Male Lower Urinary Tract Symptoms


Lower urinary tract symptoms may be classed as: 

Storage:                    Frequency, nocturia, urgency, incontinence

Voiding:                    Hesitancy, poor flow, terminal dribbling

Post voiding:            Post micturition dribble


Indications for referral: 

  • Failed medical/conservative treatment and patient bothered by symptoms.
  • UTI
  • Renal impairment secondary to bladder outlet obstruction ie hydronephrosis
  • Nocturnal enuresis
  • Neurological symptoms
  • Suspicion of prostate or bladder cancer  
  • Consider referral if hematuria
  • Consider referral if sterile pyuria

Differential diagnosis: 

  • Benign prostatic obstruction, most likely diagnosis age 55 - 80
  • Overactive bladder
  • Nocturnal polyuria
  • Detrusor failure
  • Prostate cancer
  • CCF
  • Sleep apnoea
  • Neurological conditions 

Management prior to referral:

Straightforward LUTS can be reasonably managed in primary care. 

Initial investigations:

  • Urine dipstick
  • Frequency volume chart (drinking/voiding diary for 3days)
    • to assess type and quantity of fluids prior to conservative treatments
    • to diagnose nocturnal polyuria (1/3 total 24hr urine output passes at night)
  • Check renal function if suspected chronic urinary retention (LUTS with palpable bladder/raised post void residual); recurrent UTs; history of renal stones
  • If suspected chronic retention- renal USS to exclude hydronephrosis
  • Consider PSA test - if bladder outlet obstruction symptoms or abnormal prostate examination
    • Routine PSA testing if normal DRE and over 75years is not advocated
    • (Informed consent/counselling re interpretation of results - see patient information below)
    • Delay PSA testing if – active UTI, ejaculation or strenuous exercise within last 48hrs, prostate biopsy within last 6 weeks)
  • Post void residual bladder scan (where available, NB need voided volume> 150mls for validity)
    • Residual volume <150ml not significant. 


Conservative treatment options for storage symptoms: 

  • Aim fluid intake (1.5 litres/day) and avoid drinking after 6pm if nocturia
  • Avoid bladder irritants-caffeinated/fizzy /alcoholic drinks/spicy & acidic foods/artificial sweeteners
  • If peripheral oedema and nocturia, elevate legs in evenings
  • Supervised bladder training/pelvic floor exercises –  refer directly to continence service/physio 
  • Bulbar urethral milking: for post micturition dribbling.


Medical treatment:

Initiate drug treatment after/in-combination with behavioural Tx. 

  • Alpha blocker (Uroselective eg. tamsulosin/alfuzosin) 
  • 5-alpha reductase inhibitor (eg. finasteride/dutasteride) in addition to alpha blocker for large prostates  - large prostate:  >30cc, “plum” on rectal examination, or PSA > 1.4) 
  • Anticholinergic (eg. oxybutynin, tolterodine, fesoterodine, trospium xl, solifenacin etc) Consider in addition to above if storage symptoms (ie. frequency, urgency, nocturia) continue to cause bother.


Recommended drugs:

First line:                          Oxybutinin 5mg (2.5mg elderly?) bd-tds, immediate release  tolterodine 2mg bd

Second line (once daily): Solifenacin (Vesicare) 5/10mg; Fesoteridine (Toviaz 4/8mg;

                                        Trospium (Regurin XL) 60mg; oxybutynin patch (Kentera) twice weekly

Third line:                         Mirabegron (Betmiga) 50mg (25mg if eGFR<30)


Consider Mirabegron earlier if cognitive side effect of anticholinergics are of concern


Response and side effect profiles vary between individuals. It is therefore worth trying at least 3 different preparations if response is limited or side effects are not tolerated.

For products with variable dose (e.g. oxybutynin/vesicare/toviaz) increase as tolerated.


Review efficacy and side effects of alpha blockers/ anticholinergics/ mirabegron 6 weeks after initiation.

Finasteride can take 3-6 months to see full benefit



Patient information:

Psa testing: https://prostatecanceruk.org/prostate-information/prostate-tests/psa-test?scrollTo=advantages-disadvantages






NICE, LUTS in men, February 2015




Mr Christopher Blake, Consultant Urologist, RCHT

Dr Bridgitte Wesson, GP & Kernow RMS Guideline lead Urology


Date reviewed 08/11/21

Next review due 08/11/22