Symptome des unteren Harntrakts bei Männern

Was sind Symptome des unteren Harntrakts?

Lower urinary tract symptoms (LUTS) are storage, voiding and postmicturition symptoms affecting the lower urinary tract. LUTS can significantly reduce men's quality of life and may point to serious pathology of the urogenital tract.¹

Prevailing guidelines suggest that the pathogenesis of LUTS is multifactorial and can include one or several diagnoses, commonly benign prostatic obstruction, nocturnal polynocturia and detrusor muscle instability.²

LUTS are common and not necessarily a reason for suspecting prostate cancer. Patients tend to fall into three categories. Management may be conservative (if symptoms do not affect the man's life too much), medical or surgical.

• Lower urinary tract symptoms are a common problem, especially for older men. It has been reported that 30% of men over the age of 65 suffer from potentially troublesome LUTS. The prevalence of storage symptoms increases from 3% in men aged 40-44 years to about 40% in those aged 75 years or older.³

• At least half of adults aged over 65 will have one or more episodes of nocturia per night - this can be associated with sleep deprivation and a risk of falls. ⁴

• Etwa ein Drittel der Männer wird Symptome des Harntrakts (Abfluss) entwickeln, deren Hauptursache die benigne Prostatahyperplasie (BPH) ist.

• Once symptoms arise, their progress is variable and unpredictable; they may worsen over time or improve spontaneously.

Risikofaktoren für Symptome des unteren Harntrakts ³⁵⁶⁷⁸

Risk factors associated with lower urinary tract symptoms include:

• Erhöhte Serum-Dihydrotestosteronspiegel.

• Fettleibigkeit.

• The metabolic syndrome and diabetes.

• Rauchen.

Non-steroidal anti-inflammatory drugs (NSAIDs) appear to improve symptoms of LUTS. There is some evidence for an association between a healthy diet and physical exercise with reduced levels of LUTS. Moderate alcohol intake appears to be associated with a lower risk of LUTS than being teetotal, but significant alcohol intake is a risk factor for LUTS.

Siehe auch das separate Genitourinäre Anamnese und Untersuchung (männlich) und International prostate symptom score (I-PSS) articles.

• Filling symptoms: urinary frequency, urgency, dysuria, nocturia.

• Voiding symptoms (previously 'obstructive'): poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence (occurs in chronic retention).

• Also enquire about: haematuria, fever, loin and pelvic pain, past history of renal calculi, past history of urinary tract infections (UTIs), sexual/erectile difficulties, constipation, medications and bone pain.

• Signs: palpable bladder, rectal examination (prostate: size, tenderness, nodules), check for loin pain and/or renal masses, perineal sensation.

• LUTS include frequency, urgency, hesitancy, dysuria, haematuria, reduced flow, dribbling, nocturia, incontinence and pelvic pain.

• Some patients develop acute retention.

• Others develop chronic retention with overflow incontinence and, on rare occasions, acute kidney injury.

Tumours localised to the prostate are unlikely to cause bladder outflow obstruction and any LUTS developing in early prostate cancer are usually due to coincidental BPH.⁹

• General medical history to identify possible causes and comorbidities, including a review of all current medication (including herbal and over-the-counter medication).

• Examination of the abdomen, including external genitalia and a digital rectal examination.

• Examination should include blood pressure, signs of uraemia, enlargement of the bladder, kidneys and the prostate gland and palpable nodes.

• Urine dipstick test to detect blood, glucose, protein, leukocytes and nitrites.

• Men with bothersome lower urinary tract symptoms should complete a urinary frequency volume chart and a validated symptom chart - eg, the International Prostate Symptom Score (I-PSS).

• Renal function tests (serum creatinine test, estimated glomerular filtration rate) should only be performed if renal impairment is suspected.

Referral for specialist assessment¹¹⁰

Refer men for specialist assessment if they have:

• Bothersome lower urinary tract symptoms that have not responded to conservative management or drug treatment.

• LUTS, die durch wiederkehrende oder persistente Harnwegsinfektionen kompliziert werden.

• Harnverhalt.

• Renal impairment thought to be due to lower urinary tract dysfunction.

• Suspected urological cancer.

• Stressinkontinenz.

Other indications for referral include immediate referral for acute retention of urine and acute kidney injury and referral on the suspected cancer pathway if the PSA is above the NICE age-specific threshold or the prostate feels malignant on digital rectal examination.¹⁰

Specialist assessment¹

• Flow-rate and post-void residual volume measurement.

