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Lower urinary tract symptoms in men: management

Initial assessment

  • Initial assessment refers to assessment carried out in any setting by a healthcare professional without specific training in managing lower urinary tract symptoms (LUTS) in men
  • At initial assessment, offer men with LUTS an assessment of their general medical history to identify possible causes of LUTS, and associated comorbidities. Review current medication, including herbal and over-the-counter medicines, to identify drugs that may be contributing to the problem
  • At initial assessment, offer men with LUTS a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE)
  • At initial assessment, ask men with bothersome LUTS to complete a urinary frequency volume chart
  • At initial assessment, offer men with LUTS a urine dipstick test to detect blood glucose, protein, leucocytes and nitrites
  • At initial assessment, offer men with LUTS information, advice and time to decide if they wish to have prostate specific antigen (PSA) testing if:
    • their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement or
    • their prostate feels abnormal on DRE or
    • they are concerned about prostate cancer
  • Manage suspected prostate cancer in men with LUTS in line with the NICE guidelines on prostate cancer and referral guidelines for suspected cancer
  • At initial assessment, offer men with LUTS a serum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation) only if you suspect renal impairment (for example, the man has a palpable bladder, nocturnal enuresis, recurrent urinary tract infections or a history of renal stones)
  • Do not routinely offer cystoscopy to men with uncomplicated LUTS (that is, without evidence of bladder abnormality) at initial assessment
  • Do not routinely offer imaging of the upper urinary tract to men with uncomplicated LUTS at initial assessment
  • Do not routinely offer flow-rate measurement to men with LUTS at initial assessment
  • Do not routinely offer a post void residual volume measurement to men with LUTS at initial assessment
  • At initial assessment, give reassurance, offer advice on lifestyle interventions (for example, fluid intake) and information on their condition to men whose LUTS are not bothersome or complicated. Offer review if symptoms change
  • Offer men referral for specialist assessment if they have bothersome LUTS that have not responded to conservative management or drug treatment
  • Refer men for specialist assessment if they have LUTS complicated by recurrent or persistent urinary tract infection, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer
  • Offer men considering any treatment for LUTS an assessment of their baseline symptoms with a validated symptom score (for example, the IPSS) to allow assessment of subsequent symptom change

Conservative management

  • Explain to men with post micturition dribble how to perform urethral milking
  • Offer men with storage LUTS (particularly urinary incontinence) temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
  • Offer a choice of containment products to manage storage LUTS (particularly urinary incontinence) based on individual circumstances and in consultation with the man
  • Offer men with storage LUTS suggestive of overactive bladder (OAB) supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products
  • Inform men with LUTS and proven bladder outlet obstruction that bladder training is less effective than surgery
  • Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy. Advise them to continue the exercises for at least 3 months before considering other options
  • Refer for specialist assessment men with stress urinary incontinence
  • Do not offer penile clamps to men with storage LUTS (particularly urinary incontinence)
  • Offer external collecting devices (for example, sheath appliances, pubic pressure urinals) for managing storage LUTS (particularly urinary incontinence) in men before considering indwelling catheterisation
  • Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation to men with voiding LUTS that cannot be corrected by less invasive measures
  • Consider offering long-term indwelling urethral catheterisation to men with LUTS:
    • for whom medical management has failed and surgery is not appropriate and
    • who are unable to manage intermittent self-catheterisation or
    • with skin wounds, pressure ulcers or irritation that are being contaminated by urine or
    • who are distressed by bed and clothing changes
  • If offering long-term indwelling catheterisation, discuss the practicalities, benefits and risks with the man and, if appropriate, his carer
  • Explain to men that indwelling catheters for urgency incontinence may not result in continence or the relief of recurrent infections
  • Consider permanent use of containment products for men with storage LUTS (particularly urinary incontinence) only after assessment and exclusion of other methods of management

Drug treatment

  • Offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate
  • Take into account comorbidities and current treatment when offering men drug treatment for LUTS
  • Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin, or terazosin) to men with moderate to severe LUTS
  • Offer an anticholinergic to men to manage the symptoms of OAB
  • Offer a 5-alpha reductase inhibitor to men with LUTS who have prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml, and who are considered to be at high risk of progression (for example, older men)
  • Consider offering a combination of an alpha blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml
  • Consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone
  • Consider offering a late afternoon loop diuretic to men with nocturnal polyuria
  • Consider offering oral desmopressin to men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment
  • Do not offer phosphodiesterase-5-inhibitors solely for the purpose of treating lower urinary tract symptoms in men, except as part of a randomised controlled trial

Review

  • Discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management, drug treatment or surgery) for:
    • men with mild or moderate bothersome LUTS
    • men whose LUTS fail to respond to drug treatment
  • Review men taking drug treatments to assess symptoms, the effect of the drugs on the patient's quality of life and to ask about any adverse effects from treatment
  • Review men taking alpha blockers at 4–6 weeks and then every 6–12 months
  • Review men taking 5-alpha reductase inhibitors at 3–6 months and then every 6–12 months
  • Review men taking anticholinergics every 4–6 weeks until symptoms are stable, and then every 6–12 months

Alternative and complementary therapies

  • Do not offer homeopathy, phytotherapy or acupuncture for treating LUTS in men

Providing information

  • Ensure that, if appropriate, men's carers are informed and involved in managing their LUTS and can give feedback on treatments
  • Make sure men with LUTS have access to care that can help with:
    • their emotional and physical conditions and
    • relevant physical, emotional, psychological, sexual, and social issues
  • Provide men with storage LUTS (particularly incontinence) containment products at point of need, and advice about relevant support groups

© NICE 2015. Lower urinary tract symptoms in men: management. Available from: www.nice.org.uk/guidance/CG97. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: June 2015.