Male Lower Urinary Tract Symptoms

This guideline applies to adults.

In scope: benign prostate hypertrophy

Out of scope: prostate cancer / elevated PSA

Introduction

Lower urinary tract symptoms (LUTS) may be classed as:

Storage: Frequency, nocturia, urgency, incontinence

Voiding: Hesitancy, poor flow, terminal dribbling

Post voiding: Post micturition dribble

Red Flag Features

Urological cancer
Urological infection
Sciatica
Cauda equina syndrome

Examinations and investigations

Consider

DRE
Urine dip
Frequency volume chart (bladder diary):
- to assess type and quantity of fluids prior to conservative treatments
- to diagnose nocturnal polyuria (1/3 total 24hr urine output passes at night)
Renal function: if suspected chronic urinary retention; recurrent UTIs; history of renal stones
Post void residual (PVR) bladder scan: if available and chronic retention suspected. PVR < 150ml is not significant
Renal tract ultrasound: if suspected chronic retention, to exclude hydronephrosis
PSA: if bladder outlet obstruction symptoms or abnormal prostate examination – follow Prostate Cancer and Elevated PSA guideline to inform decision making.

Management Optimisation

Straightforward LUTS can be reasonably managed in primary care.

The NHS Prostate Decision Tool can be used to help explain all aspects of LUTS management from lifestyle modification to medications to new surgical options available if referred to secondary care.

Lifestyle modification

See NHS Prostate Decision Tool, page 5
Bulbar urethral milking is a recognised treatment for post micturition dribbling¹

Medications

Initiate drug treatment after/in-combination with conservative management as tolerated and if not contra-indicated:

Uroselective alpha blocker (e.g. Tamsulosin/Alfuzosin) – 2-3 days to work
5-alpha reductase inhibitor (e.g. Finasteride/Dutasteride) – 3-6 months to see full benefit. Use in addition to alpha blocker for large prostates (“plum” on DRE or PSA > 1.4) .
Anticholinergic (e.g. Oxybutynin, Tolterodine, Fesoterodine, Solifenacin). Consider in addition to alpha-blocker and 5-alpha reductase inhibitor if residual storage symptoms in addition to LUTS.
- Elderly - Use with caution due to increased risks of confusion, dizziness and falls. Use the ACB calculator to work out the anticholinergic burden.
Beta-3 adrenoceptor agonist (e.g. Mirabegron). Offer if anticholinergics are contraindicated, not tolerated or ineffective, or if cognitive side effect of anticholinergics are of concern².
Furosemide: Can be considered in patients with true (bladder diary proven) nocturnal polyuria, once other causes of nocturia have been excluded, given at 3-4pm to help offload fluid before bed³. Avoid starting tamsulosin and furosemide empirically due to increased risk of hypotension/falls. Consider seeking urology advice and guidance if in doubt.

Please note, 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.

Advice and Guidance

There is a Urology Advice and Guidance service available via e-RS.

Referral

Follow relevant guideline for:

Urology Referral:

BPH with LUTS where a 3-month trial of conservative and medical treatments have failed to improve symptoms or are not tolerated, and the patient is bothered by symptoms. A shared decision making approach should be used*
Suspected or confirmed bladder outflow obstruction associated with:*
Urinary tract infections
Bladder stones
Features of neurogenic bladder**
Urinary retention
Renal impairment
Nocturnal enuresis
(Consider referral) if sterile pyuria and no obvious cause found on primary care work-up

*Only men with severe LUTS and a confirmed diagnosis of bladder outflow obstruction will be offered surgical intervention.

**Urinary dysfunction secondary to suspected cauda equina syndrome should be managed as an emergency with admission to ED for a same-day MRI spine.

Bladder and Bowel Specialist Nurse Referral

For supervised bladder training and pelvic floor exercises.

District Nurse Referral (via the usual practice route)

For temporary urine containment products i.e. sheath and leg bags, absorbent pads or pants.

Supporting Information and References

For professionals

NICE CKS: LUTS in men (July 2024)

For patients

References

Page Review Information

Review date	02 May 2025 (partial update)
Next review date	02 May 2026
GP speciality lead	Dr Laura Vines
Contributors	Mr Christopher Blake, Consultant Urologist, RCHT Dr Bridgitte Wesson, former RMS urology speciality lead Ms Helen Teixeira, Consultant Urologist RCHT