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Lower urinary tract symptoms in men
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Introduction
This pathway covers the management of lower urinary tract symptoms in men.
Lower urinary tract symptoms are storage, voiding and post-micturation symptoms affecting the lower urinary tract. Lower urinary tract symptoms can significantly reduce men's quality of life, and may point to serious pathology of the urogenital tract. Bothersome lower urinary tract symptoms can occur in up to 30% of men older than 65 years. Uncertainty and variation exist in clinical practice, so this pathway gives clear recommendations on assessing, monitoring and treating lower urinary tract symptoms.
Source guidance
The NICE guidance that was used to create the pathway.
Lower urinary tract symptoms: the management of lower urinary tract symptoms in men. NICE clinical guideline 97 (2010)
Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome. NICE interventional procedure guidance 362 (2010)
Laparoscopic augmentation cystoplasty (including clam cystoplasty). NICE interventional procedure guidance 326 (2009)
Laparoscopic prostatectomy for benign prostatic obstruction. NICE interventional procedure guidance 275 (2008)
Sacral nerve stimulation for urge incontinence and urgency-frequency. NICE interventional procedure guidance 64 (2004)
Holmium laser prostatectomy. NICE interventional procedure guidance 17 (2003)
Transurethral electrovaporisation of the prostate. NICE interventional procedure guidance 14 (2003)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Information about lower urinary tract symptoms in men
Information about surgery
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
26 April 2013 Link to 'Prostate artery embolisation for benign prostatic hyperplasia' (NICE interventional procedure guidance 453) added to surgery for voiding symptoms.
Supporting information
Glossary
A painful inability to pass urine and the presence of a distended, tender palpable bladder.
Symptoms that that are worrying, troublesome or have an impact on quality of life from the patient's perspective.
For the purposes of this pathway, chronic urinary retention is defined as residual volume greater than 1 litre or presence of a palpable/percussable bladder
High-intensity focused ultrasound
Holmium laser enucleation of the prostate.
Assessment in any setting by a healthcare professional without specific training in managing lower urinary tract symptoms in men.
An International Prostate Symptom Score of 0–7.
An International Prostate Symptom Score of 8–19.
Prostate specific antigen.
An International Prostate Symptom Score of 20–35.
Assessment in any setting by a healthcare professional with specific training in managing lower urinary tract symptoms in men.
Storage symptoms include daytime urinary frequency, nocturia, urgency and urinary incontinence.
Transurethral ethanol ablation of the prostate
Transurethral incision of the prostate.
Transurethral microwave thermotherapy
Transurethral needle ablation
Transurethral resection of the prostate.
Transurethral vaporisation of the prostate.
Transurethral vaporisation resection of the prostate
Voiding symptoms include slow stream, splitting or spraying, intermittency, hesitancy, straining and terminal dribble.
Man with lower urinary tract symptoms
Man with lower urinary tract symptoms
Information and support
Information and support
Information and support
Make sure men with lower urinary tract symptoms have access to care that can help with:
- their emotional and physical conditions and
- relevant physical, emotional, psychological, sexual and social issues.
Ensure that, if appropriate, men's carers are informed and involved in managing their lower urinary tract symptoms and can give feedback on treatments.
NICE has produced information for the public explaining this guidance.
NICE has produced information for the public explaining the guidance on referral guidelines for suspected cancer.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInitial assessment
Initial assessment
Initial assessment
Offer:
- an assessment of general medical history to identify possible causes and comorbidities, including a review of all current medication (including herbal and over-the-counter medication) that may be contributing to the problem
- a physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination
- a urine dipstick test to detect blood, glucose, protein, leucocytes and nitrites.
Ask men with bothersome lower urinary tract symptoms to complete a urinary frequency volume chart.
Offer a serum creatinine test (plus estimated glomerular filtration rate calculation) only if you suspect renal impairment (for example, the man has a palpable bladder, nocturnal enuresis, recurrent urinary tract infections or a history of renal stones).
For men whose lower urinary tract symptoms are not bothersome or complicated, give reassurance, offer advice on lifestyle interventions (for example, fluid intake) and information on their condition. Offer review if symptoms change.
For men with mild or moderate bothersome lower urinary tract symptoms, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management, drug treatment or surgery).
