Definition & Key Features

Lower Urinary Tract Symptoms (LUTS) in men describe a range of symptoms related to urination. They are not a disease in themselves but a collection of clinical indicators of possible underlying pathologies, most commonly Benign Prostatic Enlargement (BPE).

• Core Pathophysiology: While often linked to bladder outlet obstruction from an enlarging prostate (BPE), LUTS can also result from detrusor muscle overactivity or underactivity, nocturnal polyuria, or a combination of factors.
• Hallmark Features/Symptom Clusters:
  • Voiding Symptoms: Weak or intermittent stream, straining, hesitancy, terminal dribbling, and incomplete emptying.
  • Storage Symptoms: Urgency, frequency, urgency incontinence, and nocturia.
  • Post-Micturition Symptoms: Post-micturition dribbling.
• Symptom Severity (IPSS Score):
  • Mild: International Prostate Symptom Score (IPSS) of 0–7.
  • Moderate: IPSS of 8–19.
  • Severe: IPSS of 20–35.
• Important Complications if Untreated:
  • Acute urinary retention
  • Chronic urinary retention, potentially leading to renal impairment or hydronephrosis
  • Recurrent Urinary Tract Infections (UTIs)
  • Significant negative impact on quality of life, including distress, sleep disturbance, and social avoidance.

Epidemiology & Risk Factors

• Who is most affected: LUTS prevalence increases significantly with age.
• Risk Factors for Progression:
  • Older age
  • Prostate estimated to be larger than 30 g
  • Prostate-Specific Antigen (PSA) level greater than 1.4 ng/ml

Clinical Presentation & Diagnosis

Typical Presentation:

Men typically present with a combination of voiding and/or storage symptoms that have become bothersome. The focus of the initial assessment is to characterise the symptoms, identify potential causes, and rule out sinister pathology.

Red Flags (Indications for Urgent Referral or Specialist Assessment):

• Recurrent or persistent urinary tract infection
• Urinary retention (acute or chronic)
• Renal impairment suspected to be caused by lower urinary tract dysfunction
• Suspected urological cancer (e.g., prostate feels malignant on DRE, unexplained haematuria)
• Bothersome LUTS that have not responded to conservative management or initial drug treatment.

Diagnostic Workup in Primary Care (Initial Assessment):

• History:
  • Full medical history to identify comorbidities and possible causes.
  • Thorough review of all current medications, including over-the-counter and herbal remedies.
• Symptom Scoring:
  • Offer a validated symptom score (e.g., IPSS) to assess baseline severity and monitor treatment response.
• Frequency Volume Chart:
  • Ask men with bothersome LUTS to complete a chart to quantify fluid intake, voiding frequency, and volumes.
• Physical Examination:
  • Examination of the abdomen (for a palpable bladder) and external genitalia.
  • Digital Rectal Examination (DRE): Essential to assess the prostate’s size, consistency, and for any abnormalities.
• Investigations:
  • Urine Dipstick: To detect blood, glucose, protein, leucocytes, and nitrites.
  • Prostate-Specific Antigen (PSA) Test: Offer information, advice, and time to decide on PSA testing if:
    • LUTS are suggestive of bladder outlet obstruction secondary to BPE.
    • The prostate feels abnormal on DRE.
    • The patient is concerned about prostate cancer.
  • Serum Creatinine (and eGFR): Offer only if renal impairment is suspected (e.g., palpable bladder, nocturnal enuresis, recurrent UTIs, history of stones).
• Investigations to AVOID in Routine Initial Assessment:
  • Do not routinely offer cystoscopy.
  • Do not routinely offer imaging of the upper urinary tract.
  • Do not routinely offer flow-rate measurement.
  • Do not routinely offer post-void residual volume measurement.

