Active Surveillance

General Lifestyle Measures:

• Adopt a prudent fluid intake (excessive limitation increases complication risks e.g., urinary tract infection).
• Limit intake of caffeine, artificial sweeteners, and fizzy drinks.
• Avoid constipation (or treat if present).
• Maintain a healthy lifestyle (body weight, exercise, diet, smoking, alcohol).

Post micturition dribble:

• Provide guidance on urethral milking (a patient information leaflet is available from RDUH).

Nocturnal Polyuria:

• Exclude or manage treatable causes.
• Advise limiting fluid intake in the late afternoon and evening.
• For further advice, see NICE CKS for LUTS in men or the local Clinical Referral Guideline for nocturia (northern locality / eastern locality)

Suspected or Confirmed Overactive Bladder:

• Exclude or manage treatable causes - see NICE CKS for LUTS in men or the local Clinical Referral Guideline for male LUTS (northern locality / eastern locality). 
• N.B. It is often not possible to identify a specific cause.

Conservative Management

Lifestyle measures (See Active Surveillance, above).

Consider referral to Bladder and Bowel Care Services and Continence Advisory Teams

• Northern locality
• Eastern locality
• Interventions may include, pelvic floor muscle training and bladder training, and advice on lifestyle measures and containment products.
  

Containment products and catheters:

• A range of absorbent pads or pants are commercially available at pharmacies or supermarkets.
• The following products (where appropriate) may be available through continence services (see above):
  • Incontinence pads or pants for severe intractable urinary incontinence.
  • Urinals, toileting aids, and external sheath systems (See 18.1 Sheath systems).
  • Intermittent self-catheterisation (See 18.2 intermittent catheters).

Drug treatment is indicated where conservative management with lifestyle advice (see above) is unsuccessful or not appropriate.

Offer an alpha blocker:

• Tamsulosin capsules modified release; 400micrograms once daily.
• See section 7.4.1 Drugs for urinary retention.

If tamsulosin not tolerated:

• Switch to alfuzosin tablets.
  • Immediate-release: 2.5mg 3 times a day, adjusted according to response to 10mg daily. Lower initial dose (2.5mg twice daily) for elderly.
  • Modified release: 10mg once daily. MR are only recommended where alfuzosin immediate release tablets are effective but not tolerated.
• See Section 7.4.1 Drugs for urinary retention.

Review at 4-6 weeks, then every 6-12 months to re-assess symptoms and quality of life (consider using an IPSS questionnaire) and identify any adverse effects.

Men with voiding symptoms AND an enlarged prostate (>30g or a PSA level >1.4ng/ml) with a high risk of symptom progression*:

Offer an alpha blocker (as above) AND a 5-alpha reductase inhibitor:

• Finasteride tablets; 5mg once daily.
• See section 6.4.2 Male sex hormones and antagonists.
• Do not use a 5-alpha reductase/alpha blocker combination product (e.g., tamsulosin with dutasteride); costs are higher with no difference in clinical benefit over the separate prescribing of individual drugs.

Review at 4-6 weeks, then every 6-12 months, to re-assess symptoms and quality of life (consider using an IPSS questionnaire) and identify any adverse effects. For men undergoing PSA monitoring: Recheck PSA level after 6 months of treatment; 5-alpha reductase inhibitors can cause a decrease in mean serum PSA levels (see 6.4.2 Male sex hormones and antagonists). If symptoms do not improve after 6 months of drug treatment (a 5-alpha reductase inhibitor and an alpha blocker), consider a referral to urology.

*The risk of progression of symptoms from benign prostatic hyperplasia is higher in older men and in men with poorer urine flow, higher symptom scores, evidence of bladder decompensation (such as chronic urinary retention), larger prostates, or higher PSA levels.

Drug treatment is indicated where conservative management with lifestyle advice (see above) is unsuccessful or not appropriate.

Chronic retention can present with frequency (particularly in the elderly). If there is doubt, arrange a bladder scan prior to initiating drug treatment.