Offer men considering treatment for lower urinary tract symptoms an assessment of their baseline symptoms with a validated symptom score (for example, the International Prostate Symptom Score).
PSA testing
Offer men information, advice and time to decide if they wish to have PSA testing if:
- their lower urinary tract symptoms are suggestive of bladder outlet obstruction secondary to benign prostate enlargement or
- their prostate feels abnormal on digital rectal examination or
- they are concerned about prostate cancer (manage suspected prostate cancer in line with the pathway on prostate cancer and referral guidelines for suspected cancer).
Tests that should not be offered routinely
Do not routinely offer:
- cystoscopy to men with no evidence of bladder abnormality
- imaging of the upper urinary tract to men with no evidence of bladder abnormality
- flow-rate measurement
- post void residual volume measurement.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeConservative management
Conservative management
Conservative management
Storage symptoms
If you suspect overactive bladder, offer supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products.
Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy. Advise men to continue the exercises for at least 3 months before considering other options.
Do not offer penile clamps.
Containment products
For men with storage lower urinary tract symptoms (particularly urinary incontinence):
- offer temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
- offer a choice of containment products based on individual circumstances and in consultation with the man
- offer external collecting devices (sheath appliances, pubic pressure urinals) before considering indwelling catheterisation (see long-term catheterisation and containment in this pathway).
- provide containment products at point of need, and advice about relevant support groups.
Voiding symptoms
Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation (see long-term catheterisation and containment in this pathway) if lower urinary tract symptoms cannot be corrected by less invasive measures.
Tell men with proven bladder outlet obstruction that bladder training is less effective than surgery.
Explain to men with post micturition dribble how to perform urethral milking.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDrug treatment
Drug treatment
Drug treatment
Offer drug treatment only to men with bothersome lower urinary tract symptoms when conservative management options have been unsuccessful or are not appropriate.
Take into account comorbidities and current treatment when offering drug treatment for lower urinary tract symptoms.
Do not offer homeopathy, phytotherapy or acupuncture.
Indication | Treatment | Review (assess symptoms and effect of the drugs on quality of life, and ask about any adverse effects) |
|---|---|---|
Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) | At 4–6 weeks, then every 6–12 months | |
Overactive bladder | Offer an anticholinergic | At 4–6 weeks until stable, then every 6–12 months |
Lower urinary tract symptoms and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/ml, and high risk of progression | Offer a 5-alpha reductase inhibitor | At 3–6 months, then every 6–12 months |
Bothersome moderate to severe lower urinary tract symptoms, and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/ml | Consider an alpha blocker plus a 5-alpha reductase inhibitor | At 4–6 weeks, then every 6–12 months for the alpha blocker At 3–6 months, then every 6–12 months for the 5-alpha reductase inhibitor |
Storage symptoms despite treatment with an alpha blocker alone | Consider adding an anticholinergic | At 4–6 weeks until stable, then every 6–12 months |
Consider offering a late afternoon loop diureticAt the time this pathway was created (October 2012), loop diuretics (for example, furosemide) did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. for nocturnal polyuria.
Consider offering oral desmopressinAt the time this pathway was created (October 2012), desmopressin did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Consult the summary of product characteristics for the contraindications and precautions. for nocturnal polyuria if other medical causes have been excluded and the man has not benefited from other treatments. (Other medical causes include diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, obstructive apnoea, dependent oedema, pyelonephritis, chronic venous stasis, sickle cell anaemia, calcium channel blockers, diuretics, and selective serotonin reuptake inhibitor antidepressants.) Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.
If lower urinary tract symptoms do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeReferral for specialist assessment
Referral for specialist assessment
Referral for specialist assessment
Refer men for specialist assessment if they have:
- lower urinary tract symptoms complicated by recurrent or persistent urinary tract infection or
- retention (see managing retention in this pathway) or
- renal impairment you suspect is caused by lower urinary tract dysfunction or
- suspected urological cancer or
- stress urinary incontinence.
Offer to refer men for specialist assessment if they have bothersome lower urinary tract symptoms that have not responded to conservative management or drug treatment.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSpecialist assessment
Specialist assessment
Specialist assessment
Offer:
- an assessment of general medical history to identify possible causes and comorbidities, including a review of all current medication (including herbal and over-the counter medication) that may be contributing to the problem
- a physical examination guided by symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination
- flow-rate and post void residual volume measurement.
