Lower urinary tract symptoms : a unique platform for urologists’ fundamental role in overall health

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Opinion: Open Science

Lower Urinary Tract Symptoms: A Unique Platform for Urologists ’ Fundamental Role in Overall Health

Thomas F. Monaghan

^a,

*, Karel Everaert

^b

, Jason M. Lazar

^c

, Alan J. Wein

^d

, Jeffrey P. Weiss

^a

aDepartmentofUrology,SUNYDownstateHealthSciencesUniversity,Brooklyn,NY,USA;^bUrologyDepartment,GhentUniversityHospital,Ghent,Belgium;

cDivisionofCardiovascularMedicine,DepartmentofMedicine,SUNYDownstateHealthSciencesUniversity,Brooklyn,NY,USA;^dDivisionofUrology, DepartmentofSurgery,PerelmanSchoolofMedicineattheUniversityofPennsylvania,Philadelphia,PA,USA

COVID-19haschallengedustobecomemoredynamicthan everbeforeinassumingnewresponsibilitiesinpatientcare andservingourcommunityvianewmeans.Throughallthe upheaval,aconsistentbeaconofhopecanbefoundinour community’sreinvigorated commitmenttoissuesbeyond the genitourinary tract and overall health [11]. As we continuetoadvanceinourfightagainstCOVID-19,wemust reflect on how these lessons learned may transcend the pandemicandbeleveragedtoimprovefuturepractice.

In many respects, the extent to which we have been asked to work hand-in-hand with general practitioners, hospitalists, and other specialty services actually bears resemblance to the means by which current European Association of Urology (EAU) and American Urological Association (AUA) guidelines ask us to approach lower urinarytractsymptoms(LUTS)inroutinepractice.Multiple LUTShavebeenincreasinglydescribedasclinicallyrelevant predictors,markers,andcentralfeaturesofseriousmedical conditions, such that best-practice management often requires a multidisciplinary treatment plan and medical diseaseoptimization[1,2].Theimportanceof“nonurologic” causesofLUTSisparticularlyevidentinthecaseofnocturia, which is prognostic of all-cause mortality and has been identifiedasahallmarkofseveralsystemiccardiovascular, respiratory, renal, hepatic, endocrine, neurologic, and immunologicdiseasestates[3].

Long before beginning to receive attention as a standalone entity, LUTS were most relevant in major urologyconsensusguidelinesastheclinicalmanifestation of common genitourinary abnormalities such as benign prostatichyperplasia(BPH).Thefirstmajorrenditionofthe

EAU guidelines on BPH in 2001 did acknowledge that

“chronicconditions,suchashypertensionordiabetes,have beenrelatedtoclinical BPH”[4].However,thedocument subsequently downplayed the possibility of a causal relationship, stating, “but given the frequent occurrence of these conditions in ageingmen, alarge proportion of patientscanbeexpectedtosufferfromsuchanassociation.” Consistently, recommendations regardingdiagnosis were squarely centered on the genitourinary tract, and the seemingly benign nature of LUTS provided the basis for watchfulwaitingasafirst-linemanagementstrategy:

“BPHaffectsqualityratherthanthequantityoflife.The risk of serious sequelae following a watchful waiting policy is small. The only related morbidities are the developmentofacuteurinaryretentionorimpairmentof renalfunction.”

The first AUA guidelines on BPH were published in 2003 andsimilarlydescribed medicaldisease to bemost relevant as a clinical distractor and implicit grounds for exclusion[5]:

“ThechallengeinpatientswithLUTSistoestablishthat the symptomsare dueto BPH. Nonprostatic causesof symptomscan beexcluded ina significant numberof patients on the basis of a medical history, physical examination, and urinalysis. (...) A medical history should be taken to identify other causes of voiding dysfunction or comorbidities that may complicate treatment.”

