Self-management in lower urinary tract symptoms: the next major therapeutic revolution
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- Yap, T.L., Brown, C.T. & Emberton, M. World J Urol (2006) 24: 371. doi:10.1007/s00345-006-0090-2
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The standard treatments for men with lower urinary tract symptoms (LUTS) range from watchful waiting to medical and finally surgical intervention. However, the role of self-management interventions such as education and reassurance, lifestyle modification and behavioural changes has not been formally investigated, although they are widely advocated and utilised for LUTS. Self-management interventions are well established in other chronic diseases such as diabetes, arthritis and asthma. These interventions, if successfully organised within a structured program for LUTS, could improve patient outcomes as well as reduce the economic burden of LUTS treatment, by replacing or augmenting other treatments. Recent studies showing that long-term urodynamic and symptomatic deterioration of LUTS is minimal suggest that this is a safe and valid treatment option. This is supported by a recent pilot study of a LUTS self-management program which showed significant improvements in I-PSS and frequency–volume parameters. The results of a recently completed randomised controlled trial are awaited.
KeywordsSelf-managementLower urinary tract symptomsBenign prostatic hyperplasiaWatchful waiting
At least one third of men with lower urinary tract symptoms (LUTS) are managed conservatively in secondary care in the United Kingdom alone . This form of management—the ‘watchful-waiting’ approach—has not been clearly defined, but varies from an annual review of symptoms, coupled with investigations such as the I-PSS and flow rate; to a more intensive programme of education, advice and lifestyle changes delivered in a multidisciplinary setting. The aim of this is to allow patients some control over their symptoms by making changes in lifestyle and behaviour. This is the basis of self-management, and these changes implemented by the patients are self-management interventions.
The potential importance of these non-invasive, low-cost interventions is immediately apparent. With more than half of men over 50 years of age having LUTS in the UK, the scale and cost of its treatment impacts on healthcare at all levels. In 2004 alone, Tamsulosin and Alfuzosin accounted for over £50 million pounds in prescription costs to the NHS in England . Furthermore, the sometimes costlier side effects that follow medical and surgical treatment are avoided.
New reports suggest that most patients with untreated bladder outlet obstruction and LUTS do not significantly deteriorate urodynamically, with only a minority deteriorating symptomatically, at more than 10 years follow-up . Previous research on patients with bladder outlet obstruction also support this finding, reporting no significant progression in the majority of men . All these data support the safety of watchful waiting and self-management interventions in men who do not want or require interventional or medical treatment.
However, the content and structure of a self-management programme has never been formalised in LUTS, despite their wide usage in other chronic diseases. Here, we describe the principles of a self-management programme and apply it to the context of LUTS and benign prostatic hyperplasia (BPH) treatment. We also describe a model of a LUTS self-management programme, how it was devised and what current evidence there is of its effectiveness.
What is self-management?
Self-management refers to the involvement of patients in the day-to-day management of their own care, utilising problem-solving strategies and transfer of skill to allow control of their symptoms. Characterised in chronic illnesses such as type 2 diabetes that require extensive patient responsibility in their management, self-management entails more than just following therapeutic guidelines. Instead, it also encompasses the social and psychological management of the chronic disease. For instance, in addition to hypoglycaemic therapy for diabetes, self-management interventions such as weight control, exercise, dietary restriction and blood glucose monitoring are advocated.
The basis of self-management is the theory of self-efficacy, which describes dealing with chronic disease such as diabetes as not just a case of knowing what to do, but also the patient’s belief in their own ability to use the skills and knowledge learnt realistically to produce a desired outcome. Thus, self-management interventions aim to increase patient involvement and control in their therapy and its impact on their lives by directly targeting aspects of the patient’s management of chronic disease. These self-management interventions have been shown to be effective in other chronic diseases such as arthritis , asthma , as well as diabetes , in reducing symptoms, drug use and health seeking behaviour .
Would LUTS be amenable to self-management?
Lower urinary tract symptoms is chronic disease that involves coping with both physical and social aspects. This partly entails dealing with health professionals who provide instruction and advice on managing symptoms. Currently, men with LUTS suggestive of benign prostatic obstruction (BPH) have a number of therapeutic options including medical and surgical management. Treatment choice depends on symptom severity, as well as risks and side effects of treatment.
In men with minimal symptoms or with moderate/severe symptoms but little impairment in quality of life, watchful waiting incorporating education, reassurance, periodic monitoring and lifestyle changes, is recommended by the European Urological Association  as well as the UK National Institute for Clinical Excellence. This option is possible as the risk of progression of benign prostatic obstruction is small, as discussed above .
