Signs and Symptoms

Storage symptoms

• Daytime urinary frequency
• Nocturia
• Urinary urgency (overactive bladder)
• Urinary incontinence
• Altered bladder sensations

Voiding symptoms:

• Slow stream
• Splitting or spraying
• Intermittency, hesitancy
• Straining
• Incomplete emptying, terminal dribble
• Double voiding
• Acute urinary retention

Post-micturition symptoms:

• Post-micturition dribble
• Sensation of incomplete emptying

History and Examination

Assessment of symptoms:

• Ask the patient why they have consulted
  • Anxiety regarding prostate cancer may be the main reason
• Ask him to keep a voiding diary or frequency/volume chart for three days to use in interpreting symptoms
• Assess the severity of urinary symptoms over the last month, (using a validated scoring system such as the International Prostate Symptom Score (IPSS)
• Assess for factors that may aggravate urinary symptoms such as:
  • medications
  • alcohol and caffeine consumption
  • constipation
• Ask about the use of herbal treatments, such as saw palmetto
• Ask about the presence of sexual problems
• Check medications:
  • Drugs with an antimuscarinic action (such as tricyclic antidepressants, sedating antihistamines, antimuscarinic drugs for urinary incontinence, and disopyramide). Source Clinical Knowledge Summaries (CKS)
  • Drugs such as calcium channel blockers, diuretics, and SSRIs can cause night time polyuria. Source CKS
  • Night time sedatives reduce the awareness of micturition need.

Examination:

• On abdominal examination, the bladder may be palpable if there is urinary retention
• Assess prostate for evidence of malignancy
  • Enlargement alone is not predictive of malignancy
• Examine the external genitalia to exclude phimosis

Red Flag/Urgently refer patients if:

• A suspicion of prostate or bladder cancer see 2WW referral
• Storage symptoms in a heavy smoker
• Chronic retention which may present as night time enuresis / over flow incontinence and/ or painless palpable bladder needs renal function checking and refer urgently

Consider asking the patient to complete a voiding diary chart, especially in the assessment of nocturia or suspected overactive bladder.

All patients should have:

• Renal function test AND
• Urinalysis
  • Use urine dipsticks to identify:
    • Haematuria
    • Proteinuria
    • Glycosuria
    • Pyuria and nitrites are not specific for UTI although may suggest infection

Some patients should have:

• Full blood count (FBC) (especially if considering surgery)
• Midstream urine sample (MSU) (to exclude UTI if dipstick positive)
• Prostate specific antigen (PSA)

Prostate specific antigen (PSA) with appropriate counselling:

• Offer men with lower urinary tract symptoms (LUTS) information, advice and time to decide if they wish to have PSA testing if:
  • their LUTS are suggestive of bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH)
  • their prostate feels abnormal on digital rectal examination (DRE)
  • they are concerned about prostate cancer

• Urinary infection should be excluded by urinary dipstick before PSA testing, especially in men presenting with lower tract symptoms
• The PSA test should be postponed for:
  • at least 3 months after treatment of a proven urinary infection or catheterisation

For Non-bothersome symptoms:

Provide the following for men presenting with lower urinary tract symptoms (LUTS) which are not bothersome or complicated:

• Give explanation and information on their condition
• Offer advice on lifestyle interventions, e.g. fluid intake
• Offer review if symptoms change

For Bothersome voiding symptoms:

Lower urinary tract symptoms (LUTS) that are troublesome and have an impact on quality of life (QoL)

Mild symptoms - International Prostate Symptom Score (IPSS) score 0-7

• Provide the following:
  • Give explanations of lifestyle intervention and review if symptoms change in the community

Moderate 8-19

• Consider the above plus offering alpha blockers, if improvement is not seen after 2 weeks consider referral to Urology

Severe greater than 19

• Consider alpha blocker and referral to Urology

For Bothersome Storage symptoms:

If predominantly storage symptoms (confirm with frequency volume chart)

• Give advice on the modification of the type of fluids consumed − advise patients to:
  • reduce the intake of fluids containing alcohol, caffeine and artificial sweeteners
  • avoid carbonated drinks
  • be aware some foods can increase fluid intake
• CKS advises referral to bladder and bowel and trial of antimuscarinics or mirabegron second line
• If symptoms progress consider referral to Urology

For Post-micturition symptoms:

Post-void milking:

• This is a technique used to improve post micturition dribble (PMD)
• Involves drawing the tips of the fingers behind the scrotum and pushing up and forward to expel the pooled urine
• Explain to men with post-micturition dribble how to perform urethral milking

If milking is ineffective a referral to Urology is unlikely to add benefit for the patient. In this instance containment products might be considered.

Referral Criteria

For Storage and Voiding symptoms:

Refer to Urology

Please include in referral letter the following results from investigations:

• Urinalysis
• Renal function test
• PSA

Please note these referrals are subject to Pre-choice Triage.

Significant caffeine intake has the potential to cause clinically significant LUTS and should be minimised prior to referral.

Referral Instructions

Referral to Urology

e-Referral service selection:

• Specialty: Urology
• Clinic Type: Not otherwise specified
• Service: DRSS-Western – Urology – Devon ICB – 15N

Referral to local continence service

e-Referral service selection:

• Specialty: Urology
• Clinic Type: (In) Continence
• Service: DRSS-Western – Urology – Devon ICB – 15N

Referral Form

DRSS Referral form

• IPSS leaflet
• Surgical procedures for the treatment of LUTS caused by BPH

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: July 2020