Page options

Lower Urinary Tract Symptoms (LUTs) in Men Glos Care Pathway Overview

 

This pathway has been designed to clarify the management of Lower Urinary Tract Symptoms in men in Gloucestershire.

Please click the relevant flowchart box to be taken directly to textual information

                                                                                                        

Red Flags
Suspected cancer refer via 2ww pathway.
Presentation

Lower urinary tract symptoms may be:

  • Storage - Frequency, nocturia, urgency, incontinence
  • Voiding - Hesitancy, poor flow, terminal dribbling
  • Post voiding - Post micturition dribble
     

Risk factors associated with LUTS include:

  • Increased serum dihydrotestosterone levels
  • Obesity
  • Elevated fasting glucose
  • Diabetes
  • Fat and red meat intake
  • Inflammation, which increases the risk
Differential Diagnosis
  • Benign prostatic obstruction, most likely diagnosis age 55 - 80
  • Overactive bladder
  • Nocturnal polyuria
  • Detrusor failure
  • Prostate cancer
  • Congestive Cardiac Failure (CCF)
  • Sleep apnoea
  • Neurological conditions (e.g. multiple sclerosis, spinal cord injury, cauda equine syndrome)
Initial Primary Care Assessment

Consider the symptoms – are they predominantly voiding or storage?

  • Voiding symptoms – incomplete emptying, intermittency, weak stream, hesitancy
    • Voiding symptoms suggest bladder outflow obstruction. This is usually caused by benign prostatic hyperplasia but can also be caused by stricture, meatal stenosis etc.
  • Storage symptoms – urgency, frequency, nocturia
    • Isolated storage symptoms are most commonly due to overactive bladder. This is very common (almost as common in men as women), and becomes more common place over the age of 60.
    • Urgency may be associated with urge incontinence.
  • A mixed pattern is common with prostatic enlargement due to benign prostatic hyperplasia

 

Examination:

  • Check for significant signs of prostatic enlargement with digital rectal examination (DRE). Note that benign prostatic hyperplasia is not a risk factor for prostate cancer.
  • Check urine dipstick for glucose, signs of infection or blood.
  • Check serum creatinine if significant outflow obstruction (e.g. palpable bladder) is suspected.

 

Assess impact of symptoms:

  • The International Prostate Symptom Score (IPSS) can be used to assess symptoms. Score can also be used to assess response to treatment.
  • Only consider drug treatment is symptoms are at least moderately bothersome.
  • If symptoms are bothersome, then check a frequency volume chart to check for:
    • Polyuria (>3L urine per 24 hours)
    • Nocturnal polyuria (>33% of the 24 hour urine output occurs at night)

Practice Point:

Benign Prostatic Hyperplasia is not a risk factor for prostate cancer.

NICE recommend offering a PSA test in men under 70 who have LUTS suggestive of benign prostatic hyperplasia, an abnormal digital rectal examination or concerns about prostate cancer (after adequate counselling). Men should be given time to consider whether they wish to have a PSA test.

There is a need to wait for one week after a digital rectal examination and one month after treatment for a UTI before undertaking a PSA test. The patient should avoid ejaculation and vigorous exercise for 48 hours.

Initial Primary Care Management

Management prior to referral:
Straightforward LUTS can be reasonably managed in primary care.
 

Initial investigations:

  • Urine dipstick (treat haematuria, sterile pyuria on merits)
  • Digital rectal examination to check for signs of prostatic enlargement
  • Frequency volume chart (drinking and voiding diary for 3 days)
    • to assess type and quantity of fluids prior to conservative treatments
    • to diagnose nocturnal polyuria (>33% total 24hr urine output passed at night)
  • Renal function if suspect significant obstruction or renal impairment
    • Ultrasound if suspected obstruction and/or chronic retention
       

Conservative treatment options for storage symptoms: 

  • Reduce fluid (1.5 litres/day) and caffeine intake
  • Supervised bladder training/pelvic floor exercises –  refer directly to continence   service/physio 
  • Bulbar urethral milking: for post micturition dribbling.
     

Medical treatment:

Initiate drug treatment after/in-combination with behavioural therapy. Generally only consider drug treatment if LUTs are moderate (International Prostate Symptom Score of 8-19) to severe (International Prostate Symptom Score of 20-35).