Ask men to complete a urinary frequency volume chart.
When to offer further tests or procedures
Offer cystoscopy to men with lower urinary tract symptoms having specialist assessment only when clinically indicated, for example if there is a history of any of the following:
- recurrent infection or
- sterile pyuria or
- haematuria or
- profound symptoms or
- pain.
Offer imaging of the upper urinary tract to men with lower urinary tract symptoms having specialist assessment only when clinically indicated, for example if there is a history of any of the following:
- chronic retention or
- haematuria or
- recurrent infection or
- sterile pyuria or
- profound symptoms or
- pain.
Consider offering multichannel cystometry if men are considering surgery.
Offer pad tests only if the degree of urinary incontinence needs to be measured.
PSA testing
Offer men information, advice and time to decide if they wish to have PSA testing if:
- their lower urinary tract symptoms are suggestive of bladder outlet obstruction secondary to benign prostate enlargement or
- their prostate feels abnormal on digital rectal examination or
- they are concerned about prostate cancer (manage suspected prostate cancer in line with the pathway on prostate cancer and referral guidelines for suspected cancer).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSurgery for voiding symptoms
Surgery for voiding symptoms
Surgery for voiding symptoms
Offer surgery only if voiding symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate. Discuss the alternatives to and outcomes from surgery.
Surgery for voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement
Prostate size | Type of surgery |
|---|---|
All | |
Estimated to be smaller than 30 g | TUIP as an alternative to other types of surgery (TURP, monopolar TUVP or HoLEP) |
Estimated to be larger than 80 g | TURP, TUVP or HoLEP, or open prostatectomy as an alternative. Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place |
If offering surgery to manage voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement, offer botulinum toxin injection into the prostate only as part of a randomised controlled trial.
If offering surgery to manage voiding lower urinary tract symptoms presumed secondary to benign prostate enlargement, offer the following only as part of a randomised controlled trial that compares these techniques with TURP:
Do not offer any of the following as an alternative to TURP, TUVP or HoLEP:
NICE interventional procedures guidance
NICE interventional procedures guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use, and whether special arrangements are needed for patient consent. The interventional procedures NICE considers are usually new, but NICE also issues guidance for established procedures when there is uncertainty about their safety or how well they work. The following NICE interventional procedure guidance is relevant to this part of the pathway.
Laparoscopic prostatectomy for benign prostatic obstruction
Current evidence on the safety and efficacy of laparoscopic prostatectomy for benign prostatic obstruction is inadequate in both quantity and quality. Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit or research.
Clinicians wishing to undertake laparoscopic prostatectomy for benign prostatic obstruction should take the following actions.
- Inform the clinical governance leads in their Trusts.
- Ensure that patients understand the uncertainty about the procedure's safety and efficacy, make them aware of alternative treatment options and provide them with clear written information. In addition, use of NICE's information for the public is recommended.
This procedure should only be carried out by surgeons with special training and experience in laparoscopic radical prostatectomy. BAUS has produced training standards.
Patients should only be offered this procedure if they would otherwise be considered for open prostatectomy, rather than transurethral resection, for benign prostatic obstruction.
NICE may review the procedure on publication of further evidence.
These recommendations are from laparoscopic prostatectomy for benign prostatic obstruction (NICE interventional procedure guidance 275).
Holmium laser prostatectomy
Current evidence on the safety and efficacy of holmium laser prostatectomy appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.
Clinicians undertaking this procedure require specialist training. The British Association of Urological Surgeons has agreed to produce training standards.
These recommendations are from holmium laser prostatectomy (NICE interventional procedure guidance 17).
NICE has produced information for the public explaining this guidance.
Transurethral electrovaporisation of the prostate
Current evidence on the safety and efficacy of transurethral electrovaporisation of the prostate appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.
These recommendations are from transurethral electrovaporisation of the prostate (NICE interventional procedure guidance 14).
NICE has produced information for the public explaining this guidance.
Prostate artery embolisation for benign prostatic hyperplasia
NICE has produced guidance on prostate artery embolisation for benign prostatic hyperplasia (NICE interventional procedure guidance 453).
