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Lifestyle Changes Helpful for Men With Urinary Symptoms, Clinical Trial Shows

Worst Pills, Best Pills Newsletter article July, 2024

Almost one-third of older men experience lower urinary tract symptoms (hereafter, urinary symptoms), such as hesitancy or slow urinary stream, dribbling or incomplete emptying of the bladder, urinary urgency, or need to urinate many times during the day (urinary frequency) or at night (nocturia).[1] These symptoms usually are caused by problems in the bladder, urethra (the tube through which urine leaves the body) or prostate. Problems with urination also can be a consequence of problems...

Almost one-third of older men experience lower urinary tract symptoms (hereafter, urinary symptoms), such as hesitancy or slow urinary stream, dribbling or incomplete emptying of the bladder, urinary urgency, or need to urinate many times during the day (urinary frequency) or at night (nocturia).[1] These symptoms usually are caused by problems in the bladder, urethra (the tube through which urine leaves the body) or prostate. Problems with urination also can be a consequence of problems elsewhere in the body (secondary problems), such as in the cardiovascular, endocrine or respiratory systems.

Once secondary and structural problems have been ruled out, treatment guidelines for urinary symptoms (such as those from the European Association of Urology) recommend using lifestyle changes before drug treatment.[2] However, strong evidence about the effectiveness of lifestyle changes in men with urinary symptoms has been limited. Additionally, many clinicians may not have the time or skills to be able to coach patients about how to successfully implement lifestyle changes.

A new well-conducted randomized, controlled clinical trial, called TRIUMPH, found that use of standardized assessments and lifestyle advice for men in the primary-care setting led to sustained reductions in urinary symptoms compared with usual care. The trial was funded by the U.K.’s National Institute for Health and Care Research, and its findings were published in the BMJ in November 2023.

The TRIUMPH trial[3]

The trial team recruited 1,077 adult men, whose mean age was approximately 68 years, from 30 primary-care sites in England. The subjects had had primary-care visits in the previous five years due to urinary symptoms and were currently experiencing at least one bothersome urinary symptom. These men could pass urine without a catheter, had not undergone prostate surgery, were not treated for prostate or bladder cancer and did not have neurological diseases or poorly controlled diabetes.

The trial team randomly assigned 13 primary-care sites to provide usual care to 553 subjects and the remaining 17 sites to provide a special-care program (intervention) to 524 subjects. The trial team trained nurses and health care assistants at the intervention sites to conduct standardized baseline assessments of urinary symptoms for each subject and guided them about how to implement relevant advice from a booklet with lifestyle advice for managing their symptoms. The booklet included exercises for strengthening the pelvic floor muscles in men to help stop bladder leakage (as described in the Text Box below) as well as advice on liquid intake, controlling urinary urgency, emptying the bladder as much as possible, getting rid of the last drops of urine and decreasing sleep disturbance due to nocturia.

Subsequently, the nurses or health care assistants at the intervention sites followed up with the subjects by phone after one week of their enrollment and then by phone, email or text at four and 12 weeks to encourage and gauge their adherence to the lifestyle advice.

At the beginning of the trial, subjects in the intervention and usual-care groups had comparable clinical characteristics. On average, subjects in both groups also had moderately severe urinary symptoms, as their average score on a validated 35-point scale called the International Prostate Symptom Score (IPSS) was 14. Higher scores indicate more severe urinary symptoms.

After 12 months of follow-up, the average adjusted IPSS score was 1.8 points lower among subjects in the intervention group than those in the usual-care group, a modest but statistically significant difference favoring the intervention. The trial researchers noted that this difference means that the effect of the intervention was sustained for at least nine months after the final communication between the intervention subjects and the nurses or health care assistants about the lifestyle advice booklet. Also, secondary outcomes involving urinary incontinence, dribble after urination and quality of life demonstrated more improvement among subjects in the intervention group. Referral rates to urologists and reports of adverse effects did not differ significantly between the groups.

