Lower urinary tract symptoms

Rationale

Lower urinary tract symptoms (LUTS), which can include urinary incontinence or urinary retention with or without obstruction, are common in adults of all ages. The prevalence and severity of LUTS increase with age and are a major concern for older adults (≥ 65 years) in particular. Although LUTS does not usually cause severe illness, it is a common reason for seeking medical care. LUTS can reduce quality of life and may point to serious pathology of the urogenital tract.

Causal Conditions

(list not exhaustive)

1. Infections and inflammation (e.g., cystitis, prostatitis)
2. Structural conditions (e.g., urolithiasis, prolapse, benign prostatic hyperplasia, postpartum pelvic floor changes)
3. Medical conditions (e.g., diabetes mellitus, multiple sclerosis, spinal cord pathology)
4. Medications (e.g., anticholinergics, opioids)
5. Incontinence
   1. Transient (e.g. polyuria, impaired ability to reach toilet, medications, alcohol use)
   2. Neurologic
   3. Anatomic (e.g., stress incontinence, urgency incontinence, overflow incontinence, mixed incontinence)

Key Objectives

Given a patient with LUTS, the candidate will diagnose the cause, severity, predisposing conditions, and complications, and will construct an appropriate initial management plan.

Enabling Objectives

Given a patient with LUTS, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. the determination of which LUTS are present (e.g., storage, voiding, postmicturition symptoms), including their time course, severity, and impact on quality of life,
   2. the identification of possible causes and associated comorbidities through a proper assessment of the patient’s medical history,
   3. the use of medications, including natural health products and over-the-counter medicines,
   4. the presence or absence of systemic symptoms, and
   5. a physical examination that is guided by the patient’s urological symptoms and other medical conditions (e.g., abdominal examination, pelvic examination, digital rectal examination);
2. recognize that appropriate initial investigations vary depending on the individual presentation, and list possible critical clinical investigations and interpret the investigations, including
   1. laboratory tests (e.g., renal function, urinalysis, culture), and
   2. imaging (e.g., ultrasonography, computed tomography);
3. construct an effective initial management plan, including
   1. immediate management if indicated (e.g., bladder catheterization),
   2. determination of whether urgent and/or specialized care is required,
   3. conservative management if appropriate (e.g., referral for incontinence program),
   4. use of screening measures (e.g., prostate-specific antigen [PSA]),
   5. appropriate pharmacotherapy (e.g., antibiotics, anticholinergics),
   6. assessment of the psychosocial impact (e.g., urinary incontinence), and
   7. referral for appropriate counselling if needed.