Men’s Guide to Lower Urinary Tract Symptoms: What’s Causing Them and What Can Be Done?

Getting up at night to pee? A weaker stream? Feeling like your bladder never quite empties?

If you are a man over 40, there is a reasonable chance you have experienced one or more of these symptoms:

• Getting up several times during the night to urinate
• A weak or slowing urinary stream
• Difficulty getting started
• Having to strain or wait for the urine to start
• Urgency or rushing to the toilet
• Going to the toilet frequently
• Dribbling after urination
• Feeling that your bladder has not emptied
• Stopping and starting during urination
• Occasionally leaking urine

Collectively, these are called lower urinary tract symptoms, or LUTS.

The important thing to understand is that LUTS are symptoms, not a diagnosis.

And while an enlarged prostate is a common culprit, it isn’t the only one.

Your bladder, prostate, urethra, medications, fluid intake, sleep, diabetes, neurological conditions and even certain lifestyle factors can all contribute.

The good news? There is a surprisingly large toolbox available to treat bothersome urinary symptoms.

First things first: it isn’t always “just the prostate”

The prostate sits underneath the bladder and surrounds the urethra, the tube through which urine leaves the body.

As men get older, the prostate commonly enlarges. This is known as benign prostatic enlargement (BPE) and is part of the condition commonly referred to as benign prostatic hyperplasia (BPH).

An enlarged prostate can narrow the urinary channel and create bladder outlet obstruction (BOO).

But there is a twist.

A man can have a large prostate and relatively few symptoms. Another man can have a modestly enlarged prostate and significant symptoms.

And sometimes the prostate isn’t the main problem at all.

The bladder may become overactive, underactive or less compliant. A urethral stricture may narrow the urinary passage. Infection, stones, neurological disease, diabetes, excessive evening fluid intake and sleep disorders can also contribute.

This is why simply saying, “Your prostate is enlarged, let’s treat the prostate,” isn’t always the right answer.

So how do you investigate LUTS?

The aim of the assessment is not simply to measure the size of your prostate.

The real question is:

Why are you having these symptoms, and which treatment is most likely to help you?

Current European guidelines recommend a structured assessment that includes symptoms, examination and appropriate testing.

1. Your story matters

Your doctor will ask about:

• What symptoms you have
• How long you’ve had them
• How much they bother you
• How often you urinate
• How many times you get up at night
• Your urinary stream
• Urgency and leakage
• Previous urinary problems or operations
• Medications
• Fluid, caffeine and alcohol intake
• Medical conditions such as diabetes or neurological disease
• Sexual and ejaculatory function

You may be asked to complete a questionnaire such as the International Prostate Symptom Score (IPSS).

This is useful because your perception of the problem matters. A slightly abnormal test with minimal bother doesn’t necessarily require treatment, whereas quite modest objective abnormalities can be very troublesome for another man.

2. Examination

This generally includes an abdominal and genital examination and, where appropriate, a digital rectal examination (DRE) to assess the prostate.

Yes, it is brief.

No, it isn’t anyone’s favourite part of the consultation.

But it can provide useful information.

3. Urine testing

A urine dipstick or microscopy can look for:

• Infection
• Blood
• Glucose
• Protein
• Other abnormalities

Blood in the urine should not simply be blamed on an enlarged prostate. It may require further investigation.

4. PSA

A prostate-specific antigen (PSA) blood test may be appropriate.

PSA is not simply a “prostate enlargement test.” It can contribute to assessment of prostate cancer risk and can also provide information relevant to prostate enlargement and the risk of future progression.

Whether you should have a PSA depends on your age, risk factors, symptoms and whether the result would change management.

5. Bladder scan

An ultrasound scan can measure the amount of urine left in the bladder after you have urinated.

This is called the post-void residual (PVR).

A large residual may indicate significant obstruction, poor bladder contraction or a combination of the two.

6. Uroflowmetry

This is one of my favourite simple urological tests because it is essentially a sophisticated way of answering:

“How fast does this man actually pee?”

You urinate into a special machine that measures the flow rate.

It provides information about the strength and pattern of the urinary stream and is particularly useful when interpreted alongside the PVR and symptoms.

Guidelines recommend performing uroflowmetry before treatment when possible.

7. Ultrasound

Ultrasound can assess:

• Prostate size
• Prostate shape
• Median lobe enlargement
• Bladder abnormalities
• Residual urine
• Kidneys and upper urinary tract where indicated

Knowing the size and shape of the prostate becomes particularly important if surgery or a minimally invasive procedure is being considered.