Offer an anticholinergic drug:

• Solifenacin tablets; 5 mg once daily, increased if necessary to 10 mg once daily (see 7.4.2 Drugs for urinary frequency).
• If the patient is at risk of cognitive impairment (e.g., dementia) consider trospium tablets (immediate release); 20mg twice daily, before food (see 7.4.2 Drugs for urinary frequency). Where trospium is ineffective or not tolerated, consider vibegron or mirabegron (see below).

If symptoms persist (after 4-6 weeks) or solifenacin not tolerated:

• Switch to tolterodine tablets (immediate release); 2mg twice daily, reduced to 1mg twice daily if not tolerated (see 7.4.2 Drugs for urinary frequency).
  • Modified release tablets (4mg once daily) are only indicated where tolterodine immediate release tablets are effective but not tolerated.

If the above options are effective but not tolerated:

• Switch to fesoterodine; 4 mg once daily, increased if necessary up to 8 mg once daily (see 7.4.2 Drugs for urinary frequency).

If the above anticholinergic drugs are contraindicated, not tolerated, or not effective:

• Switch to vibegron tablets 75mg once daily or mirabegron tablets modified release 50mg once daily (see 7.4.2 Drugs for urinary frequency).

Darifenacin and oxybutynin are not routinely recommended for initiation in primary care without advice and guidance from urology; treatment may be continued in established patients (See 7.4.2 Drugs for urinary frequency for further details).

For all anticholinergic drugs  / beta-3 adrenoreceptor agonists (vibegron or mirabegron):

Review every 4-6 weeks until symptoms stabilise, then every 6-12 months, to re-assess symptoms and quality of life (consider using an IPSS questionnaire), and to identify any adverse effects (consider assessing anticholinergic burden e.g., acbcalc.com).

If symptoms do not improve following a trial of two or more anticholinergics and/or a beta-3 adrenoreceptor agonist (vibegron or mirabegron) (as above) consider a referral to urology. Management options may include specialist drug treatment (e.g., botulinum toxin type A for urinary incontinence due to detrusor overactivity; See 4.9.3).

Drug treatment is indicated where conservative management with lifestyle advice (see above) is unsuccessful or not appropriate.

Offer an alpha blocker:

• Tamsulosin capsules modified release; 400micrograms once daily (or alfuzosin hydrochloride tablets).
• See "Voiding Symptoms" above for additional information (including advice for men with an enlarged prostate, when to review, and when to consider referral).

Review at 4-6 weeks, then every 6-12 months to re-assess symptoms and quality of life (consider using an IPSS questionnaire) and identify any adverse effects.

If symptoms persist (after 4-6 weeks), consider adding an antimuscarinic:

• Solifenacin tablets; 5mg once daily, increased if necessary to 10mg once daily.
• If the patient is at risk of cognitive impairment (e.g., dementia), consider trospium tablets (immediate release); 20mg twice daily, before food.
• See "Storage Symptoms" above for additional information (including further treatment options, when to review, and when to consider referral).
• Do not use a combination alpha blocker / anticholinergic product (e.g., solifenacin with tamsulosin); costs are higher with no difference in clinical benefit over the separate prescribing of individual drugs.

Drug treatment is indicated where nocturnal polyuria remains bothersome despite attempts to exclude or manage treatable causes and the use of conservative management with lifestyle advice (see above) is unsuccessful or not appropriate.

For further advice, see NICE CKS for LUTS in men or the local Clinical Referral Guideline for nocturia:

• Northern locality
• Eastern locality

Consider a loop diuretic:

• Furosemide tablets; 20mg to 40mg once daily in the late afternoon (off-label).
• If already prescribed a diuretic, consider moving a morning dose to a mid-afternoon dose.
• See NICE CKS for LUTS in men for further details.

If furosemide is ineffective or not appropriate:

• Consider a referral to urology.
• Desmopressin may be appropriate if recommended by a specialist (continence service or urology); sublingual tablets 50 micrograms once daily, one hour before bedtime (See 6.5.2 Posterior pituitary hormones and antagonists).