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Lower urinary tract symptoms or 'LUTS', is a descriptive term for a symptom complex which is often characterized by bothersome voiding. The investigation of LUTS is an excellent example of the art of deductive diagnosis as it requires a combination of good history taking, physical examination including digital rectal or pelvic examination, and appropriate use of an array of laboratory, outpatient and complex investigations. The term 'LUTS' itself requires some clarification. Contrary to the term 'prostatism' which is inaccurate but has nevertheless remained in common usage, the term LUTS is more appropriate considering that various forms of urethrovesical dysfunctions often not related to the prostate may contribute to LUTS, as may other causes outside the urinary tract, obvious examples being excessive diuresis, cardiovascular pathology and diabetes.

When one considers the underlying pathology, LUTS tend to be rather non-specific. In relation to symptomatic benign prostatic enlargement (BPE), no specific symptom can reliably suggest benign prostatic hyperplasia, and furthermore there is no correlation between the degree of prostatic enlargement and the severity of symptoms. In addition, the relationship between symptoms and objective data from urodynamic studies is also weak.

In evaluating a person with LUTS, the clinician should endeavour to formulate a urodynamic diagnosis from the start to achieve an understanding of the individual's symptoms from an ætiological point of view, on the intuitive presumption that reversal of these causative processes should intuitively lead to more effective management. This is built up progressively from the available clinical information available, and altered accordingly as further information is received. Subsequent confirmation or refutation of this understanding by further investigations also serves to enhance the clin ician's understanding of the disease process.

It should be noted however, that the pathway of achieving a urodynamic diagnosis is not always completed, and often does not need to be, as complex investigations are reserved for more complex situations where the diagnosis is not apparent from initial tests. In clinical practice, the majority of cases actually require a minimum number of tests to achieve a working diagnosis. The diagnostic pathway chosen also depends largely on the presentation and results of preceding tests. For example, the investigation of an elderly man initially presenting with straightforward voiding symptoms suggestive of symptomatic benign prostatic enlargement (BPE) is quite different from a woman re-presenting after failed incontinence surgery with voiding dysfunction. However, a broad diagnostic pathway is summarized in Table 3.1.

Table 3.1Investigations for LUTS and incontinence

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