Lifestyle changes, education and reassurance are self-management interventions, as are behavioural interventions like double voiding and pelvic floor exercises. However, the principles of self-management programmes importantly differ from watchful waiting by adopting a problem-solving and goal-setting approach. This difference emphasises the roots of self-management interventions in social cognitive theory. In this psychological model, an individual’s behaviour is thought to be influenced by expectations, especially the confidence in their ability to perform a particular behaviour or lifestyle modification. This idea has been used in self-management interventions through skill teaching to increase self-efficacy, rather than the traditional didactic form of simple information provision which is insufficient for behavioural change .
A majority (82%) of urologists, urology nurses and continence advisers in the UK reported using self-management interventions in selected patients, but in an informal and non-systematic manner. These interventions have little scientific evidence supporting their use. The most widespread interventions reportedly used—reassurance about prostate cancer, educating about the prostate and bladder, caffeine avoidance and milking of the urethra—have been advocated despite this lack of effectiveness data, reflecting their potential benefits .
Although self-management programmes in LUTS have never been formally assessed, their elements have been included in watchful-waiting policies such as the ones above, as well as in protocols for randomised trials comparing watchful waiting with transurethral resection of the prostate. In the Veterans Affairs Cooperative study, all participants were advised to avoid coffee, evening fluids and were informed of medications that may worsen their symptoms . In another study, patients randomised to conservative management of BPH were advised on bladder retraining and fluid restriction . Thus, there has been indirect acknowledgement of the usefulness of these interventions.
What would a LUTS self-management programme look like?
To produce a LUTS self-management programme, both its content, patient selection and structure have to be rigorously defined.
There are three major categories of LUTS self-management interventions. These are (1) Education and Reassurance, (2) Lifestyle Modification and (3) Behavioural interventions directed towards specific symptoms . The specific content within each component should be defined by a consensus panel of experts in the field, including urologists, nurses and general practitioners.
A multidisciplinary panel such as this has recently defined these components through a consensus panel approach using the Research and Development Appropriateness Method–RAM (UCLA) . Using this method, 94 items were assessed for their appropriateness to be incorporated into the self-management programme. The item list was developed using semi-structured interviews with health care professionals and a national UK practice survey. A formal two-round consensus process then took place. The first round was conducted by post, with a formal panel meeting in the second round to discuss the initial ratings of the items, chaired by an independent moderator. A second and final vote was then made. From this approach, a list of self-management interventions was selected as suitable for a LUTS self-management programme. These interventions are summarised in Table 1.
Education and reassurance
Discuss the causes of LUTS, including normal prostate and bladder function
Discuss the natural history of BPH and LUTS, including the expected future symptoms
Reassure that no evidence of a detectable prostate cancer has been found
Advise a daily fluid intake of 1,500–2,000 ml (minor adjustments made for climate and activity), avoid inadequate or excessive intake on the basis of a frequency/volume chart
Advise fluid restriction when symptoms are most inconvenient, e.g. long journeys or when out in public
Advise evening fluid restriction for nocturia (no fluid for 2 h prior to retiring)
Caffeine and alcohol
Avoid caffeine by substituting with alternatives, e.g. de-caffeinated or non-caffeinated drinks
Avoid alcohol in the evening if nocturia is bothersome
Substitute large volume alcoholic drinks, e.g. pint of beer with small volume alcoholic drinks, e.g. a short
Adjust the time medication with an effect on the urinary system is taken to improve LUTS at times of greatest inconvenience, e.g. long journeys and when out in public
Substitute anti-hypertensive diuretics to suitable alternatives with less urinary effects (via the patient’s GP)
Types of toileting and bladder retraining
Advise men to double-void (especially for men with a sensation of incomplete emptying)
Advise urethral milking for men with post-micturition dribble
Education and reassurance
The provision of information aids for men with LUTS/BPH about their condition reduces anxiety and decisional conflict, and increases patient’s participation in decision-making [1, 22]. A large part of this anxiety involves misconceptions of their LUTS, often linked with concerns about prostate cancer. Reassuring these men, and educating them on their true risk of prostate cancer may help reduce the severity of their LUTS . Indeed, this may be the main reason why some men seek medical help for their LUTS.
