LUTS in men

Overview and assessment

Clinical Knowledge Summaries has good advice on assessment and management of lower urinary tract symptoms in men. 

This includes advice on management of common conditions that cause LUTS that can often be managed in primary care initially once red flags have been excluded.

Symptoms can help to direct clinicians to the most likely underlying cause as summarised below:

•  storage symptoms (overactive bladder), eg:
  • urgency
  • daytime urinary frequency
  • nocturia
  • urgency incontinence
  • feeling the need to urinate just after passing urine
• voiding (obstructive) symptoms, eg:
  • weak or intermittent stream
  • hesitancy
  • splitting or spraying
  • straining
• post-micturition symptoms, eg:
  • sensation of incomplete emptying 
  • post-micturition dribble

Further assessment may include:

• completion of a urinary frequency-volume chart for at least 3 days, to distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.
• an assessment of their baseline symptoms with a validated symptom score, such as the International Prostate Symptom Score (IPSS), to allow assessment of subsequent symptom change. Printable versions of the IPSS questionnaire are available on the GPcare Urology website (see pre-appointment leaflets).

It is also important to establish the man's main concerns, for example whether he is worried about cancer, symptom progression, or acute urinary retention.

Who to refer

Once a diagnosis has been made, and if there are no red flags then most men with LUTS can be managed in primary care (see red flag and before referral sections below).

However, referral should be considered in the following scenarios [1]:

• men with lower urinary tract symptoms (LUTS) complicated by:
  • recurrent or persistent urinary tract infection (UTI)
  • retention
  • renal impairment that is suspected to be caused by lower urinary tract dysfunction

• men that have not responded to conservative management or medication
• men that require permanent use of containment products only after assessment and exclusion of other methods of management
• when considering offering surgical management

(1) Clinical Knowledge Summaries - LUTS in Men (March 2019)

Red Flags

Refer the patient via Urology 2WW if:

Prostate

• a hard, irregular prostate typical of prostate cancer is felt on DRE (PSA should be measured and the result should accompany the referral)
• the patient is symptomatic with high PSA levels
• the patient presents with or without lower urinary tract symptoms (LUTS) and the prostate is normal on DRE but the age-specific PSA is raised or rising

Bladder or renal cancer is suspected:

• Unexplained visible haematuria  in adults without UTI - refers to patients where UTI and urinary  stone disease have been excluded.
• Visible haematuria that persists or recurs after successful treatment of a UTI.
• Non- visible haematuria in patients aged 60 or over with either dysuria or raised white cell count on a blood test.
• Abdominal mass identified clinically or on imaging thought to arise from urinary tract. Includes solid renal masses, complex renal cysts (i.e cysts containing septa, calcification or soft tissue elements) and soft tissue bladder masses.

Before referral

Before referral consider the following investigation and management of symptoms in primary care (1):

Lifestyle advice

Advise patients on fluid intake:

• recommend limiting fluid intake in the late afternoon and evening for patients with nocturne
• the recommended total daily fluid intake of 1500mL should not be reduced – patients will often reduce their fluid intake excessively as a coping strategy, resulting in worsened symptoms and increased risk of infection 
• some foods contain large amounts of water and may be a source of increased fluid intake

Other lifestyle advice:

• avoidance or moderation of caffeine and alcohol
• maintaining a healthy lifestyle:
  • body weight
  • exercise
  • diet
  • smoking cessation
  • moderating alcohol consumption
• limiting intake of artificial sweeteners and carbonated drinks

Provide information about self-help resources:

• Consider recommending the Bladder & Bowel self-care CONfidence App
• The NHS provides online information for people with urinary incontinence, available at www.nhs.uk

Medication Review

Conduct a medication review with the aim of:

• optimising the timing of administration
• substituting medications for others that have fewer urinary effects

Investigations

Urinalysis - to check for blood, glucose, protein, leucocytes, and nitrites. Exclude a urinary tract infection (UTI) before PSA testing, especially in men presenting with LUTS

Consider Prostate-specific antigen (PSA) testing

• If symptoms suggest bladder outlet obstruction due to benign prostatic enlargement — the test result can guide drug treatment.
• If the man is concerned about prostate cancer or if the prostate feels abnormal on digital rectal examination — the test result can guide assessment of the risk of prostate cancer.

Renal function testing - Offer a serum creatinine test and estimated glomerular filtration rate (eGFR) if renal impairment is suspected, eg in those with: 

• Chronic urinary retention — suggested by bedwetting or an enlarged bladder detected on abdominal palpation or percussion.
• Recurrent urinary tract infection.
• History of renal stones.

Treatment

See the management section of CKS for advice on treatment of common causes of LUTS in men.

For advice on medication, please also see the Bladder and urinary disorders chapter of the BNSSG formulary

Benign Prostatic Hyperplasia (BPH) should initially be managed in primary care as advised above.

Referral

If symptoms are not controlled then consider Urology Advice and Guidance.

Referral for further assessment of patients or for consideration of surgical treatments such as TURP should be made to urology via eRS. Most patients with LUTS requiring referral will initially be directed to GPcare urology unless otherwise requested.

Patients who do not require, or who are not appropriate for surgery can also be supported by a referral to the Community Bladder and Bowel Service (Sirona). Please see the Remedy page for referral criteria and link to a self care app.

Referrals for minimally invasive procedures

Minimally invasive procedures are becoming more widely used and may be requested by patients. There are commissioning restrictions on available procedures as below:

• Prostatic Urethral Lift (Urolift) - this procedure is commissioned by BNSSG ICB for certain patients as outlined in the Prostatic Urethral Lift (UroLift® System) Criteria Based Access Policy.
• No other minimally invasive procedures are currently commissioned by BNSSG ICB and will not be available to patients within the BNSSG area (even if referred to other outlying providers). This includes: Rezum, HoLEP 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.