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Taking a comprehensive history of male lower urinary tract symptoms (LUTS) is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a history from a patient with LUTS in an OSCE setting.
Background
Normal functioning of the urinary system relies upon producing a normal quantity of urine, which can be stored in a bladder of normal capacity. Voiding urine requires voluntary and involuntary neurological control of the bladder and the urethral sphincters, correctly functioning pelvic floor muscles and an unobstructed urethra.
When each part of this system functions correctly, the bladder fills as urine passes from the kidneys via the ureters. During this phase, which is under sympathetic control, there is no detrusor activity and the muscle tone of the urethral sphincter increases.
When the bladder reaches capacity, the voiding phase (which is under parasympathetic control) begins with the relaxation of the urethral sphincter and contraction of the detrusor muscle in the bladder wall. If the person does not wish to pass urine at that time, the distal (voluntary) urethral sphincter contracts and enables the person to delay voiding. The frontal lobe controls this voluntary part of the process via the somatic nervous system.
Lower urinary tract symptoms (LUTS)
A problem with this system can give rise to two broad groups of symptoms:
- Storage symptoms (caused by problems storing urine): urgency, frequency, nocturia and incontinence
- Voiding symptoms (caused by problems voiding urine): hesitancy, weak stream, terminal dribbling, incomplete bladder emptying and chronic retention
These symptoms are collectively called lower urinary tract symptoms (LUTS).
Causes of LUTS
Over-production of urine
- Primary (or psychogenic) polydipsia: a primarily psychological problem seen in conditions such as schizophrenia, which causes the patient to consume a greater volume of fluid than they require
- Diabetes insipidus: an inability to concentrate urine, which may be cranial or nephrogenic in origin
- Acute kidney injury (AKI): although most commonly associated with oliguria, in some patients, the urine volume may be increased due to reduced tubular reabsorption; additionally, during recovery from AKI, some patients experience a diuretic phase
- Osmotic polyuria: due to hyperglycaemia (diabetes mellitus) or hypercalcaemia
- Diuretics (particularly loop diuretics): cause increased urine production secondary to increased excretion of sodium chloride
Nocturnal polyuria can also be considered here. Whilst the overall volume of urine produced may be normal, more than 35% occurs at night, secondary to redistribution of fluid from peripheral oedema when the patient lies supine. This causes nocturia, which can be very disruptive to sleep and may increase the risk of falls. This is seen in conditions such as heart failure, liver failure and chronic venous insufficiency.
Reduction in actual bladder capacity
- Constipation: due to pressure on the bladder from a loaded colon and/or rectum
- Rectal tumour: due to pressure on the bladder
Reduction in functional bladder capacity
- Detrusor over-activity: causes increased bladder pressure during the filling phase; this stresses the urethral sphincter, resulting in urgency with or without urge incontinence
- Sensory urgency (resulting from irritation or inflammation in the urinary tract): may be due to urinary tract infection (UTI), prostatitis, bladder stones or a bladder tumour; it can also be caused by caffeine and alcohol
- Ketamine: although the precise mechanism is unknown, using ketamine can cause bladder inflammation, resulting in frequency and urgency
Loss of unconscious bladder control
- Upper motor neuron lesions (e.g. multiple sclerosis): occurring in the pons or spinal cord; this results in a spastic bladder, with frequency, urgency, and urge incontinence. In spinal cord compression, there may be painless urinary retention.
- Lower motor neuron lesion (e.g. trauma, malignancy): occurring in the sacral nerve roots, conus medullaris or within the pelvis; this results in a flaccid bladder with difficulty initiating micturition and overflow incontinence. In cauda equina syndrome, there may be a loss of awareness of the need to pass urine, or of the fact that urine is being passed.
- Autonomic neuropathy (e.g. diabetes mellitus): causes an atonic bladder, which results in voiding and/or storage symptoms
Loss of voluntary bladder control
- Damage to the frontal lobe: trauma, dementia, hydrocephalus, and tumours
- Weakness of the pelvic floor muscles or urethral sphincter (e.g. following prostatectomy): when intra-abdominal pressure rises (e.g. coughing or sneezing), pressure in the bladder exceeds urethral pressure, and there is leakage of urine referred to as stress incontinence
Problems with the flow of urine from the bladder through the urethra
- Prostatic enlargement: prostate cancer, benign prostatic hypertrophy or hyperplasia (BPH)
- Urethral stricture
- Anatomical penile abnormalities: including phimosis (inability to contract the foreskin) or concealed (or buried) penis
- Urinary retention secondary to antimuscarinics: such as tricyclic antidepressants
- Post-micturition dribble: occurs due to urine pooling within the bulbar urethra; this urine then comes out when the patient moves.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
- Demonstrating empathy in response to patient cues: both verbal and non-verbal.
