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.
- Renal impairment secondary to bladder outlet obstruction ie hydronephrosis
- Nocturnal enuresis
- Neurological symptoms
- Suspicion of prostate or bladder cancer
- Benign prostatic obstruction, most likely diagnosis age 55 - 80
- Overactive bladder
- Nocturnal polyuria
- Detrusor failure
- Prostate cancer
- Sleep apnoea
- Neurological conditions
Management prior to referral:
Straightforward LUTS can be reasonably managed in primary care.
- 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
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.
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.
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
NICE, LUTS in men, February 2015
Mr Christopher Blake, Consultant Urologist, RCHT
Dr rnow RMS Guideline lead Urology