Lower urinary tract symptoms in men overview NICE GUIDELINES

Information and support

Make sure men with lower urinary tract symptoms have access to care that can help with:

• their emotional and physical conditions and
• relevant physical, emotional, psychological, sexual and social issues.

Ensure that, if appropriate, men's carers are informed and involved in managing their lower urinary tract symptoms and can give feedback on treatments.

NICE has produced information for the public explaining this guidance.

NICE has produced information for the public explaining the guidance on referral guidelines for suspected cancer.

Urological cancer services

NICE has published cancer service guidance on improving outcomes in urological cancers.

Initial assessment

Offer:

• an assessment of general medical history to identify possible causes and comorbidities, including a review of all current medication (including herbal and over-the-counter medication) that may be contributing to the problem
• a physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination
• a urine dipstick test to detect blood, glucose, protein, leucocytes and nitrites.

Ask men with bothersome lower urinary tract symptoms to complete a urinary frequency volume chart.

Offer a serum creatinine test (plus estimated glomerular filtration rate 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).

For men whose lower urinary tract symptoms are not bothersome or complicated, give reassurance, offer advice on lifestyle interventions (for example, fluid intake) and information on their condition. Offer review if symptoms change.

For men with mild or moderate bothersome lower urinary tract symptoms, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management, drug treatment or surgery).

Offer men considering treatment for lower urinary tract symptoms an assessment of their baseline symptoms with a validated symptom score (for example, the International Prostate Symptom Score).

PSA testing

Offer men information, advice and time to decide if they wish to have PSA testing if:

• their lower urinary tract symptoms are suggestive of bladder outlet obstruction secondary to benign prostate enlargement or
• their prostate feels abnormal on digital rectal examination or
• they are concerned about prostate cancer (manage suspected prostate cancer in line with the pathway on prostate cancer and referral guidelines for suspected cancer).

Tests that should not be offered routinely

Do not routinely offer:

• cystoscopy to men with no evidence of bladder abnormality
• imaging of the upper urinary tract to men with no evidence of bladder abnormality
• flow-rate measurement
• post void residual volume measurement.

Quality standards

The following quality statements are relevant to this part of the pathway.1Initial assessment – physical examination2Initial assessment – urinary frequency and volume chart3Initial assessment – advice on lifestyle interventions

Initial assessment – physical examination

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) are offered a full physical examination, including a digital rectal examination, as part of their initial assessment.

Rationale

It is important to carry out a full physical examination so that abnormalities of the abdomen and external genitalia are not missed and left untreated. Performing a digital rectal examination is essential to assess the size of the prostate and to detect abnormalities that might indicate malignancy. It is also good practice to identify abnormalities, such as prostatitis (inflammation of the prostate) and associated conditions, which might affect bladder function.

Initial assessment – urinary frequency and volume chart

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with bothersome lower urinary tract symptoms (LUTS) are asked to complete a urinary frequency and volume chart, as part of their initial assessment.

Rationale

Urinary frequency and volume charts add important information to the medical history. They can also help the healthcare professional to make an accurate diagnosis and to distinguish nocturnal polyuria (greater than a third of daily urine output during the night) from detrusor overactivity (normal urine production but increased urinary frequency with urgency and small volumes of urine passed each time).

Initial assessment – advice on lifestyle interventions

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) whose symptoms are not bothersome or complicated are given written advice on lifestyle interventions, as part of their initial assessment.

Rationale

It is important to offer advice on lifestyle interventions as soon as possible so that the man is aware of all the options that might help to manage his condition. The content of this advice should be holistic and cover the benefits of attaining and maintaining a healthy weight, exercise and healthy eating. Also, the man should be given advice on specific health interventions, such as altering the type, quantity and timing of fluid and food intake, pelvic floor exercises and bladder training.

Definitions of terms used in this quality statement

Advice on lifestyle interventions

Advice on lifestyle interventions should be holistic and cover the benefits of attaining and maintaining a healthy weight, exercise and healthy eating. Also, the man should be advised on specific health interventions, such as altering the type, quantity and timing of fluid and food intake and avoiding bladder irritants (for example, certain foods, caffeine and smoking). Advice should also include information about pelvic floor exercises and bladder training.

Conservative management

Storage symptoms

If you suspect overactive bladder, offer supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products.

Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy. Advise men to continue the exercises for at least 3 months before considering other options.

Do not offer penile clamps.

Containment products

For men with storage lower urinary tract symptoms (particularly urinary incontinence):

• offer 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 based on individual circumstances and in consultation with the man
• offer external collecting devices (sheath appliances, pubic pressure urinals) before considering indwelling catheterisation (see long-term catheterisation and containment in this pathway).
• provide containment products at point of need, and advice about relevant support groups.

