Lower Urinary Tract Symptoms (LUTS) in men

 

Lower urinary tract symptoms (LUTS) comprise storage, voiding and post-micturition symptoms affecting the lower urinary tract.  Voiding symptoms include weak or intermittent urinary stream, straining, hesitancy, terminal dribbling and incomplete emptying. Storage symptoms include urgency, frequency, urgency incontinence and nocturia. The major post-micturition symptom is post-micturition dribbling, which is common and bothersome

There are many possible causes of LUTS such as abnormalities or abnormal function of the prostate, urethra, bladder or sphincters. In men, the most common cause is benign prostate enlargement (BPE), which obstructs the bladder outlet.  Age is an important risk factor for LUTS and the prevalence of LUTS increases as men get older. Bothersome LUTS can occur in up to 30% of men older than 65 years, who may go on to require surgery/treatment

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Exclude Red Flag Symptoms

Exclude the following red flag symptoms:

  • Visible (frank) haematuria (in adults) and recurrent non-visible haematuria if >40 years of age
  • Solid swelling in body of testis
  • Palpable renal mass
  • Elevated age specific PSA in men with ten year life expectancy
  • High PSA (>20  ng/ml) in man with clinically malignant prostate or bone pain
  • Any suspected penile cancer

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Assessment

  1. Establish what type (or combination of types) of lower urinary tract symptoms (LUTS) the man has by asking about:
    1. Storage (irritative) symptoms:  urgency, daytime urinary frequency, nocturia, urinary incontinence, and feeling the need to urinate again just after passing urine
    2. Voiding (obstructive) symptoms:  hesitancy, weak or intermittent urinary stream sometimes causing splitting or spraying, straining, intermittency, incomplete emptying, and terminal dribbling
    3. Post-micturition symptoms:  post-micturition dribble, and the sensation of incomplete emptying
  2. Assess symptom severity and impact quality of life by asking the man to complete: 
    1. an urinary frequency and volume chart for at least 3 days
    2. the International Prostate Symptom Score (IPSS)
      1. These will help with pin pointing the diagnosis e.g. high frequency with variable volumes suggests overactive bladder
  3. Exclude or manage other causes, including serious causes of LUTS, including:
    1. urological cancer
    2. urological infection
    3. sciatica

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Examination

  1. Examine the abdomen for signs of a distended bladder such as abdominal distention and suprapubic dullness on percussion
  2. Check the external genitalia to identify conditions which may cause or contribute to LUTS, for example urethral discharge, phimosis, meatal stenosis, or penile cancer
  3. Perform a digital rectal examination to assess the prostate for size, consistency, nodules, and tenderness
  4. Examine the perineum and/or lower limbs to evaluate motor and sensory function

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Investigations

  1. Dipstick test the urine to check for blood, glucose, protein, leucocytes, and nitrites
  2. Measure U&E and eGFR if clinically indicated (e.g. chronic urinary retention, recurrent UTI, history of renal stones)
  3. Offer advice and information on PSA testing and consider performing if have voiding symptoms and/or abnormal feeling prostate.  Patient Decision Aid on PSA testing takes a patient through the risks and benefits and limitations of the PSA test as a screening tool

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Advice on PSA testing

Prior to the test men should not have:

  • UTI (treat and test after 1 month)
  • Ejaculated in previous 48 hours
  • Performed vigorous exercise in previous 48 hours
  • Had a prostate biopsy in previous 6 weeks
  • Had a DRE in previous week

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Indications for referral

Referral for the following indications is recommended:

  • Acute retention of urine (admit immediately)
  • Acute kidney injury (admit immediately)
  • Visible haematuria (to be seen in two weeks)
  • Suspicion of prostate cancer based on the finding of a nodular or firm prostate, or a raised PSA level, or both (to be seen in two weeks)
  • Culture-negative dysuria (to be seen in two weeks)
  • Chronic urinary retention with overflow or night-time incontinence (to be seen in two weeks)
  • Recurrent UTI
  • Microscopic haematuria
  • Failure to respond to treatment in primary care with poor quality of life as assessed by the IPSS