Fluid management is an important lifestyle change, but adequate information on intake and voiding habits have to be collected, usually and most easily by means of frequency–volume charts. This objective measure of symptoms allows us to analyse fluid intake and the corresponding voiding patterns, as well as types of liquids drunk, volumes voided, frequency of voiding and nocturia or urgent episodes. Those with excessive fluid intake, or excessive alcohol or caffeine consumption, can be advised and monitored for improvement accordingly. Important aspects of fluid management include advice on overall fluid intake (1,500–2,000 ml/day, modified for climate and activity level); reducing fluid intake at times when urinary frequency is inconvenient and avoiding fluid intake 2 h prior to retiring if nocturia is a problem. The myth of drinking eight glasses of water a day for health benefit only propagates excessive fluid intake. There is no evidence supporting claims that drinking more water than needed is better for health . Fluid reduction has been shown to reduce incontinent episodes in the elderly and cognitively impaired , as well as in women with nocturnal polyuria . However, its effect on LUTS is as yet unclear.
Caffeine has both diuretic and bladder irritant effects. It is commonly encountered in tea, coffee, chocolate, energy drinks and even over-the-counter remedies. It has been shown to increase early detrusor contractions during bladder filling in patients with overactive bladders . Epidemiological studies have also shown that high caffeine consumers have more LUTS  and are more likely to have been diagnosed with BPH or have BPH-related surgery , although this relationship was not seen in some other studies . In one randomised study, caffeine reduction significantly reduced the symptoms of frequency and urgency in women . Although there are no studies to date reporting the effects of caffeine on men with LUTS, there is a suggestion from the above findings that avoiding or moderating caffeine intake (by substituting with decaffeinated or non-caffeinated options) may improve LUTS.
Alcohol, besides also being a diuretic and bladder irritant, has been associated with urgency and higher I-PSS scores in community epidemiological studies . The large fluid intake frequently associated with high alcohol consumption will also exacerbate LUTS. Thus, advice to cut down on alcohol intake, especially with small volume instead of large volume drinks, may help with LUTS.
Medicines which affect the urinary system may cause and worsen LUTS. Commonly encountered are diuretics which cause diuresis, as well as tricyclics, anti-histamines and anti-spasmodics which can reduce bladder emptying, as can anti-parkinsonian drugs and calcium-channel blockers. Medication changes such as replacing a diuretic with a beta-blocker and ACE-inhibitor in hypertension may help improve LUTS. Where an alternative is unavailable, the timing of drugs can be altered. For instance, taking Frusemide (in patients with heart failure) early in the evening rather than in the morning may reduce daytime frequency and nocturia. This is due to the off-loading of peripheral fluid that accumulates during the day .
A significant proportion of men with LUTS have irritative symptoms. As anti-cholinergics are used for symptom reduction in some of these men, it is reasonable to suggest that interventions such as bladder retraining may have a role. This involves resisting the sensation of urgency with distraction techniques and pelvic floor squeezes to delay voiding and thereby overcoming abnormal voiding patterns. Voiding is initially postponed for only a short time (1 min), progressing according to patient ease to longer intervals with the aim of increasing bladder capacity to 300–400 ml and inter-void intervals of 3–4 h. This requires regular consultation with a healthcare professional such as the nurse practitioner, who can review progress with frequency–volume charts. These techniques have been shown to improve urgency, frequency and nocturia  as the chief treatment strategy, as well as augment medical therapy in patients with overactive bladders .
Besides bladder retraining, other behavioural interventions can also be attempted. Men with LUTS often experience the sensation of incomplete bladder emptying, with some leaving a post-micturition volume of urine that results in premature bladder filling and frequency. Double voiding may help reduce this volume. In this process the first void is performed normally, with the second planned void attempted within 2–5 min. Milking of the urethra, through perineal pressure, contraction of the pelvic floor muscles and leaning forward can expel urine left in the urethra after voiding. This has been shown to help the troublesome and often underreported symptom of post-micturition dribble [10, 24].
Self-management interventions can be used by almost all patients to help with LUTS. This can be advised at consultation with a nurse practitioner or a clinician. However, patients enrolling for a LUTS self-management programme should not have severe symptoms necessitating immediate medical or surgical treatment, and should not have complications potentially related to their symptoms (PSA over 4 ng/ml, residual volumes over 200 ml, creatinine above 130 μmol/l, bladder stones, haematuria, urinary retention, recurrent urinary tract infections). Other exclusion criteria should include uncontrolled diabetes, dementia and end-stage cardiac or respiratory failure. As the programme will involve communication and active patient participation, these factors, and the fact that they are willing to try a self-management programme, will be important in the outcome. These programmes should be useful not only for men suitable for watchful waiting, but more generally those with uncomplicated LUTS.