Voiding symptoms

Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation (see long-term catheterisation and containment in this pathway) if lower urinary tract symptoms cannot be corrected by less invasive measures.

Tell men with proven bladder outlet obstruction that bladder training is less effective than surgery.

Explain to men with post micturition dribble how to perform urethral milking.

Quality standards

The following quality statements are relevant to this part of the pathway.4Conservative management – temporary containment products5Conservative management – urethral milking

Conservative management – temporary containment products

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) who have urinary incontinence are offered a choice of temporary containment products, as part of their initial assessment.

Rationale

Temporary containment products (for example, pads or collecting devices) help manage incontinence, offering security and comfort. These products can help men to continue their normal daily activities, including social activities, and therefore improve quality of life.

It is important that a choice of suitable containment products is offered by a healthcare professional as early as possible, even if there is no definite diagnosis and agreed plan on how to manage the symptoms. Containment products only help manage the urinary incontinence – they are not a cure and should not generally be a long-term solution, unless other treatments don't help or are unsuitable.

Definitions of terms used in this quality statement

Temporary containment products

Containment products are designed to contain or divert the urine leaked during an episode of incontinence and are widely used by men with LUTS and incontinence. Products include absorbent pads (pads worn next to the body, pants with integral pads, bed pads), external collection devices (sheath appliances, pubic pressure urinals), disposable and reusable pads. Based on expert consensus, temporary containment products are used for a maximum of3 months, by which time their use should be reviewed and a management plan should be in place.

Drug treatment

Offer drug treatment only to men with bothersome lower urinary tract symptoms when conservative management options have been unsuccessful or are not appropriate.

Take into account comorbidities and current treatment when offering drug treatment for lower urinary tract symptoms.

Do not offer homeopathy, phytotherapy or acupuncture.

Indication	Treatment	Review (assess symptoms and effect of the drugs on quality of life, and ask about any adverse effects)
Moderate to severe lower urinary tract symptoms	Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin)	At 4–6 weeks, then every6–12 months
Overactive bladder	Offer an anticholinergic	At 4–6 weeks until stable, then every 6–12 months
	Mirabegron is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effectsa. People currently receiving mirabegron that is not recommended for them above should be able to continue treatment until they and their clinician consider it appropriate to stopa.
Lower urinary tract symptoms and a prostate estimated to be larger than 30 g or PSA greater than1.4 ng/ml, and high risk of progression	Offer a 5-alphareductase inhibitor	At 3–6 months, then every6–12 months
Bothersome moderate to severe lower urinary tract symptoms, and a prostate estimated to be larger than 30 g or PSA greater than1.4 ng/ml	Consider an alpha blocker plus a 5-alpha reductase inhibitor	At 4–6 weeks, then every6–12 months for the alpha blocker At 3–6 months, then every6–12 months for the 5-alphareductase inhibitor
aThese recommendations are from Mirabegron for treating symptoms of overactive bladder(NICE technology appraisal guidance 290). NICE has written information for the public explaining its guidance on mirabegron.

Consider offering a late afternoon loop diuretic¹ for nocturnal polyuria.

Consider offering oral desmopressin² for nocturnal polyuria if other medical causes have been excluded and the man has not benefited from other treatments. (Other medical causes include diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, obstructive apnoea, dependent oedema, pyelonephritis, chronic venous stasis, sickle cell anaemia, calcium channel blockers, diuretics, and selective serotonin reuptake inhibitor antidepressants.) Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.

Tadalafil for the treatment of symptoms associated with benign prostatic hyperplasia (terminated appraisal)

The appraisal of tadalafil for the treatment of symptoms associated with benign prostatic hyperplasia (NICE technology appraisal 273) was terminated because no evidence submission was received from the manufacturer or sponsor of the technology. Therefore NICE is unable to make a recommendation about the use in the NHS of tadalafil for symptoms associated with benign prostatic hyperplasia.

If lower urinary tract symptoms do not respond to drug treatment

If lower urinary tract symptoms do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery).

Quality standards

The following quality statement is relevant to this part of the pathway.6Medication review

Referral for specialist assessment

Refer men for specialist assessment if they have:

• lower urinary tract symptoms complicated by recurrent or persistent urinary tract infection or
• retention (see managing retention in this pathway) or
• renal impairment you suspect is caused by lower urinary tract dysfunction or
• suspected urological cancer or
• stress urinary incontinence.

Offer to refer men for specialist assessment if they have bothersome lower urinary tract symptoms that have not responded to conservative management or drug treatment.

Specialist assessment

Offer:

• an assessment of general medical history to identify possible causes and comorbidities, including a review of all current medication (including herbal and over-the counter medication) that may be contributing to the problem
• a physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination
• flow-rate and post void residual volume measurement.

Ask men to complete a urinary frequency volume chart.

