NICE Guidelines on Lower Urninary Tract symptoms in men

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

In this guidance, 'mild' refers to an International Prostate Symptom Score (IPSS) of 0 to 7, 'moderate' refers to an IPSS of 8 to 19 and 'severe' refers to an IPSS of 20 to 35.

Recommendations are marked as [new 2015] or [2010]:

• [new 2015] indicates that the evidence has been reviewed and the recommendation has been added or updated.


• [2010] indicates that the evidence has not been reviewed since 2010.

The guidelines are as follows:-

Initial Assessment

Initial assessment refers to assessment carried out in any setting by a healthcare professional without specific training in managing lower urinary tract symptoms (LUTS) in men.

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. [2010]

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). [2010]

At initial assessment, ask men with bothersome LUTS to complete a urinary frequency volume chart. [2010]

At initial assessment, offer men with LUTS a urine dipstick test to detect blood, glucose, protein, leucocytes and nitrites. [2010]

At initial assessment, offer men with LUTS information, advice and time to decide if they wish to have prostate specific antigen (PSA) testing if:

• Their LUTS are suggestive of bladder outlet obstruction secondary to benign prostatic enlargement (BPE) or


• Their prostate feels abnormal on DRE or


• They are concerned about prostate cancer [2010]

Manage suspected prostate cancer in men with LUTS in line with the NGC summaries of the NICE guidelines Prostate cancer: diagnosis and treatment and Suspected cancer: recognition and referral. [2010]

At initial assessment, offer men with LUTS a serum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation) only if you suspect renal impairment (for example, the man has a palpable bladder, nocturnal enuresis, recurrent urinary tract infections or a history of renal stones). [2010]

Do not routinely offer cystoscopy to men with uncomplicated LUTS (that is, without evidence of bladder abnormality) at initial assessment. [2010]

Do not routinely offer imaging of the upper urinary tract to men with uncomplicated LUTS at initial assessment. [2010]

Do not routinely offer flow-rate measurement to men with LUTS at initial assessment. [2010]

Do not routinely offer a post void residual volume measurement to men with LUTS at initial assessment. [2010]

At initial assessment, give reassurance, offer advice on lifestyle interventions (for example, fluid intake) and information on their condition to men whose LUTS are not bothersome or complicated. Offer review if symptoms change. [2010]

Offer men referral for specialist assessment if they have bothersome LUTS that have not responded to conservative management or drug treatment. [2010]

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. [2010]

Offer men considering any treatment for LUTS an assessment of their baseline symptoms with a validated symptom score (for example, the IPSS) to allow assessment of subsequent symptom change. [2010]

Specialist Assessment

Specialist assessment refers to assessment carried out in any setting by a healthcare professional with specific training in managing LUTS in men.

Offer men with LUTS having specialist assessment 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. [2010]

Offer men with LUTS having specialist assessment a physical examination guided by urological symptoms and other medical conditions, an examination of the abdomen and external genitalia, and a DRE. [2010]

At specialist assessment, ask men with LUTS to complete a urinary frequency volume chart. [2010]

At specialist assessment, offer men with LUTS information, advice and time to decide if they wish to have PSA testing if:

• Their LUTS are suggestive of bladder outlet obstruction secondary to BPE or


• Their prostate feels abnormal on DRE or


• They are concerned about prostate cancer [2010]

Offer men with LUTS who are having specialist assessment a measurement of flow rate and post void residual volume. [2010]

Offer cystoscopy to men with LUTS having specialist assessment only when clinically indicated, for example if there is a history of any of the following:

• Recurrent infection


• Sterile pyuria


• Haematuria


• Profound symptoms


• Pain [2010]

Offer imaging of the upper urinary tract to men with LUTS having specialist assessment only when clinically indicated, for example if there is a history of any of the following:

• Chronic retention


• Haematuria


• Recurrent infection


• Sterile pyuria


• Profound symptoms


• Pain [2010]

Consider offering multichannel cystometry to men with LUTS having specialist assessment if they are considering surgery. [2010]

Offer pad tests to men with LUTS having specialist assessment only if the degree of urinary incontinence needs to be measured. [2010]

Conservative Management

Explain to men with post micturition dribble how to perform urethral milking. [2010]

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. [2010]

Offer a choice of containment products to manage storage LUTS (particularly urinary incontinence) based on individual circumstances and in consultation with the man. [2010]

Offer men with storage LUTS suggestive of overactive bladder (OAB) supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products. [2010]

Inform men with LUTS and proven bladder outlet obstruction that bladder training is less effective than surgery. [2010]

Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy. Advise them to continue the exercises for at least 3 months before considering other options. [2010]

Refer for specialist assessment men with stress urinary incontinence. [2010]

Do not offer penile clamps to men with storage LUTS (particularly urinary incontinence). [2010]

Offer external collecting devices (for example, sheath appliances, pubic pressure urinals) for managing storage LUTS (particularly urinary incontinence) in men before considering indwelling catheterisation (see recommendation below). [2010]

Offer intermittent bladder catheterisation before indwelling urethral or suprapubic catheterisation to men with voiding LUTS that cannot be corrected by less invasive measures. [2010]

Consider offering long-term indwelling urethral catheterisation to 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 [2010]

If offering long-term indwelling catheterisation, discuss the practicalities, benefits and risks with the man and, if appropriate, his carer. [2010]

Explain to men that indwelling catheters for urgency incontinence may not result in continence or the relief of recurrent infections. [2010]

Consider permanent use of containment products for men with storage LUTS (particularly urinary incontinence) only after assessment and exclusion of other methods of management. [2010]

Drug Treatment

Offer drug treatment only to men with bothersome LUTS when conservative management options have been unsuccessful or are not appropriate. [2010]

