Lower urinary tract symptoms in men - NICE guideline

Lower urinary tract symptoms (LUTS) comprise storage, voiding and post‑micturition symptoms affecting the lower urinary tract. There are many possible causes of LUTS such as abnormalities or abnormal function of the prostate, urethra, bladder or sphincters. In men, the most common cause is benign prostate enlargement (BPE), which obstructs the bladder outlet. BPE happens when the number of cells in the prostate increases, a condition called benign prostatic hyperplasia.

Other conditions that can cause LUTS include detrusor muscle weakness or overactivity, prostate inflammation (prostatitis), urinary tract infection, prostate cancer and neurological disease. This clinical guideline will advise on the effective evidence‑based management of LUTS in men.

LUTS in men are best categorised into voiding, storage or post‑micturition symptoms to help define the source of the problem. Voiding symptoms include weak or intermittent urinary stream, straining, hesitancy, terminal dribbling and incomplete emptying. Storage symptoms include urgency, frequency, urgency incontinence and nocturia. The major post‑micturition symptom is post‑micturition dribbling, which is common and bothersome. Although LUTS do not usually cause severe illness, they can considerably reduce men's quality of life, and may point to serious pathology of the urogenital tract.

LUTS are a major burden for the ageing male population. Age is an important risk factor for LUTS and the prevalence of LUTS increases as men get older. Bothersome LUTS can occur in up to 30% of men older than 65 years. This is a large group potentially requiring treatment.

Key priorities for implementation

Initial assessment

• At initial assessment, offer men with LUTS an assessment of their general medical history to identify possible causes of LUTS, and associated comorbidities. Review current medication, including herbal and over‑the‑counter medicines, to identify drugs that may be contributing to the problem.
• At initial assessment, offer men with LUTS a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a digital rectal examination (DRE).
• At initial assessment, ask men with bothersome LUTS to complete a urinary frequency volume chart. 
• Refer men for specialist assessment if they have LUTS complicated by recurrent or persistent urinary tract infection, retention, renal impairment that is suspected to be caused by lower urinary tract dysfunction, or suspected urological cancer.

Conservative management

• Offer men with storage LUTS (particularly urinary incontinence) temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed.
• Offer men with storage LUTS suggestive of overactive bladder (OAB) supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products.

Surgery for voiding symptoms

• If offering surgery for managing voiding LUTS presumed secondary to BPE, offer monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place.
• If offering surgery for managing voiding LUTS presumed secondary to BPE, do not offer minimally invasive treatments (including transurethral needle ablation [TUNA], transurethral microwave thermotherapy [TUMT], high‑intensity focused ultrasound [HIFU], transurethral ethanol ablation of the prostate [TEAP] and laser coagulation) as an alternative to TURP, TUVP or HoLEP.

Providing information

• Make sure men with LUTS have access to care that can help with:
  • their emotional and physical conditions and
  • relevant physical, emotional, psychological, sexual and social issues.
• Provide men with storage LUTS (particularly incontinence) containment products at point of need, and advice about relevant support groups.

You can read the guideline on NICE's website.