Wei John T, Dauw Casey A, Brodsky Casey N
Department of Urology, University of Michigan, Ann Arbor.
JAMA. 2025 Sep 2;334(9):809-821. doi: 10.1001/jama.2025.7045.
Up to 40% of men older than 50 years have lower urinary tract symptoms, including urinary urgency, nocturia, and weak urinary stream, due to disorders of the bladder and prostate. These symptoms negatively affect quality of life and may be associated with urinary retention, which can cause kidney insufficiency, bladder calculi, hematuria, and urinary tract infections.
In men, lower urinary tract symptoms can be caused by bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), an overactive bladder detrusor (a syndrome of urinary urgency and frequency), or both. Behavioral therapy, including pelvic floor physical therapy, timed voiding (voiding at specific intervals), and fluid restriction, can improve symptoms. Medications including α-blockers (such as tamsulosin), 5α-reductase inhibitors (such as finasteride), and phosphodiesterase 5 inhibitors (such as tadalafil) improve lower urinary tract symptoms (mean improvement, 3-10 points on the International Prostate Symptom Score [IPSS], which ranges from 0-35, with higher scores indicating greater severity) and can prevent symptom worsening measured by increased IPSS greater than or equal to 4 points or development of secondary sequelae, such as urinary retention. Combination therapies are more effective than monotherapy. For example, α-blockade (eg, tamsulosin) combined with 5α-reductase inhibition (eg, finasteride) lowers progression risk to less than 10% compared with 10% to 15% with monotherapy. Treatment for overactive bladder detrusor muscle, including anticholinergics (eg, trospium) and β3 agonists (eg, mirabegron), reduces voiding frequency by 2 to 4 times per day and reduces episodes of urinary incontinence by 10 to 20 times per week. Surgery (eg, transurethral resection of the prostate, holmium laser enucleation of the prostate) and minimally invasive surgery are highly effective for refractory or complicated cases of BPH, defined as persistent symptoms despite behavioral and pharmacologic therapy, and these therapies can improve IPSS by 10 to 15 points. Minimally invasive procedures, such as water vapor therapy (endoscopic injection of steam into BPH tissue) and prostatic urethral lift (endoscopic insertion of nonabsorbable suture implants that mechanically open the urethra), have lower complication rates of incontinence (0%-8%), erectile dysfunction (0%-3%), and retrograde ejaculation (0%-3%) but are associated with increased need for surgical retreatment (3.4%-21%) compared with transurethral resection of the prostate (5%) and holmium laser enucleation of the prostate (3.3%).
Lower urinary tract symptoms, defined as urinary urgency, nocturia, or weak stream, are common among men and are usually caused by BPH, overactive bladder detrusor, or both. First-line therapy consists of behavioral interventions, such as pelvic floor physical therapy and timed voiding, as well as pharmacologic therapy, including α-adrenergic blockers (tamsulosin), 5α-reductase inhibitors (finasteride), phosphodiesterase inhibitors (tadalafil), anticholinergics (trospium), and β3 agonists (mirabegron).
50岁以上的男性中，高达40%的人因膀胱和前列腺疾病出现下尿路症状，包括尿急、夜尿和尿流无力。这些症状会对生活质量产生负面影响，并且可能与尿潴留有关，尿潴留可导致肾功能不全、膀胱结石、血尿和尿路感染。
在男性中，下尿路症状可能由良性前列腺增生（BPH）继发的膀胱出口梗阻、膀胱逼尿肌过度活跃（尿急和尿频综合征）或两者共同引起。行为疗法，包括盆底物理治疗、定时排尿（按特定间隔排尿）和限制液体摄入，可改善症状。药物包括α受体阻滞剂（如坦索罗辛）、5α还原酶抑制剂（如非那雄胺）和磷酸二酯酶5抑制剂（如他达拉非）可改善下尿路症状（国际前列腺症状评分[IPSS]平均改善3 - 10分，IPSS范围为0 - 35分，分数越高表明症状越严重），并可预防症状恶化，症状恶化定义为IPSS增加大于或等于4分或出现继发性后遗症，如尿潴留。联合治疗比单一疗法更有效。例如，α受体阻滞（如坦索罗辛）联合5α还原酶抑制（如非那雄胺）可将进展风险降至10%以下，而单一疗法的风险为10%至15%。针对膀胱逼尿肌过度活跃的治疗，包括抗胆碱能药物（如曲司氯铵）和β3激动剂（如米拉贝隆），可使每日排尿频率降低2至4次，每周尿失禁发作次数减少10至20次。手术（如经尿道前列腺切除术、钬激光前列腺剜除术）和微创手术对难治性或复杂性BPH病例非常有效，难治性或复杂性BPH定义为尽管进行了行为和药物治疗仍持续存在症状，这些治疗可使IPSS提高10至15分。微创手术，如水蒸气疗法（通过内镜向BPH组织注射蒸汽）和前列腺尿道悬吊术（通过内镜插入不可吸收缝线植入物机械性打开尿道），与经尿道前列腺切除术（5%）和钬激光前列腺剜除术（3.3%）相比，尿失禁（0% - 8%）、勃起功能障碍（0% - 3%）和逆行射精（0% - 3%）的并发症发生率较低，但再次手术治疗的需求增加（3.4% - 21%）。
下尿路症状定义为尿急、夜尿或尿流无力，在男性中很常见，通常由BPH、膀胱逼尿肌过度活跃或两者共同引起。一线治疗包括行为干预，如盆底物理治疗和定时排尿，以及药物治疗，包括α肾上腺素能阻滞剂（坦索罗辛）、5α还原酶抑制剂（非那雄胺）、磷酸二酯酶抑制剂（他达拉非）、抗胆碱能药物（曲司氯铵）和β3激动剂（米拉贝隆）。