• Diagramm zur Häufigkeit und Menge des Urinierens.

• Cystoscopy and/or ultrasound imaging of the upper urinary tract only when clinically indicated - eg, history of: recurrent infection, sterile pyuria, haematuria, profound symptoms, pain or chronic retention.

• Multichannel cystometry if men are considering surgery.

• Bieten Sie Pad-Tests nur an, wenn der Grad der Harninkontinenz gemessen werden muss.

• Consider prostate specific antigen (PSA) testing if:

  • LUTS deuten auf eine Blasenauslassobstruktion infolge einer Prostatavergrößerung hin.

  • The prostate feels abnormal on rectal examination.

  • The patient is concerned about prostate cancer.

• BPH with obstruction.

• Detrusor muscle weakness and/or instability.

• Harnwegsinfektion.

• Chronische Prostatitis.

• Urinary tract stones.

• Bösartigkeit: Prostatakrebs oder Blasenkrebs.

• Neurological disease - eg, Multiple Sklerose, spinal cord injury, Cauda-equina-Syndrom.

• Polyurie (eg, secondary to diabetes mellitus, excessive fluid intake, diuretics, etc).

For men whose lower urinary tract symptoms are not bothersome or complicated, it is reasonable to offer 'watchful waiting' (WW). This involves giving reassurance and information and advice on lifestyle measures such as:

• Fluid intake (moderation of fluid intake is important but excessive reduction of fluid intake can cause a worsening of symptoms and increased risk of infection).

• Reduction in the intake of fluids containing alcohol, caffeine and artificial sweeteners together with avoidance of carbonated drinks is often advised.

Other helpful measures may include:

• Distraction techniques, such as breathing exercises, squeezing the penis and perineal pressure, which may all help to take the mind off the urge to micturate.

• Optimising medication to ensure that drugs promoting urinary frequency are kept to a minimum.

The patient should be reviewed if symptoms change or become worse.

• For men with mild or moderate bothersome lower urinary tract symptoms, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management, drug treatment or surgery).

• Offer men considering treatment for LUTS an assessment of their baseline symptoms with a validated symptom score - eg, I-PSS.

• Surgical treatment is generally reserved for men who have failed or are unable to tolerate drug treatment, or for those who have developed complications.

Konservative Behandlung³

Storage symptoms

• Overactive bladder (OAB): supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products.

• Supervised pelvic floor muscle training for men with stress urinary incontinence caused by prostatectomy. Advise men to continue the exercises for at least three months before considering other options.

• Containment products: for men with storage LUTS (particularly urinary incontinence):

  • Temporary containment products (eg, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed.

  • External collecting devices (sheath appliances, pubic pressure urinals) before considering indwelling catheterisation.

Voiding symptoms

• Consider intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation if LUTS cannot be corrected by less invasive measures.

• Bladder training is less effective than surgery.

• Men with postmicturition dribble should be shown how to perform urethral milking.

Medikamentöse Behandlung ^{23 10 11}

• Offer drug treatment only to men with moderate-to-severe lower urinary tract symptoms (equivalent to an International Prostate Symptom Score of 8 or more) when conservative management options have been unsuccessful or are not appropriate. An alpha-blocker (alfuzosin, doxazosin, tamsulosin or terazosin) should be tried.

• The patient should be reviewed at 4-6 weeks, then every 6-12 months to monitor for adverse effects.

• Overactive bladder: offer an anticholinergic.

• Mirabegron, a selective beta₃ agonist, can be used second-line, for patients in whom anticholinergics are ineffective, cannot be tolerated or are contra-indicated.

• LUTS and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/mL and high risk of progression: offer a 5-alpha reductase inhibitor (5-ARI).

• Bothersome moderate-to-severe LUTS and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/mL: consider an alpha-blocker plus a 5-ARI. Treatment should be continued for at least one year.

• Storage symptoms despite treatment with an alpha-blocker alone: consider adding an anticholinergic. Caution should be exerted in patients suspected of having bladder outlet obstruction.

• Consider offering a late afternoon loop diuretic for nocturnal polyuria.

• Consider offering oral desmopressin for nocturnal polyuria if other medical causes have been excluded and the man has not benefited from other treatments. Measure serum sodium three days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.

• If LUTS do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery).

