Christine Williams, RGN, DPSN.
Clinical Nurse Specialist (Urology) at Derby City General Hospital, DerbyLower urinary tract symptoms (LUTS), which can be defined as bothersome changes in the voiding and storage of urine, are increasingly prevalent in men in middle age and beyond. The causative factor for such symptoms tends to be prostatic disease, most commonly benign prostatic hypertrophy (BPH). These men are also more likely to experience sexual dysfunction (Feldman et al, 1994).
Lower urinary tract symptoms (LUTS), which can be defined as bothersome changes in the voiding and storage of urine, are increasingly prevalent in men in middle age and beyond. The causative factor for such symptoms tends to be prostatic disease, most commonly benign prostatic hypertrophy (BPH). These men are also more likely to experience sexual dysfunction (Feldman et al, 1994).
There is now evidence that suggests that patients who are experiencing moderate to severe LUTS are likely to experience sexual dysfunction, erectile and ejaculatory difficulties and a reduction in libido (Rosen et al, 2002). Whether this is due to a shared pathology, the psychological consequences of LUTS (tiredness or worry of potential illness), or an amalgamation of the two is currently unclear. The health-care professional needs to address all aspects of symptomatology to ensure a successful treatment outcome for the patient.
Nursing involvement in the management of LUTS has changed dramatically over recent years. This ranges from opportunistic screening by the practice nurse in primary care to the specialist service offered by continence advisers and urology nurse specialists, often with little or no medical participation.
In tandem with this rising nursing profile there has been a significant change in the way LUTS are assessed and managed. The treatment of urinary symptoms follows a three-step model:
- Watchful waiting for those who are mildly symptomatic
- Medical treatment for the moderately symptomatic, or those who are deemed unsuitable for surgical intervention
- Surgery for those with severe symptoms or who are non-responders to the medical option.
It is no longer the sole objective simply to increase the patient's urinary flow; far more emphasis is focused on improving the patient's quality of life.
Both LUTS and sexual dysfunction cover a wide array of symptoms, each of which can have a significant effect on the patient's quality of life and lifestyle. Of central importance is the patient's own perception of his problem. Thus the impact of identical symptoms on an elderly retired male and a younger man in full-time employment may be very different. For example, ejaculatory dysfunction may be of little importance to an ageing couple but of some importance to a younger man with a partner who is keen to start a family.
Few patients are impressed by clinical measures of improvement as documented by a flow meter. Successful treatment is more likely to be reported as one less trip to the toilet at night, fewer soiled undergarments or the ability to resume sexual relations.
The patient-focused approach to LUTS and sexual dysfunction problems begins with the initial assessment. It is well recognised that men are reluctant to seek health-care advice (Barton, 2000), and this reticence is further compounded by the nature of the symptoms they need to discuss (Laumann et al, 1999). The taboo subjects of both bladder dysfunction and sexual difficulties, and the belief that the symptoms may just be a sign of ageing, may make effective communication between the nurse and the patient difficult.
Patients look to the professional to outline the remit of the consultation. It is important to realise that patients may be reluctant to discuss their problems, whether these are specific to them or sexual problems as a whole. They may quickly reveal that they have to go to the toilet a bit more often than previously, but be much less willing to discuss dribbling of urine or a declining sexual function.
Nurses should refrain from stereotypical concepts of sexual behaviour. A study of over 14,000 American and European men aged between 50 and 80 years showed that over 80% reported that they were sexually active, undertaking sexual activity on average 5.8 times a month (Rosen et al, 2002). Furthermore, patients who are elderly, single, ill or disabled may be sexually active and need this aspect of their lifestyle addressed. Studies have shown that, unless the patient raises the issue first, nurses tend not to initiate discussion on matters of sexuality, either because of embarrassment or ignorance (Waterhouse, 1996). The Royal College of Nursing (2000) recommends further support and education to enable nurses to fulfil this aspect of their role.
It is very important that the consultation between nurse and patient not only focuses on specific symptoms but is also broad enough to encompass the patient's own views and expectations surrounding quality-of-life issues. This requires a consultation that gives the patient time to express himself and enables him to feel relaxed. Nurses should strive to be informative, supportive and non-judgemental. There are a number of patient questionnaires that can assist in this task: the International Prostate Symptoms Score (IPSS) (Barry et al, 1992); the Danish Prostate Symptom Score (DAN-PSS) (Hald et al, 1991), which has a supplement that focuses specifically on sexual function; and the International Index of Erectile Function (IIEF) (Rosen et al, 1997).