  • Offer alpha blocker as first line (Uroselective e.g. Tamsulosin/Alfuzosin). International Prostate Symptom Score can be used to assess response – expect 30-40% improvement after a few weeks. 
  • Overactive bladder (urgency, frequency symptoms) – If drug treatment required after lifestyle advice (reduction in caffeinated drinks) offer 1st line anticholinergic (e.g. Solifenacin 5-10mg as now generic, Oxybutynin has higher SE profile).  Note: this can be used in addition to alpha blocker. Second line therapy with Beta 3 Agonist Mirabegron 50mg OD (not 25mg). In the elderly to reduce anticholinergic burden consider Mirabegron/ Regurin XL first line.
  • Obstructive symptoms – If clinically significant prostatic enlargement, offer 5-alpha reductase inhibitor (e.g. Finasteride). Need 6 months to assess response. Expect a 25% reduction in prostate size and 50% fall in PSA levels. In more severe symptoms consider alpha blocker and 5-alpha reductase inhibitor in combination.
  • Nocturnal polyuria – If >35% urinary output at night consider early afternoon diuretic. Second line consider oral Desmopressin (check serum Na 3 days after starting and stop if hyponatraemic).

Practice Point:

Response and side effect profiles vary between individuals. It is therefore worth trying at least 3 different preparations if response is limited or side effects are not tolerated.

For products with variable dose (e.g. oxybutynin/vesicare/toviaz) increase as tolerated. Mirabegron is a new Beta-3 agonist, trial data suggests similar efficacy to anticholinergics (may be better tolerated).

NICE suggest a review of efficacy and side effects with each drug used, perhaps at 6-12 weeks after initiation.

When to Refer

Referral to a specialist urology service should be considered in the following circumstances:

  • Failed medical/conservative treatment where the patient continues to be bothered by symptoms
  • Recurrent UTI
  • Suspicion of prostate or bladder cancer
  • Haematuria
  • Nocturnal enuresis
  • Acute or chronic retention
Secondary Care Management

Specialist assessment and management to include:

  • Physical examination guided by urological symptoms
  • Urinary frequency volume chart
  • Information, advice and time to decide if they wish to have PSA testing
  • Measurement of flow rate and post residual volume
  • Cystoscopy where clinically indicated (for example if there is a history of recurrent infection, sterile pyuria, haematuria, profound symptoms, pain).
  • Imagine of upper urinary tract where clinically indicated (e.g. chronic retention, haematuria, recurrent infection, sterile pyuria, profound symptoms, pain).

 

Conservative and drug treatment:

See above sections.

 

Surgery:

Voiding symptoms:

  • For men with voiding symptoms surgery should only be offered where symptoms are severe or if conservative management and drug treatments are unsuccessful or inappropriate.
  • Surgery for LUTs presumed to be secondary to benign prostatic hyperplasia - monopolar or bipolar transurethral resection of the prostate, urolift in appropriate patients, or holium laser resection of the prostate (subject to CCG IFR policy criteria).
  • Only offer open prostatectomy as an alternative to TURP to men with prostates estimated to be larger than 80g

 

Storage symptoms:

  • For men with storage symptoms surgery should only be offered where symptoms are severe or if conservative management and drug treatments are unsuccessful or inappropriate. Discuss the alternatives of containment or surgery. Inform men being offered surgery that effectiveness, side effects and long‑term risk are uncertain.
  • Consider offering cystoplasty to manage detrusor over activity only to men whose symptoms have not responded to conservative management or drug treatment and who are willing and able to self‑catheterise. Before offering cystoplasty, discuss serious complications (that is, bowel disturbance, metabolic acidosis, mucus production and/or mucus retention in the bladder, urinary tract infection and urinary retention).
  • Consider offering bladder wall injection with botulinum toxin to men with detrusor overactivity only if their symptoms have not responded to conservative management and drug treatments and the man is willing and able to self‑catheterise.
  • Consider offering implanted sacral nerve stimulation (subject to CCG funding approval) to manage detrusor over activity only to men whose symptoms have not responded to conservative management and drug treatments.

 

Urinary retention:

  • Immediately catheterise men with acute retention.
  • Offer an alpha blocker to men for managing acute urinary retention before removal of the catheter
  • Consider offering self‑ or carer‑administered intermittent urethral catheterisation before offering indwelling catheterisation for men with chronic urinary retention
  • Carry out a serum creatinine test and imaging of the upper urinary tract in men with chronic urinary retention (residual volume greater than 1 litre or presence of a palpable/percussable bladder).
  • Catheterise men who have impaired renal function or hydronephrosis secondary to chronic urinary retention.
  • Consider offering intermittent or indwelling catheterisation before offering surgery in men with chronic urinary retention
  • Consider offering surgery on the bladder outlet without prior catheterisation to men who have chronic urinary retention and other bothersome LUTS but no impairment of renal function or upper renal tract abnormality.
  • Consider offering intermittent self- or carer‑administered catheterisation instead of surgery in men with chronic retention who you suspect have markedly impaired bladder function
  • Continue or start long‑term catheterisation in men with chronic retention for whom surgery is unsuitable.
  • Provide active surveillance (post void residual volume measurement, upper tract imaging and serum creatinine testing) to men with non‑bothersome LUTS secondary to chronic retention who have not had their bladder drained.
Expand all