How can you tell if your urinary frequency problems are caused by a condition in the bladder or the prostate – and what should you do about it? In this excerpt from a recent Johns Hopkins Prostate Bulletin, Dr. Jacek Mostwin explains how to differentiate LUTS, BPH, and LOO.
Q. I am confused. I’m 52, and for the past three years I have had urinary frequency and urgency problems. I finally decided to go to a urologist. After taking my history, the doctor gave me a DRE (I had a “large” prostate, he said) and then took blood for a PSA test.
A week later, the doctor called to say that he wanted me to have a prostate biopsy. My PSA test had come back at 6 ng/ml. Long story, short: My prostate biopsy was negative. I was given Proscar and Flomax for my urinary problems and the doctor said to come back to see him in about six months.
I assume that he gave me this vague time frame because it may take that long for the drugs to work. I can accept that. However, what if the urinary problems are not caused by my prostate, but by my bladder? I don’t want to embarrass my doctor by second-guessing him, but can any urologist really ascertain whether urination complaints arise from the bladder or prostate, or is the diagnosis made by exclusion? Bronxville, NY
Dr. Mostwin: You are right to be concerned about the source of your lower tract urinary symptoms (LUTS) being either the prostate or bladder. LUTS can be caused by benign prostatic hyperplasia (BPH), bladder outlet obstruction (BOO), and other conditions. LUTS are only rarely caused by prostate cancer in early stages.
Urinary cytology and cystoscopy are often sufficient to exclude these conditions, but sometimes a transurethral (as opposed to a transrectal) biopsy may be needed. The most common situation is the man with LUTS and BPH. Formerly, all LUTS in men were attributed to prostatic enlargement, and prostatectomy was frequently the recommended treatment.
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More recently, it has become clear that both men and women suffer from a similar age-related increase in LUTS, and that LUTS may be complicated by BPH, but may not always be caused by it. LUTS, BPH and BOO may all co-exist, but may not be directly related, so that LUTS may be improved by medications affecting the bladder or the sensory nerves to the bladder, or it may be affected by reducing prostatic volume, or both.
Sound complicated? Welcome to the world of urology! If prostate cancer is excluded and there is no blood in the urine at the time of initial evaluation, it is reasonable to offer combined medical therapy for LUTS in the setting of BPH. There should be some sign of improvement within the first few weeks from the Flomax alone; the improvement from Proscar takes a good six months to kick in. If there is no improvement in the first month, it is reasonable to re-assess the situation and decide whether the patient should wait a full six months for further improvement, or if invasive testing is required.
