LUTS (R)evolution: Let's Jump on the Bandwagon

Abstract

The concept of male lower urinary tract symptoms (M-LUTS) emerged nearly 20 yr ago [1]. However, the paradigm shift in symptom terminology has yet to be completed, despite continuous efforts to promote the use of the right terms among the medical community [2]. Following the introduction of the concept of lower urinary tract symptoms (LUTS), the underlying pathophysiology was reconsidered. Bladder dysfunction (underactivity or hyperactivity of the detrusor), bladder outlet obstruction (mostly benign prostatic obstruction [BPO]), aging of the kidney, and the whole urinary tract as well as numerous nonurologic diseases have been analyzed as potential factors to explain LUTS [3–5]. Current considerations for LUTS management are thus based on symptom characteristics (voiding symptoms, storage symptoms/overactive bladder, storage symptoms/nocturia, mixed voiding and storage symptoms) and clinical evaluation assessing all the potential urologic and nonurologic conditions potentially interacting with LUTS. According to consensual algorithms, medical therapy by a1-blockers, 5a-reductase inhibitors, antimuscarinics, phosphodiesterase type 5 inhibitors (aloneor in combination), and surgical relief of BPO are the cornerstone of M-LUTS management [5]. But again, recent data reflecting current clinical practice have shown a gap between guidelines and current clinical practice, among primary care practitioners as well as urologists [6]. The field will become even more complex as new therapies (eg, b3-agonists) are approved, although their indications for M-LUTS management remain unclear [7]. In the current issue of the journal, Soler et al. deliver a breakthrough article by comprehensively reviewing the current advances in LUTS pathomechanisms, new drug targets, and innovative therapies [8].Althoughnotspecifically covering the field of nocturia and the topic of detrusor underactivity [9], the authors set the scene for future understanding and treatment of one of the most common clinical conditions in aging men, representing an annual market of billions of dollars. Although concise and accurate, their results offer an idea of the complexity of the challenge facing the urologic community to further refine our approach to M-LUTS. The first issue deals with diagnosis and initial assessment. All the pathomechanisms described by Soler et al. [8] (hormonal status, inflammation, lower urinary tract aging, neural pathways, metabolic factors) are potential critical factors for LUTS genesis and progression, but they are not completely understood in terms of respective influence, interactions, and ‘‘passenger’’ or ‘‘driver’’ status. LUTS are considered a dynamic condition, to be analyzed in the spectrum of aging. However, this increasing body of knowledge should lead urologists to rethink patient evaluation in a different way. If the accurate classification of symptoms, described earlier as the LUTS paradigm, is mandatory, it will soon become insufficient if a myriad of associated conditions are proven to influence the disease and treatment outcomes. Just as it occurred for nocturia, a comprehensive and rigorous assessment will become the key to treatment success and the body of patient-centered care (claimed by current recommendations). Thus patients consulting for LUTS should be better considered as aging men and treated in dedicated male health clinical units. Furthermore, these patients are mostly concerned with prostate cancer screening/treatment issues, sexual dysfunction, and/or late-onset hypogonadism, needing concomitant management. This global approach would also allow urologists to interact in a common integrated environment with endocrinologists, neurologists, and other specialists. These tertiary reference centers would also be an important E U RO P E AN URO L OG Y 6 4 ( 2 0 1 3 ) 6 2 2 – 6 2 3