EUROPEANUROLOGYOPEN SCIENCE20(2020)12–13

a v a i l ab l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e u -o p e n s c i en c e . eu r o p e an u r o l o g y . c o m

*Correspondingauthor.DepartmentofUrology,SUNYDownstateHealthSciencesUniversity,Brooklyn,NY11203,USA.Tel.+17182702554;

Fax:+17182215220.

E-mailaddress:[email protected](T.F.Monaghan).

http://dx.doi.org/10.1016/j.euros.2020.06.008

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In2010,theEAUGuidelinesonBPHwererebrandedasthe EAUGuidelinesonConservativeTreatmentofNon-neurogenic Male LUTS [6]. As the authors explained themselves, contemporaryscientificadvanceshadprovided thenidus forthischangeinnomenclature:

“The latest knowledgeand developmentssuggest that notallbladdersymptomsofelderlymenarenecessarily linked to the prostate (BPH-LUTS) (...) This more distinguishedviewofLUTShasledtore-formationofthe contentandpaneloftheEAUguidelines.”

The intricate relationship betweenLUTS andsystemic diseasehasbeenfurtherexpandedinthemostrecentmajor revisions to the EAU (2019) and AUA (2018) guidelines.

Current EAU guidelinescontend thatcauses unrelatedto lowerurinarytractdysfunction“havetobeconsideredinall cases” [2]. This concept has been operationalized in the currentInternationalContinenceSocietyConsensusstate- ment on the diagnosis andtreatment of nocturia, which detailsaholistic,patient-orienteddiagnosticandtherapeu- ticalgorithmfornocturiathatmaybegeneralizedtoother LUTS [7]. Likewise, the AUA guidelines now feature the complex etiology of LUTS as a pressing future research direction[8]:

“Thereareenormousgapsinknowledgeand,therefore, ensuingopportunitiesfordiscovery.These includebut arenotlimitedtomanyunansweredquestions,suchas theroleofinflammation,metabolicdysfunction,obesity, andenvironmentalfactorsinetiology,aswellastherole ofbehaviormodification,self-management,andevolv- ingtherapeuticalgorithmsin boththepreventionand progressionofdisease.”

Taken together, thepast two decadesof EAU and AUA guidelinesonBPHreflectafundamentalshiftinthewayin whichcontemporaryevidenceonLUTShasbeeninterpreted, synthesized, and disseminated by the primary urological professionalsocietiesinEuropeandtheUSA.Thisthemeis likewisesalientincurrentevidenceonurinaryincontinence andoveractivebladdersyndrome[9].Oncemostrelevantasa clinicaldistractorintheevaluation ofother genitourinary abnormalities,medicaldiseasehasbecomeacentraltenetin theevaluationandmanagementofLUTS.

Theimportanceofacomprehensivemedicalassessment wasemphasizedinarecentsystematicreviewofnocturia bytheEAUguidelinespanelformaleLUTS,whichaffirmed that“thesymptomofnocturiaisanimportantone,since theremaybeasignificantmedicalcause,[and]potentially anopportunitytoscreenforundiagnosedorsuboptimally- manageddisease ...”[10]. Nocturiaandother LUTS, as potential harbingers of serious systemic disease, thus provide another unique platform from which urologists

may tangiblyimproveoverall healthand survival.There- fore,acomprehensivemedicalexamination,oftenwarrant- ingreferraltoanotherspecialtyandamultimodalcareplan, mustnowbeconsideredafundamentalresponsibilityinthe managementofapatientpresentingwithLUTS.Tothisend, eveninthewakeofCOVID-19, ourreinvigoratedspiritof interdisciplinarycollaborationmustnotbeforgotten.

Conflicts ofinterest: Karel Everaert is aconsultant and lecturer for Medtronic and Ferring and has received institutional grants from Allergan,Ferring,Astellas,andMedtronic.AlanJ.Weinhasservedasan advisor/consultant for Bulkamid, Medtronic, Serenity, Urovant, and Velicept.JeffreyP.WeissisaconsultantforFerringandtheInstitutefor BladderandProstateResearch.ThomasF.MonaghanandJasonM.Lazar havenothingtodisclose.

References

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