Male Lower Urinary Tract Symptoms (LUTS)

• Evidence from digital rectal examination of a hard, irregular prostate
• Elevated or rising age-specific PSA. Rough guide to normal PSA levels (ng/ml):
  • Less than 60 years < 3
  • Aged 60-69 years < 4
  • Aged 70-79 years < 5

These figures are a pragmatic aid based on clinical consensus. The principles of Realistic Medicine should be applied when considering referral and, in older men, routine or no referral may be appropriate for PSA levels of:

• Aged 80-85 years > 10
• Aged 86 years and over > 20

A PSA test may be raised within three days of ejaculation or six weeks of a proven UTI, catheterisation or other invasive procedure, such as prostate biopsy. 5 alpha reductase inhibitors such as finasteride may reduce the PSA level. Please refer men with more than one PSA to stratify whether referral should proceed along a cancer pathway or otherwise. It should be noted that the majority of men with prostate cancer have no symptoms at all.

Initially, a urine infection and urinary retention should be ruled out and other medical conditions or medications which result in LUTS should be optimised e.g. diabetes, cardiac failure, renal failure and neurological conditions.

The severity of LUTS and response to treatment is categorised using the International Prostate Severity Scoring (IPSS) tool (see below). Many patients can be managed in the community with the following recommendations from NICE and European Association of Urology (EAU) guidelines.

– trial for 3 months:

• Education and reassurance
• Fluid intake: at least 1.5L per day to maintain adequate hydration, limiting fluid intake to thirst, 2-3 hours before bedtime.
• Avoid caffeinated/fizzy drinks/alcohol as these can cause bladder irritation and worsen urgency.
• Pelvic floor exercises at least 3x per day and bladder retraining exercises can help with incontinence and urgency symptoms. These should be continued for a minimum of 6 weeks.
• Maintain a normal BMI to reduce the pressure on the pelvic floor.
• Avoid constipation
• Use of relaxed and double voiding times
• urethral milking to prevent post-micturition dribble

• Moderate-severe LUTS:

Currently available α1-blockers are: alfuzosin hydrochloride (alfuzosin); doxazosin mesylate (doxazosin); silodosin; tamsulosin hydrochloride (tamsulosin); terazosin hydrochloride (terazosin); and naftopidil.

• • Side effects include: dizziness, drowsiness, weakness, nausea, diarrhoea
  • headache, chest pain, abnormal ejaculation, decreased amount of semen
  • back pain, blurred vision, fever, chills, body aches, flu symptoms.

• Enlarged prostate or high risk of progression of symptoms: 5 alpha reductase inhibitor – review at 6months
  • Side effects include: Sexual dysfunction, breast abnormalities; skin reactions
  • Rare side effects: Angioedema; severe depression; infertility male; palpitations; testicular pain

• Moderate – severe LUTS with prostatic enlargement: Combination therapy of above
• Storage LUTS: Add an anti-cholinergic or B3 agonist (Mirabegron 50mg OD) to the above - review at 6weeks
• Risk factors for progression of symptoms - older men, poor urinary flow, higher symptom score, bladder decompensation (chronic urinary retention), larger prostates, or higher PSA levels.

If medical management fails, and the patient wishes to pursue further treatment please refer to secondary care. This may include further tests, including a flow test, post void residual scan and potentially invasive urodynamics to guide further management including surgery.

This chart above is a very important part of the preparation you need for your appointment with your health professional. It will help provide them with information that may relate to your symptoms and may be useful in making a diagnosis and providing treatment.  

Please keep the diary for a minimum of 3 days and continue your normal eating/drinking patterns as well as daily activities. This will give a record of how much you normally drink (fluid intake), how much urine you pass, and how often you empty your bladder on a daily basis as well as any leakage you have. Bring this form with you when you next attend the clinic.

Please record as accurately as possible on this form the quota of fluids you drink and volume of urine you pass. Please record the fluids in millitres (1 fluid ounce = 30ml). Each time you pass urine you will need to catch it in a container calibrated in volumes.

What you need to do

For a minimum of 3 days and nights record how much you drink (intake) and how much urine you pass (output) - they DO NOT have to be 3 days in a row. • Pick days which will be convenient for you to measure and record everything

• A plastic jug which measures in millilitres (mls) or ounces (oz)
• If you pass urine but cannot measure put a √ in the appropriate column

PLEASE FILL THIS IN THIS VALIDATED QUESTIONNAIRE TO HELP GUIDE YOUR TREATMENT