Male lower urinary tract symptoms

Scope

This guidance covers the diagnosis and management of males over 18 years, with male lower urinary tract symptoms (LUTS) − storage, voiding, and post-micturition − across primary and secondary care.

Red Flag/Urgently refer patients if:

  • A suspicion of prostate or bladder cancer see 2WW referral
  • Storage symptoms in a heavy smoker
  • Chronic retention which may present as night time enuresis / over flow incontinence and/ or painless palpable bladder needs renal function checking and refer urgently

Pre-choice Triage is currently active for this specialty.

Out of scope

  • Management of male urinary tract infections
  • Management of acute urinary retention

Assessment

Signs and Symptoms

Storage symptoms
  • Daytime urinary frequency
  • Nocturia
  • Urinary urgency (overactive bladder)
  • Urinary incontinence
  • Altered bladder sensations
Voiding symptoms
  • Slow stream
  • Splitting or spraying
  • Intermittency, hesitancy
  • Straining
  • Incomplete emptying, terminal dribble
  • Double voiding
  • Acute urinary retention
Post-micturition symptoms
  • Post-micturition dribble
  • Sensation of incomplete emptying

History and Examination

Assessment of symptoms
  • Ask the patient why they have consulted
    • Anxiety regarding prostate cancer may be the main reason
  • Ask him to keep a voiding diary or frequency/volume chart for three days to use in interpreting symptoms
  • Assess the severity of urinary symptoms over the last month, (using a validated scoring system such as the International Prostate Symptom Score (IPSS)
  • Assess for factors that may aggravate urinary symptoms such as:
    • Medications
    • Alcohol and caffeine consumption
    • Constipation
  • Ask about the use of herbal treatments, such as saw palmetto
  • Ask about the presence of sexual problems
  • Check medications:
    • Drugs with an antimuscarinic action (such as tricyclic antidepressants, sedating antihistamines, antimuscarinic drugs for urinary incontinence, and disopyramide). Source Clinical Knowledge Summaries (cks)
    • Drugs such as calcium channel blockers, diuretics, and SSRIs can cause night time polyuria. Source cks
    • Night time sedatives reduce the awareness of micturition need
    • Alpha blockers can cause stress incontinence
Examination
  • On abdominal examination, the bladder may be palpable if there is urinary retention
  • Assess prostate for evidence of malignancy
    • Enlargement alone is not predictive of malignancy
  • Examine the external genitalia to exclude phimosis

Red Flags

Red Flag/Urgently refer patients if:
  • A suspicion of prostate or bladder cancer see 2WW referral
  • Storage symptoms in a heavy smoker
  • Chronic retention which may present as night time enuresis / over flow incontinence and/ or painless palpable bladder needs renal function checking and refer urgently

Investigations

Consider asking the patient to complete a voiding diary chart, especially in the assessment of nocturia or suspected overactive bladder.

All patients should have:

  • Urinalysis and
  • Renal function test and
  • Some patients (see below) should have a discussion about Prostate specific antigen (PSA)
  • ? Hba1c
  • ? Calcium

Use urine dipsticks to identify:

  • Haematuria
  • Glycosuria
  • Pyuria and nitrites are not specific for UTI although may suggest infection
  • Further investigation is required if haematuria is detected - see Haematuria guideline
  • Proteinuria

Prostate specific antigen (PSA) with appropriate counselling:

  • Offer men with lower urinary tract symptoms (LUTS) 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 prostatic hyperplasia (BPH)
    • Their prostate feels abnormal on digital rectal examination (DRE)
    • They are concerned about prostate cancer
  • Urinary infection should be excluded by urinary dipstick before PSA testing, especially in men presenting with lower tract symptoms
  • The PSA test should be postponed for at least 3 months after treatment of a proven urinary infection or catheterisation

Management

For Non-bothersome symptoms:

Provide the following for men presenting with lower urinary tract symptoms (LUTS) which are not bothersome or complicated:

  • Give explanation and information on their condition
  • Offer advice on lifestyle interventions, e.g. fluid intake
  • Offer review if symptoms change
For Bothersome voiding symptoms:

Lower urinary tract symptoms (LUTS) that are troublesome and have an impact on quality of life (QoL)

Mild symptoms - International Prostate Symptom Score (IPSS) score 0-7

  • Provide the following:
    • Give explanations of lifestyle intervention and review if symptoms change in the community

Moderate 8-19

  • Consider the above plus offering alpha blockers, if improvement is not seen after 2 weeks consider referral to Urology

Severe greater than 19

For Bothersome Storage symptoms:

If predominantly storage symptoms (confirm with frequency volume chart)

  • Give advice on the modification of the type of fluids consumed − advise patients to:
    • Reduce the intake of fluids containing alcohol, caffeine and artificial sweeteners
    • Avoid carbonated drinks
    • Be aware some foods can increase fluid intake
  • CKS advises referral to bladder and bowel and trial of antimuscarinics or mirabegron second line
  • If symptoms progress consider referral to Urology
For Post-micturition symptoms:

Post-void milking:

  • This is a technique used to improve post micturition dribble (PMD)
  • Involves drawing the tips of the fingers behind the scrotum and pushing up and forward to expel the pooled urine
  • Explain to men with post-micturition dribble how to perform urethral milking
  • If milking is ineffective a referral to Urology is unlikely to add benefit for the patient. In this instance containment products might be considered.

Joint Formulary – Chapter 7

​Referral

Referral Criteria

For Storage and Voiding symptoms:

Please include in referral letter the following results from investigations:

  • Urinalysis
  • Renal function test
  • PSA (if done)

Please note these referrals are subject to Pre-choice Triage.

Significant caffeine intake has the potential to cause clinically significant LUTS and should be minimised prior to referral.

Referral Instructions

Referral to Urology

e-Referral Service Selection

  • Specialty: Urology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS – Urology Eastern – New Devon CCG – 99p
Referral to local bladder & bowel service

This service is not available on e-Referrals

Referral Forms

DRSS referral form

Supporting Information

IPSS leaflet

Bladder diary

Pathway Group

This guideline has been signed off on behalf of the Eastern Locality of NEW Devon CCG.

Publication date: November 2017

 

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