Surgery for storage symptoms
Surgery for storage symptoms
Surgery for storage symptoms
If offering surgery for storage symptoms, consider offering only to men whose storage symptoms have not responded to conservative management and drug treatment. Discuss the alternatives of containment or surgery. Inform men that effectiveness, side effects and long-term risks of surgery are uncertain.
If considering offering surgery for storage lower urinary tract symptoms, refer men to a urologist to discuss:
- the surgical and non-surgical options appropriate for their circumstances and
- the potential benefits and limitations of each option, particularly long-term results.
Do not offer myectomy to manage detrusor overactivity.
Indication | Type of surgery |
|---|---|
Detrusor overactivity | Consider offering:
|
Stress urinary incontinence | Consider offering:
|
Intractable urinary tract symptoms if cystoplasty or sacral nerve stimulation are not clinically appropriate or are unacceptable to the man | Consider offering urinary diversion |
NICE interventional procedures guidance
NICE interventional procedures guidance makes recommendations on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use, and whether special arrangements are needed for patient consent. The interventional procedures NICE considers are usually new, but NICE also issues guidance for established procedures when there is uncertainty about their safety or how well they work. The following NICE interventional procedure guidance is relevant to this part of the pathway.
Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome
Current evidence on percutaneous posterior tibial nerve stimulation (PTNS) for overactive bladder syndrome shows that it is efficacious in reducing symptoms in the short and medium term.
There are no major safety concerns. Therefore the procedure may be used provided that normal arrangements are in place for clinical governance, consent and audit.
These recommendations are from percutaneous posterior tibial nerve stimulation for overactive bladder syndrome (NICE interventional procedure guidance 362).
NICE has produced information for the public explaining this guidance.
Sacral nerve stimulation for urge incontinence and urgency-frequency
Current evidence on the safety and efficacy of sacral nerve stimulation for urge incontinence and urgency-frequency appears adequate to support the use of this procedure provided that the normal arrangements are in place for consent, audit and clinical governance.
Patient selection is important. The diagnosis should be defined as clearly as possible and the procedure limited to patients who have not responded to conservative treatments such as lifestyle modifications, behavioural techniques and drug therapy. Patients should be selected on the basis of their response to peripheral nerve evaluation.
These recommendations are from sacral nerve stimulation for urge incontinence and urgency-frequency (NICE interventional procedure guidance 64).
NICE has produced information for the public explaining this guidance.
Laparoscopic augmentation cystoplasty (including clam cystoplasty)
Current evidence on the safety and efficacy of laparoscopic augmentation cystoplasty (including clam cystoplasty) is limited in quantity and quality but raises no major safety concerns, and the open procedure is well established. This procedure may therefore be used with normal arrangements for clinical governance, consent and audit.
Patient selection and treatment should be carried out by a multidisciplinary team with specialist expertise in the management of urinary incontinence and experience in complex laparoscopic reconstructive surgery.
Clinicians undertaking laparoscopic augmentation cystoplasty (including clam cystoplasty) should submit data on all patients undergoing the procedure to the Female and Reconstructive Urology database run by the British Association of Urological Surgeons to allow monitoring of safety outcomes in the long term.
These recommendations are from laparoscopic augmentation cystoplasty (including clam cystoplasty) (NICE interventional procedure guidance 326).
NICE has produced information for the public explaining this guidance.
Managing retention
View the 'Managing retention in men with lower urinary tract symptoms' pathLong-term catheterisation and containment
Long-term catheterisation and containment
Long-term catheterisation and containment
Consider offering long-term indwelling urethral catheterisation if medical management has failed and surgery is not appropriate, and the man:
- is unable to manage intermittent self-catheterisation or
- has skin wounds, pressure ulcers or irritation that are being contaminated by urine or
- is distressed by bed and clothing changes.
Discuss the practicalities, benefits and risks of long-term indwelling catheterisation with the man and, if appropriate, his carer.
Explain that indwelling catheters for urgency incontinence may not result in continence or the relief of recurrent infections.
Consider permanent use of containment products only after assessment and excluding other methods of management.
NICE has produced guidance on preventing infections relating to catheterisation. See the NICE pathway Long-term urinary catheters: prevention and control of healthcare-associated infections in primary and community care.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeUrological cancer services
Urological cancer services
Urological cancer services
NICE has published cancer service guidance on improving outcomes in urological cancers.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: October 2012 Last updated: April 2013
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