- Active listening: through body language and your verbal responses to what the patient has said.
- An appropriate level of eye contact throughout the consultation.
- Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
- Making sure not to interrupt the patient throughout the consultation.
- Establishing rapport (e.g. asking the patient how they are and offering them a seat).
- Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
- Summarising at regular intervals.
Presenting complaint
Use open questioning to explore the patient’s presenting complaint:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, can you tell me more about the urinary symptoms?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Gather further details about the patient’s urinary symptoms using the SOCRATES acronym.
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Site
N/A
Onset
Clarify how and when the urinary symptoms started:
- “How long have the urinary symptoms been going on for?”
- “How did the urinary symptoms start? Did they come on suddenly or gradually?”
Presentation within hours to days of the onset of symptoms may suggest an infective or acute neurological cause. It may also be seen in acute hyperglycaemia, or AKI. Other causes would likely cause a more gradual onset of symptoms and a longer history before presentation.
Character
Ask about the specific characteristics of the urinary symptoms:
- “Can you describe what you feel when you need to pass urine?”
- “Which symptom is the most troublesome?”
It is helpful to establish whether the symptoms primarily relate to storage or voiding of urine.
Storage vs voiding symptoms
Urgency, frequency, nocturia and incontinence suggest a storage problem
Difficulty initiating urination, a weak stream, dribbling at the end of the stream, or a feeling of not having fully emptied the bladder suggest a voiding problem
Nocturia may also be seen with a voiding problem, as the bladder has not been fully emptied during the day. In some patients who cannot fully empty the bladder, chronic retention leads to nocturnal enuresis due to overflow incontinence. Some patients may also experience post-micturition dribble.
Radiation
N/A
Associated symptoms
Ask if there are other symptoms that are associated with the urinary symptoms:
- “Have you noticed any other symptoms?”
Pain is a common associated symptom:
- Dysuria (urethral pain during urination): suggests UTI or prostatitis; it may also be a symptom of bladder cancer
- Supra-pubic pain: UTI or prostatitis
- Perineal pain: prostatitis
- Flank pain: pyelonephritis (where infection migrates from the bladder to one of the kidneys) or ureteric calculi
- Groin pain: ureteric calculi (classically ‘loin to groin’ pain)
- Bone pain (in the lower back or elsewhere): may indicate advanced prostate cancer due to bony metastases
- Lower back pain: seen in some neurological causes of LUTS, such as cauda equina syndrome
Fever suggests an infective cause (e.g. pyelonephritis or prostatitis).
Haematuria has a broad range of causes, including UTI, prostatitis, ureteric calculi, bladder cancer and prostate cancer.
Other symptoms that patients may experience include:
- Erectile dysfunction: may be seen in prostate cancer
- Excessive thirst: either in the context of primary polydipsia or secondary to polyuria in diabetes mellitus, diabetes insipidus and hypercalcaemia
- Bone pain, abdominal pain, vomiting and constipation: in the context of hypercalcaemia
- Other neurological symptoms (e.g. limb weakness, sensory disturbance, visual disturbance, or cognitive difficulties): if there is a neurological cause of LUTS
Time course and exacerbating or relieving factors
Clarify how the symptoms change over time:
- “Are the urinary symptoms there all the time, or do they come and go?”
Ask if anything makes the urinary symptoms worse or better:
- “Is there anything that makes the urinary symptoms worse or better?”
Episodic symptoms are seen in the context of recurrent infections or recurrent episodes of constipation. In relapsing-remitting multiple sclerosis, symptoms initially occur in discrete episodes.
Where symptoms are due to caffeine, alcohol, or drugs, they will fluctuate in severity depending on exposure to the causative agent.
In diabetes mellitus, osmotic symptoms vary depending on the severity of hyperglycaemia.
Asking the patient to complete a frequency-volume chart (‘bladder diary’) is a very helpful way to gain objective information about the nature of the symptoms and possible triggers.
Severity
The severity of symptoms is not particularly helpful in guiding the diagnosis of LUTS. However, assessing severity is important to help guide management once a diagnosis has been made.
The International Prostate Symptom Score (IPSS) is a validated tool to assess the severity of a patient’s voiding symptoms.
Red flag symptoms
Red flags for prostate cancer include:
- LUTS (although it is important to note that early prostate cancer does not usually cause these symptoms)
- Erectile dysfunction
- Visible haematuria
- Lower back pain
- Bone pain
- Weight loss
- Anorexia
- Lethargy
Red flags for bladder cancer include:
- Haematuria (visible or non-visible)
- Recurrent or persistent UTI
- Dysuria
- Urinary frequency
- Weight loss
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue:
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
- “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Concerns
Explore the patient’s current concerns:
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number one concern regarding this problem at the moment?”