8. Bladder diary

If your main complaint is frequency or getting up repeatedly at night, a three-day bladder diary can be extremely useful.

You record:

• When you drink
• How much you drink
• When you urinate
• How much you pass
• How many times you get up at night

This can reveal whether the problem is actually prostate obstruction, an overactive bladder, excessive nighttime urine production or something else.

9. Cystoscopy

A small camera can be passed through the urethra to look directly at the urethra, prostate and bladder.

It isn’t necessary for every man with LUTS.

It becomes particularly useful when there is concern about a urethral stricture, bladder pathology, haematuria, previous surgery, or before certain procedures where the findings could influence treatment selection.

10. Urodynamics

Sometimes the most important question is:

Is the prostate obstructing the bladder, or is the bladder itself struggling to push urine out?

Urodynamic testing can distinguish conditions such as bladder outlet obstruction, detrusor overactivity and impaired bladder contractility.

It isn’t necessary for everyone. It is generally reserved for selected men when the diagnosis is uncertain or when the result could change the treatment decision, particularly before invasive treatment in certain circumstances.

Treatment: there is no single “best” treatment

Treatment should be tailored to the man, not simply to his prostate.

The options range from doing nothing for now, through lifestyle measures and medication, all the way to minimally invasive procedures and major surgery.

The right treatment depends on:

• Your symptoms
• How much they bother you
• Prostate size and anatomy
• Flow rate
• Residual urine
• Bladder function
• Your general health
• Your priorities
• Your attitude toward medication and procedures
• Whether preservation of ejaculation is important to you

1. Watchful waiting and lifestyle changes

Not every man needs a procedure.

If symptoms are mild and aren’t significantly affecting your quality of life, monitoring may be entirely appropriate. Many men remain stable for years.

Simple measures can help:

Things worth trying

• Reduce large amounts of fluid before bed
• Moderate caffeine intake
• Reduce evening alcohol
• Avoid deliberately “holding on” for excessive periods
• Treat constipation
• Review medications that may worsen urinary symptoms
• Manage diabetes and other medical conditions
• Maintain a healthy weight
• Stay physically active

For some men, these seemingly boring interventions make a surprisingly large difference.

2. Medication

If symptoms are bothersome, medication is often the first active treatment.

Alpha-blockers

Examples include:

• Tamsulosin
• Silodosin
• Alfuzosin
• Doxazosin
• Terazosin

These medications relax smooth muscle around the prostate and bladder outlet, making it easier for urine to pass.

They often work relatively quickly.

Potential side effects include:

• Dizziness
• Low blood pressure
• Nasal congestion
• Ejaculatory changes

The different drugs have different side-effect profiles, so the choice can be individualised.

One important point: if you are taking an alpha-blocker and are planning cataract surgery, tell your ophthalmologist because of the association with intraoperative floppy iris syndrome.

5-alpha-reductase inhibitors

These include:

• Finasteride
• Dutasteride

They work differently from alpha-blockers.

Rather than simply relaxing the prostate, they reduce the hormonal stimulation responsible for prostate growth and can gradually shrink the prostate.

They are particularly useful in men with larger prostates and a higher risk of progression.

The downside?

They take considerably longer to work.

They can also reduce libido and ejaculatory volume and may affect erectile function in some men.

They also lower PSA, which needs to be taken into account when interpreting PSA results.

Combination therapy

For some men with significant symptoms and an enlarged prostate, an alpha-blocker can be combined with a 5-alpha-reductase inhibitor.

This gives relatively rapid symptom relief from the alpha-blocker while the 5-alpha-reductase inhibitor works more slowly on the underlying prostate enlargement.

Medication for an overactive bladder

Not every man with urinary urgency and frequency needs his prostate treated.

If the bladder is overactive, medications such as:

• Antimuscarinic drugs
• Beta-3 agonists such as mirabegron

may be appropriate.

These treatments target the bladder rather than the prostate.

Tadalafil

Interestingly, a medication better known for treating erectile dysfunction can also improve LUTS.

Tadalafil, a PDE5 inhibitor, can be useful in men who have both urinary symptoms and erectile dysfunction.

This is one of those pleasing examples where treating two problems with one tablet is possible.

