The management of lower urinary tract symptoms in men continued

Conservative management

Storage symptoms

• If you suspect OAB, offer supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products

• Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy. Advise men to continue the exercises for at least 3 months before considering other options

• Do not offer penile clamps

Containment products

• For men with storage LUTS (particularly urinary incontinence):
  • offer temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed
  • offer a choice of containment products based on individual circumstances and in consultation with the man
  • offer external collecting devices (sheath appliances, pubic pressure urinals) before considering indwelling catheterisation
  • provide containment products at point of need, and advice about relevant support groups

Voiding symptoms

• Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation if LUTS cannot be corrected by less invasive measures

• Tell men with proven bladder outlet obstruction that bladder training is less effective than surgery

• Explain to men with post micturition dribble how to perform urethral milking

Drug treatment

• Offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate

• Take into account comorbidities and current treatment when offering drug treatment for LUTS

• Do not offer homeopathy, phytotherapy or acupuncture

• Consider offering a late afternoon loop diuretic^† for nocturnal polyuria

• Consider offering oral desmopressin^‡ for nocturnal polyuria if other medical causes^§ have been excluded and the man has 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

• If LUTS do not respond to drug treatment, discuss active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgery)

The management of lower urinary tract symptoms in men continued

Surgery for voiding symptoms

• If offering surgery for managing voiding LUTS presumed secondary to benign prostate enlargement (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 (see above)

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

Treatment options for LUTS

Indication	Treatment	Review*
Moderate to severe LUTS	Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin)	At 4–6 weeks, then every 6–12 months
OAB	Offer an anticholinergic	At 4–6 weeks until stable, then every 6–12 months
LUTS and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/ml, and high risk of progression	Offer a 5-alpha reductase inhibitor	At 3–6 months, then every 6–12 months
Bothersome moderate to severe LUTS, and a prostate estimated to be larger than 30 g or PSA greater than 1.4 ng/ml	Consider an alpha blocker plus a 5-alpha reductase inhibitor	At 4–6 weeks, then every 6–12 months for the alpha blocker At 3–6 months, then every 6–12 months for the 5-alpha reductase inhibitor
Storage symptoms despite treatment with an alpha blocker alone	Consider adding an anticholinergic	At 4–6 weeks until stable, then every 6–12 months
*Review to assess symptoms and the effect of the drugs on the man’s quality of life, and to ask about any adverse effects

* Manage suspected prostate cancer in line with ‘Prostate cancer: diagnosis and management’ (NICE clinical guideline 58) and ‘Referral guidelines for suspected cancer’ (NICE clinical guideline 27)

^† At the time of publication (May 2010), 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 (May 2010), 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

^§ Including 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, calcium channel blockers, diuretics, and selective serotonin reuptake inhibitor (SSRI) antidepressants

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG97

National Institute for Health and Clinical Excellence. The management of lower urinary tract symptoms in men. May 2010