An increasing number of patients with LUTS are now assessed at nurse-led clinics in urology departments. Very few will be questioned and investigated for sexual dysfunction during this consultation. Generally, the following investigations will take place:
- Complete medical history to eliminate causes such as diabetes or neurological diseases
- Flow rate assessment - the patient urinates into a flowmeter, which will determine the strength and degree of obstruction to the urinary flow
- Ultrasound or bladder scan - to measure the post-micturition residual volume
- Digital rectal examination - to assess the size and state of the prostate
- Administration of the IPSS questionnaire - to determine the severity of the symptoms and how bothersome they are
- Urea and electrolyte estimation - to assess renal function
- - Measurement of prostatic specific antigen (PSA), an enzyme produced by prostatic endothelial cells, to assist in the identification of potential prostate cancer.
Further investigations to assess sexual dysfunction should include:
- Discussion of sexual dysfunction
- Establishment of the hormone profile
- Thyroid function tests to identify possible hypothyroidism
- - Cholesterol check
- Completion of the IIEF questionnaire to determine the severity of symptoms and their effect on quality of life.
The problems associated with LUTS can be divided into three key areas: voiding symptoms, filling/storage symptoms and sexual dysfunction (Table 1).
These tend to be those most often reported by men with LUTS, although they also tend to be the easiest to tolerate (Djavan, 2003).
Although these are less frequent than voiding symptoms, they tend to be far more problematic. Frequency, urgency and related incontinence can cause severe social embarrassment and impose stringent restrictions on the patient's lifestyle. Long journeys may become impossible and the patient may have to restrict his social life to activities with easy access to a toilet.
This may severely affect the patient's self-esteem and marital relationship. A couple who are constantly disturbed by a man's increasing nocturia may, at the least, find a reduction of libido owing to tiredness, but, at the worst, progress to separate bedrooms. The inability to predict a penetrative outcome to sexual activity may cause some men to avoid intimate situations altogether. Studies have also shown that even in older men the amount and force of their ejaculate affects their ability to enjoy sex (Rosen et al, 2002).
Management of LUTS
The management of LUTS caused by BPH should be tailored to meet not only the severity of the symptoms but also to how bothersome the patient finds them, his general state of health and his suitability for surgery. If the symptoms are comparatively mild, many men can cope without much difficulty. In these cases a policy of watchful waiting is often the best option. The patient should be regularly reassessed with objective measurements to ensure his symptoms and quality of life are not deteriorating. For those men whose symptoms are affecting their lifestyle there are two options - medical management or surgery.
Available drug treatments for LUTS include alpha-blockers such as alfuzosin, doxazosin, indoramin and tamsulosin and 5alpha-reductase inhibitors such as finasteride. Alpha-blockers work by relaxing prostatic smooth muscle and muscles in the urethra and bladder neck. These have been shown to increase peak urine flow rate and improve symptoms in about 60% of patients with symptomatic BPH (Kirby, 2000). Generally, patients will see an improvement in symptoms within the first two to three weeks of treatment. Alpha-blockers also produce a significant increase in peak urine flow rate in the order of 1.5-3.5mL/sec.
The 5alpha-reductase inhibitor finasteride acts by inhibiting the enzyme 5alpha-reductase that converts testosterone to dihydrotestosterone, a key hormone in the control of prostate growth. This reduces prostatic volume in the order of 20% and causes the PSA to fall to about 50% of its original value (Ekman, 1999). Treatment is successful in one-third to one-half of patients (Steiner, 1993). On average, symptom scores are improved by about one-third after one year's treatment, and peak urine flow rate increases by 1.3-1.6mL/sec over 12 months (Kirby and McConnell, 2002).
Choosing the right drug depends on careful consideration of the patient's characteristics and preferences. For instance, the older, non- selective alpha-blockers, such as doxazosin can cause a drop in blood pressure, so may not be appropriate in patients on anti-hypertensive treatment. In this case, one of the newer selective alpha-blockers, for example alfuzosin or tamsulosin may be more appropriate. However, 5alpha-reductase inhibitors are often used for patients with large prostates, as they can cause prostate shrinkage. Finasteride appears to be particularly effective in these patients (Kaplan, 2001), but may require a higher degree of patient motivation as it can be up to six months before the drug has any effect (Marberger et al, 2000).
