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Medical intervention is not usually necessary for men with uncomplicated lower urinary tract symptoms if quality of life is not affected
MJA 1997; 167: 62-63
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A high prevalence of uncomplicated lower urinary tract symptoms
(LUTS) in an Australian community-based population is reported in
this issue of the Journal, although the authors,
Pinnock and Marshall, note that despite these symptoms many men and
women do not experience substantive dissatisfaction with their
quality of life.1
This study is timely, as it follows the recently launched National Health and Medical Research Council (NHMRC) evidence-based Clinical practice guidelines for the management of uncomplicated lower urinary tract symptoms in men.2 Developed by a multidisciplinary working party, the NHMRC Guidelines and two derivative documents, ". . . is it my prostate Doc?" A guide for general practitioners3 and " To pee . . . or not to pee". A guide for men about their urinary symptoms,4 emphasise the need to assess not only the presence of symptoms but also their nature and the "bother" they cause. The distinction between symptoms alone and their impact on quality of life is an important one. There is strong evidence that uncomplicated urinary symptoms in a man are very unlikely to represent any serious threat to his health. For example, the incidence of unsuspected and clinically significant upper-tract obstruction secondary to lower-tract abnormality in these men is very low (0.8%-2.5%).2 Accordingly, the outcome of interest for men (as typified by Pinnock and Marshall's study) is an improvement in their quality of life as related to urinary symptoms, not avoidance of a serious threat to life itself. Thus, measurement of quality of life becomes the key. Only men themselves can assess how bothered they are by their uncomplicated urinary tract symptoms and how much they subsequently improve.
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| How do we encourage men whose quality of life is severely compromised by their urinary symptoms to consult their medical practitioners? |
Pinnock and Marshall provide another important finding -- that the prevalence of LUTS is similar in men and women aged 55 or more. The factors responsible for LUTS remain to be fully determined -- while urine outflow obstruction in men and pelvic floor dysfunction in women are possible causes, it is probable that many of the changes are simply age related.2 Unfortunately, the use of terms such as "benign prostatic hyperplasia or hypertrophy" (BPH) and "prostatism" inadvertently imply that enlargement of the prostate is the definitive cause of the symptoms. However, the severity of urinary symptoms does not correlate with the presence of BPH or the degree of prostatic enlargement.2 Accordingly, the acronym "LUTS" is preferable to other terminology,5 as it permits a pragmatic definition of the symptom complex without necessarily implying a full understanding of its underlying pathology.2
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When is intervention warranted for uncomplicated LUTS? The
strongest predictor of the outcome of intervention for
uncomplicated LUTS in men is the degree of "bother" the symptoms
cause.6 If a man is not
particularly bothered by his symptoms, he can be reassured they are
unlikely to represent a health threat and that intervention is
unlikely to improve his outcome. If he is moderately or significantly
bothered, then medical and surgical interventions are more likely to
improve his quality of life. While it has been argued that urodynamic
parameters or residual urine volume can predict clinically
significant differences in the outcome of surgical treatment, this
assertion has not been validated in the literature.2
Pinnock and Marshall found that men with high levels of dissatisfaction with the symptoms did not necessarily complain or seek help. Conversely, a smaller, but still substantial, proportion of men who were "not dissatisfied" with their symptoms did visit their doctor because of these symptoms. These findings present a dual challenge. How do we encourage men whose quality of life is severely compromised by their urinary symptoms to consult their medical practitioners? And, because there is little need for or benefit from treatment of symptoms causing minimal bother, how do doctors reassure most men that medical care is unnecessary? We argue that the most effective means of achieving this balance will be via the dissemination and implementation of the NHMRC Guidelines for consumers and their practitioners.7 Of increasing concern to us is the insistence of detractors of the NHMRC Guidelines that early prostate cancer must be excluded as a cause of LUTS and, accordingly, that men must be fully investigated for this malignancy.8,9 Men with uncomplicated LUTS are at no greater risk of early prostate cancer than are their asymptomatic counterparts.2,10 As the evidence to date for prostate cancer screening does not yet meet rigorous public health criteria,11 we believe that the testing of men with LUTS for early prostate cancer is equally unjustified and has the potential to undermine an evidence-based approach to health care. In our view, prostate-specific antigen testing is ethical only when a man has been fully informed of the facts, uncertainties and consequences.12 The NHMRC Guidelines provide eight specific recommendations for further research to clarify those issues poorly supported by empirical evidence. Two priorities were larger randomised trials of the newer urological interventions (such as prostatic heating) against conventional surgical treatments, and methodological research to develop more robust outcome measures. The need for better research is self-evident, especially as the Guidelines are scheduled for review in two years. In the interim, it is our view that, in the absence of strong evidence supporting particular investigations or specific treatments, responsible guidelines should err on the side of conservatism; they should not support a more interventionist position in anticipation of some as yet unidentified future benefit. Men's health will not improve with an unquestioning acceptance of intervention for its own sake. We need to pursue an evidence-based approach with both confidence and compassion, finding new ways to accelerate rigorous, yet relevant, clinical research in areas of need. Concurrently, we need to share the empirical uncertainties of everyday clinical practice more widely with our patients, their partners, our fellow practitioners, and politicians. Geoffrey H L Hirst
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