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Male Lower Urinary Tract Symptoms

Definition:

 Lower urinary tract symptoms may be:

 

Storage:                    Frequency, nocturia, urgency, incontinence

Voiding:                     Hesitancy, poor flow, terminal dribbling

Post voiding:            Post micturition dribble

 

Differential diagnosis: 

  • Benign prostatic obstruction, most likely diagnosis age 55 - 80
  • Overactive bladder
  • Nocturnal polyuria
  • Detrusor failure
  • Prostate cancer
  • CCF
  • Sleep apnoea
  • Neurological conditions

 

Management prior to referral:

Straightforward LUTS can be reasonably managed in primary care.

 

Initial investigations:

  • Urine dipstick -(treat haematuria, sterile pyuria on merits) 
  • Frequency volume chart (drinking and voiding diary for 3 days)
    • to assess type and quantity of fluids prior to conservative treatments
    • to diagnose nocturnal polyuria(>1/3 total 24hr urine output passed at night)
  • Flow tests and post void residual bladder scan (where available, NB need voided volume> 150mls and 2-3 voids for validity). 

 

Conservative treatment options for storage symptoms: 

  • Reduce fluid (1.5 litres/day) and caffeine intake
  • Supervised bladder training/pelvic floor exercises –  refer directly to continence service/physio 
  • Bulbar urethral milking: for post micturition dribbling.

 

Medical treatment:

Initiate drug treatment after/in-combination with behavioural Tx. 

  • Alpha blocker (Uroselective eg. tamsulosin/alfuzosin) 
  • 5-alpha reductase inhibitor (eg. finasteride/dutasteride) in addition to alpha blocker for large prostates  - large prostate:  >30cc, “plum” on rectal examination, or PSA > 1.4) 
  • Anticholinergic (eg. oxybutynin, tolterodine, fesoterodine, trospium xl, solifenacin etc) Consider in addition to above if storage symptoms (ie. frequency, urgency, nocturia) continue to cause bother.

 

Pharmacutical management of OAB has been reviewed by NICE (2013) and the Local Drugs and Theraputics Committee (2014). Recommended drugs:

First line (generic):                Oxybutinin 5mg (2.5mg elderly?) bd-tds, immediate release tolteradine 2mg bd

Second line (once daily):       Solifenacin (Vesicare), 5/10mg fesoteridine (Toviaz) 4/8mg, trospium (Regurin XL) 60mg, oxybutinin patch                                                 (Kentera) twice weekly
Third line:                              Mirabegron (Betmiga) 50mg (25mg if eGFR<30)

Notes:

Response and side effect profiles vary between individuals. It is therefore worth trying at least 3 different preparations if response is limited or side effects are not tolerated.

For products with variable dose (e.g. oxybutynin/vesicare/toviaz) increase as tolerated. Mirabegron is a new Beta-3 agonist, trial data suggests similar efficacy to anticholinergics (may be better tolerated).

NICE suggest a review of efficacy and side effects with each drug used, perhaps at 6-12 weeks after initiation.

Indications for referral: 

  • Failed medical/conservative treatment and patient bothered by symptoms.
  • UTI
  • Renal impairment secondary to bladder outlet obstruction ie hydronephrosis
  • Nocturnal enuresis
  • Neurological symptoms
  • Suspicion of prostate or bladder cancer  (see separate guidelines)