Specialist nurse-run patient programmes have been shown in other areas to be the best method of intervention delivery . Thus, the self-management programme would involve nurse-led small groups of around five men. Three sessions would be organised, initially to target their most bothersome symptoms and apply possible interventions (as agreed by the consensus panel), through goal setting and problem solving, and subsequently reviewing and reinforcing beneficial interventions. The sessions would start soon the initial consultation for LUTS, after the relevant tests to ensure the suitability of the patient for self-management.
Self-management programme structure
Session 1 (e.g. week 1)
Introduction to programme and concept of self-management
Education/reassurance—prostate and bladder, cancer risk, future progression of symptoms
Managing fluid intake, caffeine abstinence, alcohol advice
Session 2 (e.g. week 2)
Adjusting medications with effect on LUTS, e.g. diuretics
Strategies for dribbling (urethral milking)
Double-voiding, bladder retraining
Session 3 (e.g. week 6)
Review of problems
Review of previous goals and new behaviours
What is the evidence that it works?
There has been a paucity of high-quality research about self-management in men with LUTS, especially in comparison to other chronic diseases. A small qualitative survey of men with LUTS revealed that some ‘self-manage’ their symptoms already to some effect, with the interventions used based on anecdotes from relatives and acquaintances, rather than from health professionals. Most men surveyed felt that they would join a self-management group or trial, and the fear of prostate cancer was a dominant theme in those surveyed . This issue is specifically addressed as a self-management intervention.
A recent pilot study of self-management interventions for men with uncomplicated LUTS has shown dramatic improvements in symptom reduction. In this study, 25 newly diagnosed men attended a nurse-led self-management programme. Symptom severity was assessed at baseline and at 8 weeks post enrolment. The self-management programme content included two initial sessions (described above). These sessions were held at 1 and 2 weeks post first enrolment. A third booster session was held at 6 weeks, incorporating problem review, feedback and review of previous goals and new behaviours. Results showed significant decreases in I-PSS score (mean reduction 9.7, P < 0.001 at 95% confidence interval) and AUA QoL score (mean reduction 1.6, P < 0.001 at 95% confidence interval). Episodes of nocturia, urgency and frequency both decreased significantly (P < 0.001) and mean voided volume increased from a mean of 61 ml (P = 0.005).
An acceptability and feasibility review done at the pilot study showed that sessions were rated very or extremely acceptable by all patients. Eighty-eight percentage of men were confident that their lifestyle and behaviour changes would continue to be adopted at their 4-month review.
This pilot study has led to a randomised controlled trial (RCT) of self-management interventions for men with uncomplicated LUTS. This RCT was completed this month, and results of this trial will be published shortly.
The future of LUTS/BPH management
Currently there is increasing evidence that neither BPH not LUTS inevitably deteriorate to the stage at which surgical intervention is required. Conservative treatment options such as a self-management programme can be both safe and economical, especially in the context of our ageing population.
The positive results of the pilot study hint at what could be a revolution in LUTS management. If these changes in patient symptoms are maintained at longer follow-up intervals, the use of self-management interventions in a formal program maybe a viable alternative to watchful waiting and pharmacotherapy in treating uncomplicated LUTS. Also, these programs may help augment existing therapy, seen in other chronic diseases like obesity . However, until clinical results of the RCT are published, these mainstays of treatment are unlikely to change.
Mr P.D. was a 51-year old accountant who was referred by his general practitioner (GP), having suffered from worsening LUTS for 3 years. Pharmacotherapy with two different alpha-blockers and finasteride, and then dual therapy did not seem to improve his symptoms significantly, and there seemed no change in his symptoms when he stopped all the medical therapy. However, his GP noted that his prostate was only mildly enlarged, and his flow rate at first clinic presentation was around 15 ml/s. His baseline PSA was 0.9 ng/ml and other than mild hypertension (not treated with tablets), he did not have any co-morbid conditions. His urinalysis did not reveal anything, and he had a negligible amount of urine on post-void bladder scanning. However, his I-PSS score at presentation was 21 and his AUA quality of life score was 6 (‘terrible’). In all respects, he was a patient with uncomplicated LUTS.
