Management of lower urinary symptoms in men

Conservative management in LUTS

• if a man has post micturition dribble then should be told how to perform urethral milking
  
  
• if storage LUTS (particularly urinary incontinence) then should be offered temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
  
  
• if storage LUTS suggestive of overactive bladder (OAB) then should be offered supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products
  
  
• supervised pelvic floor muscle training should be offered to men with stress urinary incontinence caused by prostatectomy
  • continue the exercises for at least 3 months before considering other options
    
    
• refer for specialist assessment men with stress urinary incontinence
  
  
• external collecting devices (for example, sheath appliances, pubic pressure urinals) should be offered for managing storage LUTS (particularly urinary incontinence) in men before considering indwelling catheterisation
  
  
• intermittent bladder catheterisation should be offered before indwelling urethral or suprapubic catheterisation to men with voiding LUTS that cannot be corrected by less invasive measures
  
  
• long-term indwelling urethral catheterisation should be considered for men with LUTS:
  • for whom medical management has failed and surgery is not appropriate and
  • who are unable to manage intermittent self-catheterisation or
  • with skin wounds, pressure ulcers or irritation that are being contaminated by urine or
  • who are distressed by bed and clothing changes
    
    
• consider permanent use of containment products for men with storage LUTS (particularly urinary incontinence) only after assessment and exclusion of other methods of management

Drug treatment for management of LUTS in men

• offer drug treatment only to men with bothersome LUTS when conservative management options outlined have been unsuccessful or are not appropriate
  
  
• offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) to men with moderate to severe LUTS
  
  
• offer an anticholinergic to men to manage the symptoms of OAB
  
  
• offer a 5-alpha reductase inhibitor to men with LUTS who have prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml, and who are considered to be at high risk of progression (for example, older men)
  
  
• consider offering a combination of an alpha blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and prostates estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml
  
  
• consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone
  
  
• consider offering a late afternoon loop diuretic to men with nocturnal polyuria *
  
  
• consider offering oral desmopressin ** to men with nocturnal polyuria if other medical causes*** have been excluded and they have not benefited from other treatments. Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment.

Review

• discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management, drug treatment or surgery) for:
  • men with mild or moderate bothersome LUTS
  • men whose LUTS fail to respond to drug treatment
• review men taking drug treatments to assess symptoms, the effect of the drugs on the patient's quality of life and to ask about any adverse effects from treatment
• review men taking alpha blockers at 4-6 weeks and then every 6-12 months
• review men taking 5-alpha reductase inhibitors at 3-6 months and then every 6-12 months
• review men taking anticholinergics every 4-6 weeks until symptoms are stable, and then every 6-12 months

Notes:

• * at the time of publication (June 2015), loop diuretics (for example, furosemide) did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented
• ** at the time of publication (June 2015), 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
• *** medical conditions that can cause nocturnal polyuria symptoms 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. Medications that can cause nocturnal polyuria symptoms include calcium channel blockers, diuretics, selective serotonin reuptake inhibitors (SSRI) antidepressants
• Do not offer phosphodiesterase-5-inhibitors solely for the purpose of treating lower urinary tract symptoms in men, except as part of a randomised controlled trial

Reference:

• 1) NICE (June 2015). Lower urinary tract symptoms The management of lower urinary tract symptoms in men