This is generally reserved only for those patients more severely affected by LUTS, and those who are either unwilling or unable to take long-term drug therapy. It is essential that patients are counselled about the potential effects of their surgery. Transurethral resection of the prostate (TURP) and laser surgery both cause retrograde ejaculation - where the semen passes back into the bladder rather than out through the urethra - in approximately 90% of cases (Hammadeh et al, 2000).
There is controversy as to whether prostatic surgery causes or improves erectile dysfunction. Laser ablation of the prostate has been thought to cause less erectile dysfunction than standard operative procedures. Brookes et al (2002) refutes this notion, finding that TURP resulted not only in greater improvement in erectile function but also reduction in pain and discomfort on ejaculation.
Management of sexual dysfunction
Ejaculatory disorders are a common cause of sexual dysfunction in men. Although they are not harmful they are often very distressing to the patient. When determining the appropriate therapy for a patient with BPH, it is important to take into account whether his urinary tract symptoms are accompanied by sexual dysfunction and whether the patient is worried about the latter. For instance, the 5alpha-reductase inhibitor finasteride has been associated with an increased incidence of erectile dysfunction, reduced libido and abnormal ejaculation (Debruyne and Jardin, 1998; Edwards and Moore, 2002), while the alpha1A-selective blocker tamsulosin has been linked to a dose-dependent increase in the incidence of ejaculatory disorders (Schulman, et al, 2001). It may be more appropriate to use a drug with negligible effect on sexual function, such as alfuzosin (Sanchez-Chapado et al, 2000).
Ejaculatory problems, such as reduced ejaculate and reduced force of ejaculate, are often resistant to treatment in men with BPH. Painful ejaculation, if caused by inflammation of the prostate, may be resolved after surgery or medical treatment. Antibiotics may also be helpful in the treatment of prostatic, urethral and seminal vesicle inflammation. Retrograde ejaculation is unlikely to be resolved following surgery. If this has been a consequence of medical therapy it should diminish on withdrawal of the medication. Intercourse on a full bladder may also be helpful, as can the introduction of drugs such as imipramine.
Where there is reduction in libido, psychosexual treatment has been shown to have a positive impact on treatment outcomes.
Sexual dysfunction problems should be reassessed throughout the BPH treatment phase.
If the patient continues to experience difficulty in achieving or maintaining an erection a number of treatment options may be applied (Box 1).
The increasing involvement of nurses in the management of LUTS has been accompanied by greater consideration of patients' perceptions regarding their condition.
It has become clear that symptoms should not be judged simply according to clinical measures, but also on how they affect the patient's lifestyle and sexual activity and these should be included in the management plan.
Nurses must equip themselves with the skills required to communicate effectively with their patients to ensure that all their needs are met. Knowledge of sexual dysfunction and an ability to discuss issues professionally and without embarrassment will ensure that patients receive the most appropriate care for their LUTS without further compromising their sexual status.
Author's contact details
Christine Williams, CNS (Urology), Urology Outpatients Department, Derby City General Hospital, Uttoxeter Road, Derby DE22 3NE. Email: firstname.lastname@example.org
Royal College of Nursing guidance on sexuality and sexual health
The RCN states that 'nurses need to recognise that sexuality and sexual health is an appropriate and legitimate area of nursing activity'. The guidance and discussion document aims to identify two key action areas for nurses to address:
- Personal and practical: identify issues in nursing practice that relate to sexuality. Assess your ability to deal with these issues and ascertain educational opportunities to develop sexuality and sexual health-care practice
- Organisational: ascertain whether your organisation has a sexuality/sexual health policy related to your area. Maximise communication skills and opportunities with patient, carers and the health-care team. Identify areas of resource/expert opinion for patient referral.
Source: RCN, 2000
ED TREATMENT OPTIONS
1. PDE5 INHIBITORS (sildenafil, tadalfil or vardenafil)
2. DOPAMINERGIC AGENTS (apomorphine)
3. PROSTAGLANDIN E1 (alprostadil)
4. MUSE (intraurethral application of alprostadil)
5. VACUUM TUMESCENCE DEVICES
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