When to offer further tests or procedures

Offer cystoscopy to men with lower urinary tract symptoms having specialist assessment only when clinically indicated, for example if there is a history of any of the following:

• recurrent infection or
• sterile pyuria or
• haematuria or
• profound symptoms or
• pain.

Offer imaging of the upper urinary tract to men with lower urinary tract symptoms having specialist assessment only when clinically indicated, for example if there is a history of any of the following:

• chronic retention or
• haematuria or
• recurrent infection or
• sterile pyuria or
• profound symptoms or
• pain.

Consider offering multichannel cystometry if men are considering surgery.

Offer pad tests only if the degree of urinary incontinence needs to be measured.

PSA testing

Offer men information, advice and time to decide if they wish to have PSA testing if:

• their lower urinary tract symptoms are suggestive of bladder outlet obstruction secondary to benign prostate enlargement or
• their prostate feels abnormal on digital rectal examination or
• they are concerned about prostate cancer (manage suspected prostate cancer in line with the pathway on prostate cancer and referral guidelines for suspected cancer).

Quality standards

Specialist assessment – flow rate and post-void residual volume

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) are offered a measurement of flow rate and post-void residual volume, as part of their specialist assessment.

Rationale

Measuring flow rate and post-void residual volume by post-micturition bladder scan allows a healthcare professional with specific training to more accurately determine the cause of the LUTS (for example, prostatic obstruction). Both measurements are performed as part of a specialist assessment and are non-invasive and time efficient.

Definitions of terms used in this quality statement

Flow rate

Flow rate refers to the speed at which the urine is passed in millilitres of urine passed per second (ml/s).

Post-void residual volume

Post-void residual volume can be measured by portable non-invasive ultrasound devices, which scan and calculate the volume of urine in the bladder.

The following quality statement is relevant to this part of the pathway.7Specialist assessment – flow rate and post-void residual volume

Managing retention in men with lower urinary tract symptoms

Acute retention

Immediately catheterise men with acute retention.

Offer an alpha blocker to men before removing the catheter.

Chronic urinary retention

Carry out a serum creatinine test and imaging of the upper urinary tract.

Catheterisation

Catheterise men who have impaired renal function or hydronephrosis secondary to chronic urinary retention.

Consider offering intermittent or indwelling catheterisation before offering surgery (also see surgery in this pathway).

Consider offering intermittent self- or carer-administered urethral catheterisation before offering indwelling catheterisation.

If surgery is not suitable, continue or start long-term catheterisation (see long-term catheterisation and containment in this pathway).

Consider offering intermittent self- or carer-administered urethral catheterisation instead of surgery in men who you suspect have markedly impaired bladder function.

NICE has produced guidance on preventing infections relating to catheterisation. See the NICE pathway Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care.

Active surveillance

If not catheterising, provide active surveillance (post void residual volume measurement, upper tract imaging and serum creatinine testing).

Considering surgery without prior catheterisation

Consider offering surgery on the bladder outlet without prior catheterisation to men who have chronic urinary retention and other bothersome lower urinary tract symptoms but no impairment of renal function or upper renal tract abnormality.

Surgery for voiding symptoms

Offer surgery only if voiding symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate. Discuss the alternatives to and outcomes from surgery.

Surgery for voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement

Prostate size	Type of surgery
All	Monopolar or bipolar TURP, monopolar TUVP orHoLEP. Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place
Estimated to be smaller than 30 g	TUIP as an alternative to other types of surgery (TURP, monopolar TUVP or HoLEP)
Estimated to be larger than 80 g	TURP, TUVP or HoLEP, or open prostatectomy as an alternative. Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place

If offering surgery to manage voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement, offer botulinum toxin injection into the prostate only as part of a randomised controlled trial.

If offering surgery to manage voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement, offer the following only as part of a randomised controlled trial that compares these techniques with TURP:

• laser vaporisation techniques
• bipolar TUVP
• monopolar or bipolar TUVRP.

Do not offer any of the following as an alternative to TURP, TUVP or HoLEP:

• TUNA
• TUMT
• HIFU
• TEAP
• laser coagulation.

Interventional procedures

NICE has published interventional procedures guidance on the use of the following procedures with normal arrangements for clinical governance, consent and audit:

• insertion of prostatic urethral lift implants to treat lower urinary tract symptoms secondary to benign prostatic hyperplasia
• holmium laser prostatectomy
• transurethral electrovaporisation of the prostate

NICE has published interventional procedures guidance on the use of the following procedure with special arrangements for clinical governance, consent and audit or research:

• laparoscopic prostatectomy for benign prostatic obstruction

NICE has published interventional procedures guidance on the use of the following procedure which should be used only in the context of research

• prostate artery embolisation for benign prostatic hyperplasia

The TURis system for transurethral resection of the prostate

The following recommendations are from NICE medical technologies guidance on the TURis system for transurethral resection of the prostate.

