Male Lower Urinary Tract Symptoms

Scope

This guidance covers the diagnosis and management of males over 18 years, with male lower urinary tract symptoms (LUTS) − storage, voiding, and post-micturition − across primary and secondary care.

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

Pre-choice Triage is currently active for this specialty.

Out of scope

Assessment

Signs and Symptoms

Storage symptoms
  • Daytime urinary frequency
  • Nocturia link to Nocturia CRG
  • 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 Flags

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

Investigations

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

Management

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

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

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 CCG – 15N
Referral to local continence service

e-Referral service selection:

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

Referral Forms

DRSS Referral form

Supporting Information

Pathway Group

This guideline has been signed off on behalf of the Devon CCG.

Publication date: July 2020

Last updated: 03-07-2020

 

Home > Referral > Western locality > Urology > Male Lower Urinary Tract Symptoms

 

  • First line
  • Second line
  • Specialist
  • Hospital