a perception among males that LUTS is a normal sign of ageing, which may be related to a lack of knowledge of the condition and available treatments.⁵ Indeed, qualitative research reported in the current issue of the BJGP suggests that GPs find it difficult to decide on the mechanism of LUTS in males.⁶ Remarkably, the situation is also problematic after referral for urological management, where incomplete discussions and misperceptions of LUTS and its treatment have also been identified.⁷ Unfortunately, this can lead to a situation where treatment seems to be a case of ‘trial and error’.⁶

THE CURRENT PICTURE IN PRIMARY CARE

When males do present to the GP with LUTS, it is for a variety of reasons. As well as increasing symptom burden,⁸ males commonly seek help due to prostate cancer concerns; between 15% and 32% in survey data.^9,10 Further assessments to exclude prostate cancer can mean that the treatment of non-red flag, yet bothersome, LUTS is potentially side-lined. Given that males may be already reluctant to seek help, this may result in missed opportunities for LUTS treatment.

The National Institute for Health and Care Excellence (NICE) recommend detailed symptom assessments for LUTS, including a bladder diary at initial presentation to aid diagnosis. A validated symptom score before initiation of treatment is also recommended for measurement of subsequent symptom change. However, in a 2016 Royal College of Physicians (RCP) audit of continence care in primary care, <50% of patients had completed a bladder diary and <30% a validated symptom score.¹¹

Under NICE recommendations, uncomplicated LUTS in males should initially be managed with conservative measures,¹ specifically providing information and reassurance, and advice on lifestyle interventions (such as changes to fluid intake). To be effective, conservative care needs to be tailored. For example, storage symptoms (such as urinary urgency, increased daytime frequency, and nocturia) require careful fluid advice, notably caffeine reduction, sensible total daily volume, and the timing of fluid intake. Post-micturition dribbling benefits from education on how to compress and release any drips that have been trapped in the urethral bulb.

Differences in individual symptoms and potential causative factors mean that proper explanation of conservative measures is more time-consuming and complex than it may at first appear, requiring the GP (or primary healthcare professional [HCP]) to have the time and knowledge required. In practice, GPs describe treatment as a process of trial and error, and patients report lack of treatment and unresolved symptoms.⁶ Hence, the proportion of males receiving the recommended standard of care is low in primary care. The RCP audit demonstrated that <65% of males had used lifestyle modification, <50% behavioural modification, and <35% bladder training (worse in males aged >65 years).¹¹ Furthermore, unless patients receive ongoing support and reinforcement of education, including what to expect, conservative therapy in primary care may potentially fail. Hence, improving treatment with simple measures for LUTS in primary care needs to be emphasised to ensure the presenting complaint is dealt with and to reduce potentially avoidable referrals to secondary care. In a NICE Quality and Productivity Proven Case Study, the potential cost savings made by reducing unnecessary referrals to secondary care for male LUTS were 21 652 GBP per 100 000 population.¹²

HOW CAN THE PRIMARY CARE PATHWAY BE IMPROVED?

Given that the average GP consultation is 12 minutes and contains 2.5 problems,¹³ the lack of time and resource to support the conservative approach means that there is a clear need for an evidence-based intervention to support the current NICE guidelines. The TRIUMPH randomised controlled trial¹⁴ aims to address this need within primary care. A booklet providing detailed conservative care advice for LUTS in males has been developed with extensive patient and public input. The booklet has been designed for ease of use, for example, with sections clearly linking symptoms and advice, and practical construction, including printing on water-resistant paper for use in a damp bathroom environment.

In TRIUMPH, basic symptom evaluations are used to direct the patient to the most appropriate components of the standardised booklet, allowing provision by nursing or healthcare assistant staff to reduce GP burden. Discussions draw on the Theory of Planned Behaviour¹⁵ to strengthen males’ intention to use the booklet, considering males’ attitudes toward the information and confidence with behaviour changes. Males can read and reflect on the material in their own time at their own pace. They also have follow-up support from the HCP at intervals, by their preferred method of contact, to optimise the intervention compared to a purely self-help approach. The study will primarily establish whether this approach improves symptomatic outcomes compared to usual care, and whether the result is sustained over a longer duration beyond the last follow-up contact with the HCP. Results are expected in 2021.

CONCLUSION

The article by Milosevic et al in the current edition⁶ highlights that GPs are particularly concerned about relative ineffectiveness of pharmacological treatments for LUTS and the possibility of side-effects. If the TRIUMPH approach is found to be effective, GP practices could deliver conservative treatment or initiate a practice nurse-led pathway for treatment, at first contact, retaining scope for potential prostate cancer assessment where indicated. This approach would avoid missed opportunity for treatment of a condition in which help-seeking is a well-recognised barrier to care. It has the potential to improve patient management at the level of primary care, and reduce GP reconsultation for symptoms, prescribing, and unnecessary secondary care referrals.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.