At the initial consultation, what became clear on questioning was that his two main complaints were incomplete emptying and nocturia. Mr P.D. noted that his symptoms were better when he travelled to South East Asia, and was worse in winter. He also said his symptoms were worse when he was at home, rather than at work. When asked about his drinking habits, he reported that he had never noticed the last drink he took, or how much he drank, but said that he drank enough water ‘for fitness’. Also, he denied drinking caffeinated drinks and alcohol. He agreed to fill up a frequency–volume chart to analyse his fluid intake and voiding patterns. He was told to return in a week to see a urology nurse practitioner with his chart. Before leaving, he raised some concerns about the link between prostate cancer and LUTS. He was reassured and was given a patient information booklet about LUTS and BPH.
On his return, he presented a filled 3 day frequency-volume chart. It was noted that his last drink was less than an hour before bed-time, a 300-ml cup of green tea. His average total intake volume was 2.6 litres of fluid/day, with more than half of the volume consumed after 6 pm. This was partly due to his fluid consumption whilst at the gym which he goes to in the late evening. He also had late dinners and was noted to consume a lot of green tea. His average voided volume was around1.9 litres/day; with voided volumes of between 100 and 150 ml. He voided 4–5 times during the night, and 8 times during the day. The average nocturnal volume voided was about 500 ml.
Mr P.D was keen on trying lifestyle and behavioural modifications. With the nurse practitioner, he reiterated the areas that he felt were problematic – incomplete emptying and nocturia. Fluid management advice was then put forward for discussion. Chiefly, the large volume of fluid intake in the evening and the large amount of caffeine-containing tea (even green tea) consumed were addressed. Mr P.D was surprised by the caffeine content in green tea (a 6 oz cup can contain 30 mg caffeine), as he had previously been told it was ‘different’ from other teas. Goals were set by Mr P.D. to reduce the amount of fluid consumed in the evening. This also entailed significant lifestyle changes like having an earlier dinner and gym session. Also, he agreed to give up his green tea ‘nightcap’, and have his last drink about 2 hours before sleep.
Finally, he was taught two behavioural techniques: double voiding to try to help with the feeling of incomplete emptying of his bladder and distraction techniques coupled with pelvic floor squeezing to delay micturition and allow a larger voided volume (and hopefully decrease urinary frequency as a consequence).All these goals were written down by Mr P.D. He was given another frequency-volume chart, and was told to fill it up a few days before his follow-up appointment in 3 months time. If his symptoms deteriorated in the meantime, he was told that he could call the nurse practitioner who would see him or refer him to a clinician.
At 3 months follow-up, Mr P.D. scored an improved I-PSS of 16, with drops in nocturia (to 2 episodes) and frequency, as well as the sensation of incomplete emptying. Frequency volume chart analysis showed an increased voided volume of around 200 ml. His intake volume decreased to 2.3 litres, and he had started on decaffeinated green tea. The evening intake of fluid also declined due to his earlier dinner and gym sessions.
His AUA QOL rating improved to 3. He reported that the decrease in nocturia allowed him to sleep much better, and by adjusting his lifestyle, he had felt in control of aspects of his symptoms. He was unsure about the benefit of double voiding, attributing instead his improvements in incomplete emptying to drinking less frequently and caffeine avoidance. He also reported that distraction techniques and pelvic floor squeezes, whilst initially causing a few ‘accidents’, had helped with delaying micturition. He said he would try to maintain these changes for the next 6 months, before his next follow-up. He also asked of there were ‘refresher’ sessions to learn new techniques and discuss any questions and updates on the latest developments in LUTS. He hoped that further improvements to his frequency and nocturia would occur if he persisted. Surprisingly, he felt that the most important aspect of all was the reassurance at the start that his LUTS was not related to prostate cancer.
Mr P.D was an ideal candidate for a self-management programme. The management of his uncomplicated LUTS utilised all the self-management intervention components: Education and Reassurance, Lifestyle Modification and Behavioural interventions directed towards specific symptoms. What was missing was a formal programme with structured sessions, where he could discuss his problems as well as participate with other men with LUTS in goal-setting and problem-solving. Although it was not the panacea for all his problems, it did help provide simple, cost-effective solutions for his LUTS had not responded to medical therapy.
The reasons for his lack of initial response to medical therapy could be related to his prostate size (which was only mildly enlarged) as well as a complex interplay of other factors including his fluid intake patterns and anxiety about his LUTS. Certainly, self-management interventions may help augment medical therapy in future practice. However, this case illustrates the need for strong data on the effectiveness of self-management programmes in LUTS.