Lower urinary tract symptoms in men

Lower urinary tract symptoms (LUTS) in men are very common and are present in the majority of men aged > 50 years. They are most commonly secondary to benign prostatic hyperplasia but other causes should be considered including prostate cancer.

It is useful to classify the symptoms into 3 broad groups.

Voiding	Storage	Post-micturition
Hesitancy Poor or intermittent stream Straining Incomplete emptying Terminal dribbling	Urgency Frequency Nocturia Urinary incontinence	Post-micturition dribbling Sensation of incomplete emptying

Examination

urinalysis: exclude infection, check for haematuria
digital rectal examination: size and consistency of prostate
a PSA test may be indicated, but the patient should be properly counselled first

It is useful to get the patient to complete the following to guide management:

urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.
International Prostate Symptom Score (IPSS): assess the impact on the patient's life. This classifies the symptoms as mild, moderate or severe

Management

Predominately voiding symptoms

conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
if 'moderate' or 'severe' symptoms offer an alpha-blocker
if the prostate is enlarged and the patient is 'considered at high risk of progression' then a 5-alpha reductase inhibitor should be offered
if the patient has an enlarged prostate and 'moderate' or 'severe' symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor
if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added

Predominately overactive bladder

conservative measures include moderating fluid intake
bladder retraining should be offered
antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail

Nocturia

advise about moderating fluid intake at night
furosemide 40mg in late afternoon may be considered
desmopressin may also be helpful

+PassMedicine Notes

It is useful to classify the symptoms into 3 broad groups.

Voiding _ Storage _ Post-micturition| Hesitancy Poor or intermittent stream Straining Incomplete emptying Terminal dribbling _ Urgency Frequency Nocturia Urinary incontinence _ Post-micturition dribbling Sensation of incomplete emptying| Examination

urinalysis: exclude infection, check for haematuria
digital rectal examination: size and consistency of prostate
a PSA test may be indicated, but the patient should be properly counselled first