Lower Urinary Tract Symptoms

You might be noticing as you get a bit older, you need to pee a bit more often throughout the day and you’re waking a few times at night to go to the bathroom… Tough to get the stream going strongly? Perhaps, the flow is interrupted or there’s a bit of dribble after you pee which you just can’t seem to stop. These are all a part of a cluster of Lower Urinary Tract Symptoms (LUTS). LUTS is a characterisation of symptoms that arise from the lower urinary tract which involve the bladder, urinary sphincters (muscles which help us control flow), the urethra (the pee tube), and in men, the prostate gland. These symptoms can be further separated into two groups; voiding and storage symptoms.

Voiding symptoms include:

• A weak stream
• Difficulty initiating urination
• Difficulty maintaining a regular flow whilst urinating
• Incomplete bladder emptying with voiding
• Needing to strain to pee
• Small amounts of leakage after urinating (Post-Micturition Dribble)

Storage symptoms include: 

• Increased frequency of urination
• Increased urgency of urination
• Nocturia (an increased need to go to the toilet at night time)

These symptoms are more common in men vs women and are more prevalent with age. In men in their 40s, it is estimated that 1 in 14 of men experience some LUTS. In men over the age of 70, this increases to 1 in 3. At best these symptoms can be very frustrating and at worst give great concerns for isolation due to embarrassment or feeling like a burden within social situations.

You might have had a digital rectal examination and you may have been told that you have an enlarged prostate and this is the cause of your LUTS. The prostate has a large impact on this, however there can often be more to the case. The cause seems to be more complex than that as shown in more recent research which acknowledges the complexity of the neurological system and its interactions with bladder activity. Quite literally, working out the cause of LUTS is tricky to put your finger on.

So what the heck is going on you might ask…

Well, as mentioned above, there’s no doubt that the prostate plays a role. Benign Prostate Hyperplasia (BPH) is a process in which the cells of the prostate gland proliferate (multiply) and grow in size and seems to be a natural part of ageing that is inescapable. This growth of the prostate isn’t cancerous and doesn’t increase your risk of prostate cancer. Although if you are noticing these symptoms, it is important that you have been or go to be screened for prostate cancer as the symptoms of prostate cancer and BPH are the same. Learn more about prostate cancer here. The cell growth in BPH can affect the shape of the urethra or the bladder neck (the outlet of the bladder). As above, this alteration to the shape is thought to change the flow of urine, make it more difficult to initiate voiding and increase the urge to pee. Evidence of success from procedures such as a Trans-Urethral Resection of the Prostate (TURP), or GreenLight Laser highlight that the prostate has a significant role to play in the aetiology (causes) of these symptoms.

Need surgery?

There are quite a few lifestyle changes you can make before needing to go down the route of having an operation. Procedures such as the TURP and Greenlight Laser mentioned above, have some side effects that can have a large impact on quality of life. Retrograde ejaculation occurs in about 65 to 75% of men who undergo these operations. This is where the semen doesn’t come out of the urethra as normal but flows backwards into the bladder instead. It isn’t harmful and you still experience the sensation of an orgasm with retrograde ejaculation. However, your fertility will likely be affected. For some this isn’t much of a concern but it’s important to weigh up your individual needs when considering your treatment options. Some men (up to about 10%  who undergo a TURP may experience erectile dysfunction (ED)  following the procedure. This is due to the proximity of the cavernous nerves (a bundle of nerves that supply the erectile tissue of the penis) to the prostate gland. Your risk of ED will depend on individual risk factors as well. Learn more about prostates and ED here.

Prostatitic smooth muscle

It is also thought that the cause of LUTS could be due to increased contractility of prostatic smooth muscle. The cells that make up the prostate gland are approximately 40% smooth muscle. This smooth muscle is responsible for pushing out stored ejaculate into the urethra. These muscles work when their receptors (alpha-1 receptors are activated), causing the muscle to contract. Alpha-blockers are medications that block these receptors, thereby relaxing this smooth muscle and have been commonly and effectively used to relieve LUTS. The efficacy of these medications reinforces that the reality of this mechanism being causal of at least some part of LUTS. It is thought that with BPH, these muscles are more activated which changes the shape of the urethra and obstructs the bladder outlet.

So what can you do about lower urinary tract symptoms? 

Other than the pharmacological and surgical approaches to managing LUTS, there are many lifestyle changes that can be made to influence LUTS. There is lots that is in your control that allows you to start making some progress towards improving these symptoms and getting back to life. 

Voiding habits:

Firstly, it is important to create healthy habits around voiding. This would include voiding at consistent times. It is important to have a regular fluid intake throughout the day and avoid large amounts of water intake in short bursts. Large amounts of water should be avoided before bed time as well. Make sure that you aren’t cutting back water intake excessively due to these symptoms. Poor habits can lead to further exacerbation of LUTS such as overactive bladder, where urges to pee become very frequent and strong.

Stimulant intake:

Drinking lots of coffee can increase LUTS. Stimulants such as caffeine with intake over 200mg per day can increase bladder muscle activity, which will signal to the brain that the bladder is full, even when it might not be, increasing the strength of urges to pee. This will lead to far greater frequency of voiding and even leaking if these urges can’t be suppressed. Alcohol and nicotine also increase the sensitivity of the bladder.

Weight control:

Weight loss can be beneficial for reducing LUTS. Obesity has been associated with increased prostate size in men. Not only is it related to prostate size, but it is also predictive of future prostate tissue growth. Prospective studies have shown that in men, obesity and weight gain during adulthood result in higher LUTS symptom development and worsening than those in a healthy weight range with BPH. This also links in with diet, where it has been observed that an energy dense diet has been associated with increases in LUTS symptoms as well.

Pelvic floor muscle training:

Pelvic floor muscle training is very effective for reducing LUTS. In fact, studies have shown that it can be as effective at reducing your symptoms as much as alpha blocker drugs (mentioned above) which some people experience some side effects with such as dizziness, low blood pressure, and ejaculatory dysfunction. Treatment groups who participated in PFMT also reported a perceived improvement in the level of control over their symptoms. PFMT involves intentional exercise of your pelvic floor muscles to improve your ability to control those muscles so you can activate them appropriately, strengthening so the muscle tissue is more capable of producing the required amount of force to control flow, and improve endurance so those muscles have the capacity to apply that force for long enough periods to last the day. Check out our FAQs on PFMT here for more info on the pelvic floor and training.

How we can help at Sycamore Health

We get that these lifestyle changes can be tough to implement, and that’s where we can help! Our physiotherapists, Dave and James are trained in all areas of men’s health, and can help provide the right guidance on how to go about making these changes to better your symptoms and stress they are placing on your life. We are trained with Real-Time Ultrasound so we can accurately get feedback on your current pelvic floor function and progress as we work with you to train your pelvic floor. We will work with you to help with finding the right balance with the lifestyle changes as above and help you work on the most impactful areas to get the best results. Learn more about our men’s health services, and give us a call or book online to get the support you need.