Initial Management

Non-Pharmacological Measures & Patient Education:

• Mild, Non-Bothersome LUTS (IPSS 0-7): Offer reassurance, lifestyle advice (e.g., managing fluid intake), and information on the condition. Arrange for review if symptoms change or worsen.
• Storage Symptoms (Urgency/Frequency):
  • Offer supervised bladder training for at least 6 weeks.
  • Advise on fluid intake modification.
  • Offer temporary containment products (e.g., pads) to achieve social continence while awaiting diagnosis and treatment.
• Post-Micturition Dribble: Explain how to perform urethral milking.
• Nocturnal Polyuria: Consider causes such as oedema, certain medications (calcium channel blockers, diuretics, SSRIs), or medical conditions (diabetes, heart failure).

First-Line Pharmacological Treatment:

• Indication: Offer drug treatment only when conservative options have failed or are inappropriate for men with bothersome moderate to severe LUTS (IPSS ≥8).
• For Voiding Symptoms (presumed secondary to BPE):
  • Drug: Offer an alpha-blocker.
  • Examples: Alfuzosin, Doxazosin, Tamsulosin, or Terazosin.
  • Dosage/Frequency: Follow BNF guidance for specific dosing regimens.
  • Key Side Effects: Postural hypotension, dizziness, asthenia, ejaculatory dysfunction.
  • Cautions: Caution in men at risk of postural hypotension or those taking antihypertensives.
  • Contraindications: History of postural hypotension, severe hepatic impairment (varies by drug).
• For Storage Symptoms (suggestive of Overactive Bladder – OAB):
  • Drug: Offer an anticholinergic.
  • Examples: Oxybutynin (use modified-release), Tolterodine, Solifenacin.
  • Indications: Specifically to manage symptoms of OAB.
  • Key Side Effects: Dry mouth, constipation, blurred vision, cognitive impairment.
  • Cautions/Contraindications: Use with caution in older, frail men due to risk of confusion and falls. Contraindicated in urinary retention, severe ulcerative colitis, toxic megacolon, and myasthenia gravis.

Further Management & Escalation

Second-Line Therapies & Combinations:

• For Men with a Larger Prostate and High Risk of Progression:
  • Indication: LUTS with a prostate estimated to be >30g or PSA >1.4 ng/ml.
  • Drug: Offer a 5-alpha reductase inhibitor (5-ARI) (e.g., Finasteride, Dutasteride).
  • Effect: Reduces prostate size over time (may take ≥6 months for full effect). Reduces risk of progression to acute retention and need for surgery.
  • Key Side Effects: Decreased libido, erectile dysfunction, ejaculation disorders, gynaecomastia.
  • Important Note: 5-ARIs will reduce PSA levels by approximately 50% after 6-12 months; this must be accounted for when interpreting results.
• For Men with Bothersome Moderate-to-Severe LUTS & Larger Prostate:
  • Indication: Bothering LUTS (IPSS ≥8) AND prostate >30g or PSA >1.4 ng/ml.
  • Action: Consider offering a combination of an alpha-blocker AND a 5-ARI.
• For Men with Persistent Storage Symptoms Despite Alpha-Blocker:
  • Action: Consider adding an anticholinergic to the alpha-blocker therapy.
• For OAB Symptoms where Anticholinergics are Unsuitable/Ineffective:
  • Action: Refer to NICE technology appraisals for Beta-3-adrenoceptor agonists (e.g., Mirabegron, Vibegron).
• For Nocturnal Polyuria (after excluding medical causes):
  • 1st line: Consider a late afternoon loop diuretic (e.g., Furosemide). Note: This is an off-label use.
  • 2nd line: Consider oral desmopressin if other treatments fail. Note: This is an off-label use.
    • CRITICAL SAFETY NETTING: Measure serum sodium 3 days after the first dose. Stop desmopressin immediately if serum sodium is below the normal range due to the risk of hyponatraemia.