3. Minimally invasive treatments

If medication isn’t working, causes side effects, or simply isn’t something you want to take indefinitely, there is now a growing middle ground between tablets and conventional surgery.

These treatments aim to relieve obstruction while generally reducing the surgical burden and, in some cases, preserving sexual or ejaculatory function.

UroLift / Prostatic Urethral Lift

Small implants are placed to pull prostate tissue away from the urethra and open the urinary channel.

The attraction is that there is no tissue removal and sexual and ejaculatory function are generally well preserved.

It is particularly suited to selected men with relatively small prostates and appropriate anatomy.

The trade-off is that symptom improvement may be less than with TURP, and retreatment rates are higher. Current EAU guidance recommends it for selected men with prostate volumes under about 70 mL and without a middle lobe.

Rezūm / water-vapour therapy

Steam is delivered into the prostate.

The heat destroys targeted prostate tissue, which subsequently shrinks, opening the urinary channel.

The procedure can be performed without conventional tissue resection and has the advantage of generally preserving sexual function.

The downside is that improvement is not immediate. There can be a period of urinary irritation, frequency and discomfort while the prostate settles.

Aquablation

Aquablation is a fascinating newer technology.

Instead of cutting the prostate with a conventional electrosurgical instrument or laser, a computer-guided high-pressure water jet removes precisely targeted prostate tissue.

Real-time imaging helps guide the treatment.

It can be particularly attractive to men who want effective tissue removal while placing a high priority on preservation of ejaculation.

Current EAU guidance supports Aquablation as an alternative to TURP in appropriately selected men with prostate volumes around 30–80 mL, particularly where preservation of ejaculatory function is important. Long-term data also support its use in selected larger prostates.

Aquablation is available in Australia, although access varies between centres.

Prostatic artery embolisation

This is performed by an interventional radiologist.

The blood supply to the prostate is selectively reduced, causing the prostate to shrink over time.

It avoids transurethral surgery and can be attractive to selected men who strongly prefer a minimally invasive approach.

However, outcomes are generally less predictable than established surgical procedures, and patient selection is important. Current EAU guidance emphasises collaboration between urologists and appropriately trained interventional radiologists.

4. Traditional surgery: still very much alive and kicking

Sometimes the best solution is simply to remove the obstruction.

And despite the arrival of a parade of newer technologies, conventional surgery remains extremely effective.

TURP

Transurethral resection of the prostate, or TURP, has been the benchmark against which many newer procedures are compared.

A telescope is passed through the penis into the prostate and obstructing tissue is removed from inside the prostate.

There is no abdominal incision.

TURP provides excellent, durable improvement in urinary flow and symptoms.

Potential complications include bleeding, infection, urethral stricture, bladder neck contracture, temporary or persistent urinary leakage and sexual side effects.

One of the most common long-term effects is retrograde ejaculation, where semen travels into the bladder rather than out through the penis during orgasm.

The orgasm can still occur, but fertility and the visible ejaculation of semen may be affected.

5. Laser prostate surgery

Laser technology has transformed prostate surgery.

Rather than using a conventional electrical cutting loop, lasers can vaporise, resect or enucleate prostate tissue.

HoLEP

Holmium Laser Enucleation of the Prostate, or HoLEP, is one of the most important modern surgical options.

The surgeon uses a laser to separate the obstructing prostate adenoma from the surrounding prostate capsule. The tissue is then removed from the bladder and sent for pathological examination.

Think of it as shelling the obstructing prostate out from inside its capsule.

HoLEP has several advantages:

• Excellent symptom improvement
• Excellent improvement in urinary flow
• Suitable for small and very large prostates
• Durable results
• Excellent haemostasis
• Less bleeding than some traditional approaches
• Can be performed in men taking certain blood-thinning medications in appropriately selected circumstances

Current EAU guidelines strongly recommend HoLEP as an alternative to TURP or open prostatectomy for appropriate men with moderate-to-severe LUTS due to benign prostatic obstruction.

HoLEP does, however, have a learning curve. The experience of the surgeon matters.

Thulium laser enucleation

Another laser-based option is ThuLEP, or thulium laser enucleation of the prostate.

It follows similar principles to HoLEP and can provide comparable symptom and flow improvements.

The precise technology available varies between hospitals and surgeons.

GreenLight laser / laser vaporisation

Laser vaporisation uses laser energy to vaporise obstructing prostate tissue.

It can be particularly useful in selected men with smaller or medium-sized prostates and has favourable bleeding characteristics.

