Continence (Sep 2024)
Storage-dominant lower urinary tract symptoms in the older male: Practical approach, guidelines recommendations and limitations of evidence
Abstract
Purpose:: Lower urinary tract symptoms (mLUTS) are common and bothersome in the older male with significant impact on the quality of life. There is a paucity of good evidence and guideline recommendations with regard to management decisions for men with a storage-dominant presentation. This review is based on a workshop on the subject at the International Continence Society (ICS) Annual Congress in Toronto, 2023 and follows the format of the workshop. Materials and Methods:: This review follows the structure of the workshop. Storage-dominant mLUTS is discussed is five sections: diagnosis and stratification of risk, urodynamics findings, evidence and guidelines recommendations, geriatric neuro-urological conditions in the elderly male, and recommendations for clinical practice. Results:: Careful clinical evaluation including history, examination, co-morbid conditions, co-prescriptions, use of standardized questionnaires, bladder diary, urine analysis, uroflow, postvoid residual urine, and void% can help formulate a treatment plan based on non-invasive evaluation. Behavioral therapies recommended for overactive bladder are appropriate. Drug therapy includes judicious use of alpha-adrenergic blockers, antimuscarinics, beta-3 adrenergic agonists, and other standard mLUTS medication. Men who are refractory to conservative options might often benefit from invasive urodynamics before escalation of therapy. There is a striking dearth of evidence with regard to the management of storage dominant mLUTS. Consequently, guidelines recommendations are often inadequate for individual patients encountered in clinical practice. Geriatric neuro-urological conditions are common in the elderly male and can confound diagnosis and management. Urologists have a particular responsibility to suspect neuro-urological conditions that first present with mLUTS. Conclusions:: The management of mLUTS requires detailed clinical assessment with judicious use of investigations. The underlying philosophy of management is alleviating the patient’s symptoms using the minimum number of medicines. Invasive urodynamics are useful before escalation to invasive therapies for refractory storage-dominant mLUTS. There is an urgent need to direct research to answer questions that are fundamental to the management of mLUTS.