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Management

  1. NICE flowchart for Management of LUTS
  2. 'Kent and Medway Catheter and Accessories First Choice' List - Dec 2018

Managing voiding (obstructive) symptoms

  1. Exclude or manage causes of voiding symptoms, if possible
  2. Offer the man a choice of first-line management options, including active surveillance (reassurance and lifestyle advice without immediate treatment, with regular follow up) and conservative management (pelvic floor muscle training, bladder training, prudent fluid intake, maintaining a healthy lifestyle, and containment products)
  3. If active surveillance is not appropriate and conservative management fails, offer an alpha-blocker (alfuzosin, doxazosin, tamsulosin, or terazosin) for men with moderate-to-severe voiding symptoms (International Prostate Symptom Score (IPSS) of 8 or more).  Review the man at 4–6 weeks, and then every 6–12 months. Assess symptoms, quality of life, and adverse effects.  Offer a 5-alpha reductase inhibitor (dutasteride or finasteride) for men with an enlarged prostate and who are considered at high risk of progression
  4. If treatment fails to adequately relieve symptoms consider offering referral to a urologist for assessment and further management

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Managing overactive bladder

  1. Exclude or manage treatable causes of overactive bladder, if possible
  2. Advise the man on fluid intake and lifestyle measures, and offer information on self-help resources
  3. Offer a choice of temporary urinary containment products, if necessary (such as sheath and leg bags, absorbent bags, and absorbent pants) and refer them to the Kent Continence Service
  4. Offer referral for supervised bladder training
  5. If symptoms persist, offer an antimuscarinic (anticholinergic) drug:  oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) can be used first line.  Review the man every 4–6 weeks until symptoms are stable, and then every 6–12 months. Assess symptoms, quality of life, adverse effects, and the need to continue treatment
  6. If an antimuscarinic drug is contraindicated, not tolerated, or not effective, offer mirabegron (depending on local prescribing policy)
  7. If treatment fails, refer the man for specialist urological assessment and management

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Managing nocturnal polyuria

  1. Exclude or manage treatable causes of nocturnal polyuria
  2. Advise the man to limit his fluid intake in the late afternoon and evening, and offer information on self-help resources
  3. If limiting fluid intake in the late afternoon and evening is ineffective, consider offering a loop diuretic to be taken in the late afternoon. For example, furosemide 40 mg (off-label use)
  4. If nocturnal polyuria remains bothersome, refer the man or seek specialist advice about switching to oral desmopressin to be taken at bedtime (off-label use).  Start treatment with the lowest dose of 200 micrograms

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Managing stress urinary incontinence

  1. If necessary, offer a choice of temporary urine containment products (such as sheath and leg bags, absorbent pads, and absorbent pants) to achieve social continence
  2. Refer the man to the Kent Continence Service
  3. Advise the man on fluid intake and lifestyle measures, and offer information on self-help resources
  4. If stress urinary incontinence is not caused by prostatectomy, refer the man for specialist assessment to confirm the cause
  5. If stress urinary incontinence is caused by prostatectomy, offer referral for supervised pelvic floor muscle training.  Advise that the exercises should be performed for at least 3 months before considering referral to secondary care for assessment for other invasive treatment options

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Managing urinary retention

Acute urinary retention

If this is the first episode of acute urinary retention:

  • If the expertise and facilities are available, catheterize before admission
  • Otherwise, admit the man urgently for catheterization and investigation of the cause

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If the man has recurrent acute retention, or acute-on-chronic urinary retention:

  • Admit the man, or insert a urethral catheter

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Chronic urinary retention

  1. Exclude non-obstructive causes of reduced urine flow (such as chronic heart failure)
  2. Check serum creatinine to assess renal function
  3. Refer the man for specialist assessment

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Managing post-micturition dribble

  1. Assess the severity of the symptoms by asking 'What protection do you need to cope with the leakage?'
  2. Advise the man that he can reduce the post micturition dribbling by 'milking' his urethra after urinating:  urethral milking (when the bulbar urethra is massaged) eliminates post-micturition dribble when the muscles surrounding the urethra do not completely drain it of urine. Urethral milking is unlikely to help if the post-micturition dribble is caused by urinary obstruction

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Information to include in referral letter

Include the following information when making a referral:

  • Medication tried to date
  • Bladder diary
  • PSA result or IPSS, where relevant
  • Relevant past medical / surgical history
  • Current regular medication
  • BMI/ Smoking status
  • Counsel your patients that they are likely to have a prostate biopsy and mention you have done so

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International Prostate Symptom Score

Use the International Prostate Symptom Score (IPSS) calculator to access the severity of systems.  The score can then be used to tailor treatment

The IPSS has 2 parts:

  1. Symptom Score – mild 0-7, moderate 8-19 and severe 20-35
  2. Quality of life (>4 equates to bothersome effect on QoL)

A 30g prostate equates to being able to sweep 2 finger widths and represents clinically significant enlargement.  PSA > 1.4ng/l has a higher risk of progression

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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