Laser vaporisation has also been used extensively in men taking antiplatelet or anticoagulant medications, although individual assessment is essential.

6. Very large prostates

When the prostate becomes very large, treatment choices change.

Historically, the answer was an open simple prostatectomy, where the obstructing inner portion of the prostate is surgically removed through an abdominal approach.

It remains effective, but it is considerably more invasive.

Today, endoscopic enucleation procedures such as HoLEP can often achieve similar long-term results without an open operation.

For very large glands, the choice may therefore come down to:

HoLEP or another enucleation procedure versus robotic/open simple prostatectomy, depending on anatomy, surgeon expertise and available technology.

The EAU currently recommends open prostatectomy primarily when endoscopic enucleation is unavailable for men with very large prostates.

So which treatment is best?

There isn’t one answer.

A useful way of thinking about it is:

Situation	Possible approach
Mild symptoms, little bother	Lifestyle + observation
Moderate symptoms	Medication
Enlarged prostate with progression risk	Alpha-blocker ± 5-alpha-reductase inhibitor
Urgency/frequency from overactive bladder	Bladder-directed medication
LUTS + erectile dysfunction	Consider tadalafil
Small/medium prostate, want minimally invasive treatment	UroLift, water-vapour therapy or other selected MIST
Want tissue removal with potential preservation of ejaculation	Aquablation in suitable patients
Standard durable surgical treatment	TURP
Medium/large prostate	TURP, laser or enucleation depending on anatomy
Large prostate	HoLEP/ThuLEP or simple prostatectomy
Very large prostate	Enucleation or robotic/open simple prostatectomy

The important point is that prostate size alone should not dictate the treatment.

Anatomy, bladder function, symptoms, medical history and your personal priorities all matter.

When should you stop taking tablets and consider surgery?

There is no prize for remaining on medication forever.

If medication works well and you are happy with it, excellent.

But surgery or an intervention becomes increasingly reasonable when:

• Symptoms remain troublesome despite medication
• Medication causes unacceptable side effects
• You develop recurrent urinary retention
• You have recurrent urinary tract infections
• You develop bladder stones
• There is significant bleeding attributed to prostate enlargement
• There is significant residual urine or deterioration of bladder function
• The upper urinary tract becomes affected
• Your quality of life is being significantly affected

These are recognised indications for surgical intervention in appropriate patients.

And what about sex?

This deserves a proper conversation.

Urinary symptoms and sexual function frequently coexist, but treating the prostate can sometimes affect sexual function.

Depending on the treatment, there may be effects on:

• Ejaculation
• Erectile function
• Libido
• Orgasm
• Fertility

For some men, preservation of ejaculation is a major priority.

For others, the priority is simply being able to empty their bladder properly and sleep through the night.

Neither priority is wrong.

The important thing is to tell your urologist what matters to you before choosing a procedure.

Different procedures have different sexual side-effect profiles, and this should form part of the decision rather than being discovered afterwards.

Don’t automatically blame everything on your prostate

One of the biggest mistakes men make is assuming:

“I’m getting older, my stream is weaker, therefore my prostate is enlarged.”

Perhaps.

But perhaps not.

LUTS can arise from several different mechanisms, and the treatment that works beautifully for one man may do very little for another.

A good assessment should answer three questions:

1. What symptoms am I actually experiencing?

2. What is causing them?

3. What treatment gives me the best balance between improvement, side effects, durability and quality of life?

Once those questions are answered, the treatment options become much clearer.

When should you see a doctor urgently?

Seek prompt medical assessment if you develop:

• An inability to pass urine
• Significant blood in the urine
• Fever or chills with urinary symptoms
• Severe pain
• Recurrent urinary infections
• New kidney problems
• Significant deterioration in your urinary function

Acute urinary retention, in particular, is not something to simply wait out at home.

The bottom line

Lower urinary tract symptoms are common in men, but putting up with them is not an inevitable part of ageing.

There is an increasingly sophisticated range of treatments available, from lifestyle changes and medication through to minimally invasive therapies, TURP, laser procedures, Aquablation and advanced enucleation techniques such as HoLEP.

The trick is not finding the best treatment.

It is finding the best treatment for you.

And that starts with a proper assessment rather than simply assuming that every urinary problem is caused by “the prostate.”

If your bladder is running the night shift, your stream has become a garden hose on low pressure, or you are planning your day around finding toilets, it may be time to have it properly assessed.