Management of retention

• Acute retention (see also the separate Akuter Harnverhalt article):

• Chronic retention (see also the separate Chronische Harnverhaltung article):

Operation¹

Surgery for voiding symptoms

• Offer surgery only if voiding symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate.

• Operation bei Entleerungsstörungen der unteren Harnwege, die vermutlich durch eine gutartige Prostatavergrößerung verursacht werden:

  • Alle: Monopolare oder bipolare transurethrale Resektion der Prostata (TURP), monopolare transurethrale Vaporisation der Prostata (TUVP) oder Holmium-Laser-Enukleation der Prostata (HoLEP).

  • Estimated prostate size smaller than 30 g: transurethral incision of the prostate (TUIP) or transurethral needle ablation (TUNA) as an alternative to TURP. Both treatments, however, have a higher recurrence rate than TURP.

  • Estimated prostate size larger than 80 g: TURP, TUVP or HoLEP, or open prostatectomy as an alternative.

Surgery for storage symptoms
If offering surgery for storage symptoms, consider offering only to men whose storage symptoms have not responded to conservative management and drug treatment.

• Detrusorüberaktivität (bieten Sie keine Myektomie zur Behandlung der Detrusorüberaktivität an):

  • Cystoplasty: the man must be willing and able to self-catheterise. Serious complications include bowel disturbance, metabolic acidosis, mucus production and/or mucus retention in the bladder, UTI and urinary retention.

  • Bladder wall injection with botulinum toxin (botulinum toxin does not currently have UK marketing authorisation for this indication). The man needs to be willing and able to self-catheterise.

  • Implanted sacral nerve stimulation.

• Stress urinary incontinence:

  • Implantation of an artificial sphincter.

• Unbehandelbare Symptome der Harnwege, wenn eine Zystoplastik oder sakrale Nervenstimulation klinisch nicht geeignet oder für den Mann nicht akzeptabel sind: Erwägen Sie das Angebot einer Harnableitung.

Long-term catheterisation and containment

• Consider offering long-term indwelling urethral catheterisation if medical management has failed and surgery is not appropriate and the man:

  • Is unable to manage intermittent self-catheterisation; or

  • Hat Hautwunden, Druckgeschwüre oder Reizungen, die durch Urin verunreinigt werden; oder

  • Is distressed by bed and clothing changes.

• Indwelling catheters for urgency incontinence may not result in continence or the relief of recurrent infections.

• Prostatic stents may be considered as an alternative to indwelling catheters.

• Permanent use of containment products should only be considered after assessment and exclusion of other methods of management.

Experimental treatments ^{1213 1}

Ethanol injections and botulinum toxin injections into the prostate have been explored as potential treatments for lower urinary tract symptoms in patients with benign prostatic obstruction, but more robust evidence is required. NICE advise botulinum toxin injections only as part of a randomised controlled trial.

• At least a third of men with lower urinary tract symptoms (LUTS) have persistent and progressive problems over a long period of time, whilst in others they resolve spontaneously.

• Observational studies suggest that few men with LUTS will progress to complications, such as acute urinary retention, renal insufficiency, or kidney stones.

• Daten aus Beobachtungsstudien, die hauptsächlich in Populationen mit Prostata-spezifischem Antigen (PSA)-Screening durchgeführt wurden, legen nahe, dass Männer mit selbstberichteten LUTS kein erhöhtes Risiko haben, an fortgeschrittenem oder potenziell tödlichem Prostatakrebs zu erkranken, verglichen mit Männern ohne LUTS.

• Men with LUTS and large prostates are at significant risk of disease progression, particularly if they have additional risk factors such as age >70 years or significantly reduced flow rate. These men will benefit from treatment with lifestyle advice and 5-alpha reductase inhibitors (5-ARIs).

• 5-ARIs reduce the risk of acute urinary retention and the likelihood of prostatectomy by 50-60% compared with placebo.

• Die Kombination von 5-ARI und Alpha-Blocker ist wirksamer bei der Verzögerung des klinischen Fortschreitens der Krankheit und bei der Verbesserung von LUTS und maximaler Harnflussrate als jedes der Medikamente allein.

• Nach sechs Monaten Behandlung mit einem 5-ARI werden die PSA-Werte um 50 % reduziert. Daher sollten die PSA-Werte bei Patienten unter Langzeittherapie verdoppelt werden, um eine angemessene Interpretation zu ermöglichen und die Früherkennung von lokalisiertem Prostatakrebs nicht zu verschleiern.