Management of lower urinary tract symptoms (LUTS) in men

NICE CG97 Lower urinary tract symptoms (May 2010)

Initial assessment

  • Assess general medical history, including a review of all current medication
  • Offer a physical examination, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE).
  • Offer a urine dipstick test to detect blood, glucose, protein, leucocytes and nitrites. Exclude urinary tract infection (UTI).
  • Ask a man with bothersome LUTS to complete a urinary frequency-volume chart to exclude polyuria, nocturnal polyuria and variable bladder capacity.

For mild to moderate LUTS symptoms conservative management and referral to Bladder and Bowel Care Service should be tried before commencing drug treatment.

Specialist referral

The following requires specialist referral:

  • Acute retention
  • Suspected cancer
  • Renal impairment
  • Chronic retention
  • Complicated LUTS

Prostate Specific Antigen (PSA) testing

NICE CG97 recommends men with LUTS should be offered information, advice and time to decide if they wish to have PSA testing if:

  • Their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement (BPE) or
  • Their prostate feels abnormal on DRE or
  • They are concerned about prostate cancer

It is essential that patients are thoroughly counselled on the meaning and uncertainties surrounding PSA levels to avoid unnecessary worry.

Conservative management

NICE CG97 contains advice on conservative management of LUTS. See below for lifestyle advice.

Lifestyle advice

  • Weight reduction can result in an improvement in symptoms
  • Reduce caffeine intake as this is a bladder stimulant
  • Stop smoking as this is associated with increased risk of incontinence
  • Do not drink more than 2 litres of fluid per day
  • Low fluid intake causing constipation can also provoke incontinence
  • Avoid artificial sweeteners as these can act as bladder stimulants
  • If urgency is a symptom, attempt to hold on as long as possible before going
  • Avoid using the toilet 'just in case'

Voiding (obstructive) symptoms

  1. Discuss active surveillance
  2. Conservative management (if appropriate)
  3. If treatment inappropriate or fails consider the drug treatments below:

Moderate to severe LUTS

Men with prostate volume greater than 30g or PSA greater than 1.4ng/mL considered to be at high risk of progression

  • Offer a 5-alpha reductase inhibitor (finasteride see 6.4 Sex hormones)
  • Recall at 3-6 months, then every 6-12 months

Men with prostate volumes greater than 30g or PSA greater than 1.4ng/mL WITH bothersome LUTS

  • Consider combination of an alpha blocker and a 5-alpha reductase inhibitor (finasteride) (see section 7.4 Drugs for genito-urinary disorders and 6.4 Sex hormones)
  • An attempt to withdraw the alpha blocker may be made at 9-12 months and finasteride continued as monotherapy. If symptoms recur the alpha blocker can be restarted. One further attempt to withdraw the alpha blocker 6 months later would be appropriate.

Alpha blockers in LUTS

  • Alpha blockers can rapidly alleviate symptoms of LUTS but in the long-term do not prevent progression to acute urinary retention or surgery.
  • Short-term use (3-4 months) of an alpha blocker without flow-rate measurement is considered acceptable but good practice would dictate that long-term use should not be undertaken without objective assessment of obstruction. Due to the high placebo effect associated with alpha blockers it is recommended that they are stopped after 3-4 months to see if therapy needs to continue.
  • There is no evidence that there is a difference in efficacy between the alpha blockers and the choice of agent depends upon tolerability and cost. In the frail elderly, alfuzosin or tamsulosin may be considered first line choices.
  • Alpha blockers should not be used in catheterised patients except in preparation for a trial without catheter.
  • Alpha blockers usually start to work within days, but persistence for longer than a week may bring further benefit.

Storage symptoms

  1. Discuss active surveillance
  2. Conservative management (if appropriate)
  3. See section 7.4 Drugs for genito-urinary disorders


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