The case for adopting the transurethral resection in saline (TURis) system for resection of the prostate is supported by the evidence. Using bipolar diathermy with TURis instead of a monopolar system avoids the risk of transurethral resection syndrome and reduces the need for blood transfusion. It may also reduce the length of hospital stay and hospital readmissions.

Using the transurethral resection in saline (TURis) system instead of monopolar transurethral resection of the prostate (TURP) results in an estimated saving of £71 per patient for hospitals that already use an Olympus monopolar system and an estimated additional cost of £20 per patient for other hospitals. However, there is some evidence of a reduction in readmissions with the TURis system compared with monopolar TURP. If this evidence is included, using the TURis system results in an estimated saving of £375 per patient for hospitals that already use an Olympus monopolar system and an estimated saving of £285 per patient for other hospitals.

Surgery for storage symptoms

If offering surgery for storage symptoms, consider offering only to men whose storage symptoms have not responded to conservative management and drug treatment. Discuss the alternatives of containment or surgery. Inform men that effectiveness, side effects and long-term risks of surgery are uncertain.

If considering offering surgery for storage lower urinary tract symptoms, refer men to a urologist to discuss:

• the surgical and non-surgical options appropriate for their circumstancesand
• the potential benefits and limitations of each option, particularly long-term results.

Do not offer myectomy to manage detrusor overactivity.

Indication	Type of surgery
Detrusor overactivity	Consider offering: Cystoplasty. Before offering, discuss serious complications (that is, bowel disturbance, metabolic acidosis, mucus production and/or mucus retention in the bladder, urinary tract infection and urinary retention). The man needs to be willing and able to self-catheterise Bladder wall injection with botulinum toxin. (At the time of publication [February 2012], botulinum toxin did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.) The man needs to be willing and able to self-catheterise Implanted sacral nerve stimulation
Stress urinary incontinence	Consider offering: implantation of an artificial sphincter intramural injectables, implanted adjustable compression devices and male slings only as part of a randomised controlled trial
Intractable urinary tract symptoms if cystoplasty or sacral nerve stimulation are not clinically appropriate or are unacceptable to the man	Consider offering urinary diversion

Interventional procedures

NICE has published interventional procedures guidance on the use of the following procedures with normal arrangements for clinical governance, consent and audit:

• percutaneous posterior tibial nerve stimulation for overactive bladder syndrome
• laparoscopic augmentation cystoplasty (including clam cystoplasty)
• sacral nerve stimulation for urge incontinence and urgency-frequency

Surgery for storage symptoms

If offering surgery for storage symptoms, consider offering only to men whose storage symptoms have not responded to conservative management and drug treatment. Discuss the alternatives of containment or surgery. Inform men that effectiveness, side effects and long-term risks of surgery are uncertain.

If considering offering surgery for storage lower urinary tract symptoms, refer men to a urologist to discuss:

• the surgical and non-surgical options appropriate for their circumstancesand
• the potential benefits and limitations of each option, particularly long-term results.

Do not offer myectomy to manage detrusor overactivity.

Indication	Type of surgery
Detrusor overactivity	Consider offering: Cystoplasty. Before offering, discuss serious complications (that is, bowel disturbance, metabolic acidosis, mucus production and/or mucus retention in the bladder, urinary tract infection and urinary retention). The man needs to be willing and able to self-catheterise Bladder wall injection with botulinum toxin. (At the time of publication [February 2012], botulinum toxin did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.) The man needs to be willing and able to self-catheterise Implanted sacral nerve stimulation
Stress urinary incontinence	Consider offering: implantation of an artificial sphincter intramural injectables, implanted adjustable compression devices and male slings only as part of a randomised controlled trial
Intractable urinary tract symptoms if cystoplasty or sacral nerve stimulation are not clinically appropriate or are unacceptable to the man	Consider offering urinary diversion

Interventional procedures

NICE has published interventional procedures guidance on the use of the following procedures with normal arrangements for clinical governance, consent and audit:

• percutaneous posterior tibial nerve stimulation for overactive bladder syndrome
• laparoscopic augmentation cystoplasty (including clam cystoplasty)
• sacral nerve stimulation for urge incontinence and urgency-frequency

Long-term catheterisation and containment

Consider offering long-term indwelling urethral catheterisation if medical management has failed and surgery is not appropriate, and the man:

• is unable to manage intermittent self-catheterisation or
• has skin wounds, pressure ulcers or irritation that are being contaminated by urine or
• is distressed by bed and clothing changes.

Discuss the practicalities, benefits and risks of long-term indwelling catheterisation with the man and, if appropriate, his carer.

Explain that indwelling catheters for urgency incontinence may not result in continence or the relief of recurrent infections.

Consider permanent use of containment products only after assessment and excluding other methods of management.