Referral to Specialist Assessment:

• Refer if bothersome LUTS do not respond to conservative management or drug treatment.
• Refer immediately for any red flags identified during initial assessment.
• Refer men with stress urinary incontinence for specialist assessment.
• Refer men considering surgery to a urologist to discuss options.

Surgical Options (Specialist Domain):

• Voiding Symptoms: Offered if symptoms are severe or drug treatment has failed.
  • Standard Procedures: Monopolar or Bipolar Transurethral Resection of the Prostate (TURP), Holmium Laser Enucleation of the Prostate (HoLEP).
  • For smaller prostates (<30g): Transurethral Incision of the Prostate (TUIP).
  • For very large prostates (>80g): Open prostatectomy.
• Storage Symptoms: Only considered if conservative/drug treatments fail. Options include botulinum toxin bladder injections, sacral nerve stimulation, or cystoplasty.

Follow-up & Safety Netting

• Frequency of Follow-up Visits:
  • Alpha-blockers: Review at 4 to 6 weeks, then every 6 to 12 months.
  • 5-Alpha Reductase Inhibitors (5-ARIs): Review at 3 to 6 months, then every 6 to 12 months.
  • Anticholinergics: Review every 4 to 6 weeks until symptoms are stable, then every 6 to 12 months.
• Monitoring Requirements:
  • At each review, assess symptoms (can use IPSS), impact on quality of life, and inquire about adverse effects.
  • For men with chronic retention not undergoing drainage, provide active surveillance with post-void residual volume measurement, upper tract imaging, and serum creatinine testing.
• Patient Advice on Self-Management:
  • Discuss the option of ‘active surveillance’ (reassurance and lifestyle advice with regular follow-up) versus ‘active intervention’ (conservative management, drugs, or surgery).
  • For men on long-term catheterisation, discuss the practicalities, benefits, and risks with the patient and their carer.
• Warning Signs Prompting Urgent Reassessment:
  • Sudden inability to pass urine (acute retention).
  • Development of fever, loin pain, or other signs of UTI.
  • Visible blood in the urine.
  • Significant discomfort or a palpable, distended bladder.

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Take-Home Points

• Categorise Symptoms: Differentiate between voiding, storage, and post-micturition symptoms to guide management. Use the IPSS score to quantify severity.
• Initial Assessment is Key: A thorough history, DRE, and urine dipstick are mandatory. Only perform a serum creatinine if you suspect renal impairment.
• Red Flags for Referral: Suspected cancer, recurrent UTIs, renal impairment, or urinary retention warrant specialist assessment.
• First-Line Drugs: For bothersome moderate-to-severe LUTS, offer an alpha-blocker. For OAB-predominant symptoms, offer an anticholinergic.
• Step-Up Therapy: Consider a 5-ARI (alone or with an alpha-blocker) if the prostate is large (>30g) or PSA is elevated (>1.4 ng/ml).
• Desmopressin Safety: If prescribing desmopressin for nocturnal polyuria, you must check serum sodium at day 3 and stop if it is low.
• Specific Follow-Up Times: Review alpha-blockers at 4-6 weeks, 5-ARIs at 3-6 months, and anticholinergics at 4-6 weeks to assess efficacy and side effects.
• Do Not Offer: Do not offer homeopathy, phytotherapy, or acupuncture.
• Acute Retention: This is a urological emergency requiring immediate catheterisation. Offer an alpha-blocker before trial without catheter (TWOC).

This MedDigest summary is intended for educational purposes only and should not be used for clinical purposes. It is an independent resource, prepared by MedDigest, to offer an accessible overview of information drawn from the NICE guidelines. The original NICE content is © Crown copyright and is used under the Open Government Licence v3.0. While MedDigest strives for accuracy in its educational summaries, this content has not been reviewed or produced by NICE. For comprehensive and definitive recommendations, please always refer to the complete NICE guidelines.

References

NICE (03 June 2015) Lower urinary tract symptoms in men: management. https://www.nice.org.uk/guidance/cg97