- “What’s the worst thing you were thinking it might be?”
Expectations
Ask what the patient hopes to gain from the consultation:
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
- “What do you think might be the best plan of action?
Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
- Systemic: fever, weight loss, anorexia, lethargy
- Cardiovascular: peripheral oedema
- Gastrointestinal: nausea and vomiting, abdominal pain, constipation
- Neurological: weakness, sensory disturbance, visual disturbance, cognitive changes
- Musculoskeletal: bone pain
Past medical history
Ask if the patient has any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
Ask if the patient has previously undergone any surgery (e.g. prostate or bladder surgery):
- “Have you ever previously undergone any operations or procedures?”
- “When was the operation/procedure, and why was it performed?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Examples of relevant medical conditions
Relevant medical conditions in the context of urinary symptoms include:
- Diabetes mellitus (may be causing or exacerbating LUTS, but also a risk factor for infection)
- Any previous history of malignancy
- Neurological conditions, such as multiple sclerosis
- Conditions associated with renal disease, such as systemic lupus erythematosus or systemic vasculitis
- Trauma to the head, spine, or pelvis
Allergies
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
- “Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side effects from their medication:
- “Have you noticed any side effects from the medication you currently take?”
- “Do you think your urinary symptoms started after you began taking any of your current medications?”
Medication examples
Medications that can cause or exacerbate LUTS include:
- Loop diuretics, such as furosemide and bumetanide
- Sodium-glucose co-transporter 2 (SGLT-2) inhibitors, such as dapagliflozin and empagliflozin, increase the risk of UTI and prostatitis due to the increase in urinary glucose excretion which they promote.
- Ketamine causes bladder inflammation, leading to pain, urgency, and frequency.
- Drugs with anti-muscarinic effects, such as tricyclic antidepressants and sedating antihistamines, as well as anti-cholinergics prescribed to help with urinary incontinence, may cause urinary retention, particularly in patients who have prostatic enlargement.
Medications that patients may already be taking to treat LUTS include:
- An alpha blocker, such as tamsulosin, for prostatic enlargement
- A 5-alpha-reductase inhibitor, such as finasteride, for prostatic enlargement
- An anti-cholinergic, such as solifenacin or oxybutynin, for detrusor instability
- Mirabegron for overactive bladder
Family history
Ask the patient if there is any family history of urological problems or malignancy.
- “Do any of your parents or siblings have any medical conditions?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:
- “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
- “Do you remember what medical condition was felt to have caused his death?”
Social history
General social context
Explore the patient’s general social context including:
- the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
- who else the patient lives with and their personal support network
- what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
- if they have any carer input (e.g. twice daily carer visits)
Urinary symptoms, particularly urgency, frequency and nocturia, can increase the risk of falls in older people. It is helpful to know how easy it is for the person to get to their toilet and whether they have had any falls due to their urinary symptoms. For more information, see our guide to fall history taking.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:
- pack-years = [number of years smoked] x [average number of packs smoked per day]
- one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Smoking is a risk factor for the development of bladder cancer.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excessive alcohol use can cause or worsen LUTS.
Recreational drug use
Ask the patient if they use recreational drugs, and if so, determine the type of drugs used and their frequency of use. The use of ketamine is a risk factor for LUTS.
Occupation
Exposure to chemicals, such as those used in the rubber and dye industries, is a risk factor for bladder cancer.
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
References
- Anderson, Danyon J. et al. Ketamine-Induced Cystitis: A Comprehensive Review of the Urologic Effects of This Psychoactive Drug. Health Psychology Research 2022; 10(3). Available from: [LINK]
- Barraclough, Kevin. Cauda equina syndrome. BMJ 2021; 372:n32. Available from: [LINK]
- Boon, NA. Colledge, NR, Walker, BR (eds). Davidson’s Principles & Practice of Medicine 20th Ed. Churchill Livingstone Elsevier, 2006
- BMJ Best Practice. Acute prostatitis. Available from: [LINK]
- BMJ Best Practice. Bladder cancer. Available from: [LINK]
- BMJ Best Practice. Cauda equina syndrome. Available from: [LINK]
- BMJ Best Practice. Nephrolithiasis. Available from: [LINK]
- BMJ Best Practice. Psychogenic Polydipsia. Available from: [LINK]
- BMJ Best Practice. Urinary tract infections in men. Available from: [LINK]
- Cottrell, Angela M. et al. Urinary tract disease associated with chronic ketamine use. BMJ 2008; 336. Available from: [LINK]
- NICE CKS. LUTS in men. Available from: [LINK]
- NICE CKS. Urological cancers – recognition and referral. Available from: [LINK]