Take into account comorbidities and current treatment when offering men drug treatment for LUTS. [2010]

Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) to men with moderate to severe LUTS. [2010]

Offer an anticholinergic to men to manage the symptoms of OAB. [2010]

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). [2010]

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. [2010]

Consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone. [2010]

Consider offering a late afternoon loop diuretic to men with nocturnal polyuria. (Note: At the time of publication [June 2015], loop diuretics [for example, furosemide] did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. [2010]

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. (Note: At the time of publication [June 2015], desmopressin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. 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, and selective serotonin reuptake inhibitors [SSRIs]). [2010]

Do not offer phosphodiesterase-5-inhibitors solely for the purpose of treating LUTS in men, except as part of a randomised controlled trial. [new 2015]

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 [2010]

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. [2010]

Review men taking alpha blockers at 4 to 6 weeks and then every 6 to 12 months. [2010]

Review men taking 5-alpha reductase inhibitors at 3 to 6 months and then every 6 to 12 months. [2010]

Review men taking anticholinergics every 4 to 6 weeks until symptoms are stable, and then every 6 to 12 months. [2010]

Surgery for Voiding Symptoms

For men with voiding symptoms, offer surgery only if voiding symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate. Discuss the alternatives to and outcomes from surgery. [2010]

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. [2010]

Offer transurethral incision of the prostate (TUIP) as an alternative to other types of surgery to men with a prostate estimated to be smaller than 30 g. [2010]

Only offer open prostatectomy as an alternative to TURP, TUVP or HoLEP to men with prostates estimated to be larger than 80 g. [2010]

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. [2010]

If offering surgery for managing voiding LUTS presumed secondary to BPE, only consider offering botulinum toxin injection into the prostate as part of a randomised controlled trial. [2010]

If offering surgery for managing voiding LUTS presumed secondary to BPE, only consider offering laser vaporisation techniques, bipolar TUVP or monopolar or bipolar transurethral vaporisation resection of the prostate (TUVRP) as part of a randomised controlled trial that compares these techniques with TURP. [2010]

Surgery for Storage Symptoms

If offering surgery for storage symptoms, consider offering only to men whose storage symptoms have not responded to conservative management and drug treatment. Discuss the alternatives of containment or surgery. Inform men being offered surgery that effectiveness, side effects and long-term risk are uncertain. [2010]

If considering offering surgery for storage LUTS, refer men to a urologist to discuss:

• The surgical and non-surgical options appropriate for their circumstances and


• The potential benefits and limitations of each option, particularly long-term results [2010]

Consider offering cystoplasty to manage detrusor overactivity only to men whose symptoms have not responded to conservative management or drug treatment and who are willing and able to self-catheterise. Before offering cystoplasty, discuss serious complications (that is, bowel disturbance, metabolic acidosis, mucus production and/or mucus retention in the bladder, urinary tract infection and urinary retention). [2010]

Consider offering bladder wall injection with botulinum toxin to men with detrusor overactivity only if their symptoms have not responded to conservative management and drug treatments and the man is willing and able to self-catheterise. (Note: At the time of publication [June 2015], botulinum toxin A and botulinum toxin B did not have UK marketing authorisations for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. [2010]

Consider offering implanted sacral nerve stimulation to manage detrusor overactivity only to men whose symptoms have not responded to conservative management and drug treatments. [2010]

Do not offer myectomy to men to manage detrusor overactivity. [2010]

Consider offering intramural injectables, implanted adjustable compression devices and male slings to manage stress urinary incontinence only as part of a randomised controlled trial. [2010]

Consider offering urinary diversion to manage intractable urinary tract symptoms only to men whose symptoms have not responded to conservative management and drug treatments, and if cystoplasty or sacral nerve stimulation are not clinically appropriate or are unacceptable to the patient. [2010]

Consider offering implantation of an artificial sphincter to manage stress urinary incontinence only to men whose symptoms have not responded to conservative management and drug treatments. [2010]

Treating Urinary Retention

Immediately catheterise men with acute retention. [2010]

Offer an alpha blocker to men for managing acute urinary retention before removal of the catheter. [2010]

Consider offering self- or carer-administered intermittent urethral catheterisation before offering indwelling catheterisation for men with chronic urinary retention. [2010]

Carry out a serum creatinine test and imaging of the upper urinary tract in men with chronic urinary retention (residual volume greater than 1 litre or presence of a palpable/percussable bladder). [2010]

Catheterise men who have impaired renal function or hydronephrosis secondary to chronic urinary retention. [2010]

Consider offering intermittent or indwelling catheterisation before offering surgery in men with chronic urinary retention. [2010]

Consider offering surgery on the bladder outlet without prior catheterisation to men who have chronic urinary retention and other bothersome LUTS but no impairment of renal function or upper renal tract abnormality. [2010]

Consider offering intermittent self- or carer-administered catheterisation instead of surgery in men with chronic retention who you suspect have markedly impaired bladder function. [2010]

Continue or start long-term catheterisation in men with chronic retention for whom surgery is unsuitable. [2010]

Provide active surveillance (post void residual volume measurement, upper tract imaging and serum creatinine testing) to men with non-bothersome LUTS secondary to chronic retention who have not had their bladder drained. [2010]

Alternative and Complementary Therapies

Do not offer homeopathy, phytotherapy or acupuncture for treating LUTS in men. [2010]

Providing Information

Ensure that, if appropriate, men's carers are informed and involved in managing their LUTS and can give feedback on treatments. [2010]

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 [2010]

Provide men with storage LUTS (particularly incontinence) containment products at point of need, and advice about relevant support groups. [2010]

For full guidelines, click on the following link

NICE Guidelines on Lower Urninary Tract symptoms in men