In a detailed report, the trial researchers noted that the cost of the intervention program was slightly lower than that of usual care and that qualitative data from the study subjects demonstrated that they valued the program highly.[4] Although the improvement from the program was relatively small, the researchers concluded that with prolonged use it can possibly lead to important clinical benefits.

Pelvic Floor Muscle Exercises Used by Men in the TRIUMPH Trial

How To Locate the Correct Muscles
  • Sit on a comfortable chair, leaning forward slightly with your feet slightly apart on the floor, and try do thefollowing:*
    • Tighten the muscles that you use to clench your anus (as if you are trying to control the passage of wind),and then relax.
    • Also, tighten the muscles that can interrupt urine flow and then relax.
How To Do the Exercises
  • When you tighten your pelvic floor muscles as described above, do so slowly and as hard as you can for upto 10 seconds (or less if you cannot tighten for this long), as if you are trying to control the passage of wind.Then, slowly relax the muscles and rest for 10 seconds. Try to repeat these lift and rest steps up to 10 times.This is called a strength exercise.
  • Tighten the above muscles as quickly as possible. Hold for one second, and then let go. Do 10 of these short,fast lifts. This is called a speed exercise.
  • If you do these exercises regularly at least three times a day for two months, you can expect that your pelvicfloor will be stronger. Afterwards, doing a set of these exercises twice a day can help you to maintain thatstrength.
*Make sure that your abdomen, buttocks and thighs remain relaxed and that you breathe normally during theseexercises. When you use the right muscles, you can feel the back of your scrotum move upwards. After you masterthese exercises while sitting down, you can do them while standing up or lying down.


What You Can Do

If you are a man with urinary symptoms, do not be embarrassed to seek help to find relief and rule out serious conditions that may be causing these symptoms. Tell your clinician that you would like to try conservative approaches before drug treatment. You can access the booklet used in the TRIUMPH trial online at bit.ly/3w5EmDO or ask your clinician to suggest alternative educational materials for lifestyle changes.

If your symptoms do not improve over time, talk to your clinician about adding an anticholinergic drug, such as darifenacin (generic only), fesoterodine (TOVIAZ and generic), oxybutynin (generic only) or tolterodine (DETROL and generic), to your treatment.[5] Note that Public Citizen’s Health Research Group classifies these drugs as Limited Use because they have adverse effects including dry mouth, blurred vision, increased heart rate, high blood pressure and cognitive impairment (such as confusion, dizziness and memory problems), which can be especially problematic for older adults.

Do not use mirabegron (MYRBETRIQ and generic) or botulinum toxin drugs, such as onabotulinumtoxinA (BOTOX), for treating urinary problems, because their risks do not outweigh their minimal benefits. You should avoid surgery until after you have tried lifestyle and drug treatments.

See your clinician promptly if you experience any of the following serious symptoms:

  • Blood in your urine
  • Difficulty passing urine
  • Feeling thirsty all the time
  • Loss of feeling around your genitals and anus
  • Urine leak (other than dribbling after you urinate)
  • Wetting the bed while sleeping

 


References

 

[1] National Institute for Health and Care Excellence. The management of lower urinary tract symptoms in men. Updated June 2015. https://www.nice.org.uk/guidance/cg97. Accessed May 3, 2024.

[2] Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013;64(1):118-140.

[3] Drake MJ, Worthington J, Frost J, et al. Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: cluster randomised controlled trial. BMJ. 2023;383(November 15):e075219.

[4] Worthington J, Frost J, Sanderson E, et al. Lower urinary tract symptoms in men: the TRIUMPH cluster RCT. Heal Technol Assess. 2024;28(13):1-162.

[5] Nonsurgical treatments for urinary incontinence. Worst Pills, Best Pills News. May 2017. https://www.worstpills.org/newsletters/view/1129. Accessed May 3, 2024.

Disclaimer

The information on this website is not intended to substitute for professional medical advice, diagnosis, or treatment. Consult your doctor before changing or discontinuing any medication.