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Management of Lower Urinary Tract Symptoms In Management of Male Lower Urinary Tract Symptoms in Primary Care Male lower urinary tract symptoms (LUTS) are storage, voiding and post micturition symptoms affecting the lower urinary tract. LUTS can significantly reduce men's quality of life and may point to serious pathology of the urogenital tract: . Storage symptoms urgency, daytime urinary frequency, nocturia, urinary incontinence . Voiding symptoms include hesitancy, poor flow, intermittency, incomplete emptying, and terminal dribbling . Post-micturition symptoms: post micturition dribble, and the sensation of incomplete emptying Initial Assessment The international Prostate Symptom Score (IPSS) 1. History Use If: . medical, family, sexual, medication and drug use history . Patient is considering treatment, use to assess baseline symptoms . Urinary Frequency Volume Chart . IPSS Questionnaire . IPS o IPSS score of 0–7 = mild 2. Physical Examination o IPSS score of 8–19 = moderate . Abdomen for signs of distended bladder o IPSS score of 20–35 = severe . External genitalia: potential cause of LUTS such as urethral discharge, phimosis, meatal stenosis or penile cancer . Digital rectal examination: prostate size, consistency, nodules, and tenderness Prostate-Specific Antigen Test (PSA) . Perineum/ lower limbs to evaluate motor and sensory function Perform if: 3. Investigations . Symptoms suggestive of bladder outlet obstruction due to benign prostatic Dipstick test : blood, glucose, protein, leucocytes and nitrites enlargement Serum creatinine and eGFR . family history of prostate cancer . PSA >50 years . DRE abnormal Fasting glucose/ HbA1C Delay PSA test if: Urinary Frequency Volume Chart . Active UTI: delay for 4 weeks . Use if bothersome LUTS . DRE: delay for 1 week . Use to distinguish urinary frequency, polyuria, nocturia and nocturnal polyuria . Ejaculation/ vigorous exercise: delay for 48 hours . Frequency Volume Chart . Prostate biopsy: delay for 6 months Offer patient: Serum Creatinine and eGFR . Patient Information Leaflet PSA Offer only if you suspect: . Discussion on indication, interpretation and implications of results . Renal impairment . Time to decide if they would like to have a test . Palpable bladder . Normal PSA ranges per age group: . Nocturnal enuresis o 50-59 years ≥ 3.0 ng/mL . Recurrent UTI o 60-69 years ≥ 4.0 ng/mL, . History of renal stones o 70 years and over > 5.0 ng/mL Initial Assessment Active surveillance Lifestyle changes Secondary Care Referral Criteria 2 Week Referral Criteria Mild . Reassurance & lifestyle . Limit fluid intake, though not excessively in an . Elevated Cr related to LUTS . Abnormal DRE symp **Risk factors for progression of symptoms: advice attempt to control symptoms . Haematuria toms Older age, poorer urine flow, higher symptom Acute/chronic retention . Offer information on . Maintaining a healthy lifestyle: weight loss, exercise, . Recurrent/ Persistent UTI . Raised PSA non- Reassess 6-12 monthly scores, evidence of bladder decompensation (such their condition diet, smoking cessation, limit alcohol consumption . Suspected urological cancer both as chronic urinary retention), larger prostates, H/O renal stones . Offer review if symptoms . Limiting intake of caffeine, artificial sweeteners . Urgent referral if: erso higher PSA levels Severe LUTS not responding to change . Avoiding constipation, or treating it if present treatment . Suspect obstructive uropathy me . Mild Symptoms IPSS ≤7 Decide with the patient: Active surveillance or Active intervention (conservative management, drug therapy or surgery) Prescribing Information Antimuscarinics: Review every 4-6 weeks until symptoms stable 2nd Line Desmopressin Exclude CCF/ Diabetes and then every 6-12 months Restrict fluid after 6pm Furosemide 40mg Risk of Hyponatraemia, monitor sodium 72 hrs after 1st dose Nocturnal Polyuria Elevate legs above heart level @ 4pm Do not prescribe: in heart failure, hypertension, concurrent diuretics, First Line: TOLTERODINE Immediate release Tablets Consider support stockings psychogenic polydipsia or alcohol abuse. Avoid: CVS, age ≥65 years No Dose: 2mg BD, reduce to 1mg BD to minimise side effect im Or pro OXYBUTYNIN Immediate Release Tablets Post micturition Advice patient that he can reduce the post micturition dribbling by milking the urethra after Starting dose: 5mg BD – TDS, do not use in frail patients ve dribble urinating- unlikely to help if post micturition dribbling is caused by urinary obstruction Sy St me Oxybutynin 3.9mg / 24 hours patches BD m or nt, rd Offer ONLY if patient benefit from oral oxybutynin but cannot pt ag nd Offer 2 line 3 line tre tolerate side effects o e antimuscarinic Mirabegron at ms nd sy No drug Second Line: NICE recommends 2 line drug as one with the bo No me m nt lowest acquisition cost th Review 4-6 weeks Review 4-6 weeks No pt Bladder training 3 times/ Offer 1st line Review 4-6 weeks TROSPIUM CHLORIDE 20mg tablets TWICE daily er Overactive Bladder Symptoms Symptoms uns M week for 6 weeks Symptoms so o antimuscarinic improved? improved? od improved? ucc Third Line: if antimuscarinics are contraindicated or clinically m ms drug er Yes Yes ess ineffective, or have unacceptable side effects or not achieved e: at Yes rd ful control consider: IP st nd Continue 3 line e Continue 1 line Continue 2 line or SS Mirabegron IP antimuscarinic antimuscarinic MIRABEGRON 25mg Modified Release Tablets: 50mg Once Daily & sy SS Reduce dose to 25mg once daily in patients with mild renal/ Ur mp 8- hepatic impairment or if drug interactions (See SCP) in to 19 Mirabegron is contraindicated in patients with severe uncontrolled ar Advise to use containment products Advice on fluid intake Supervised pelvic floor muscle training for to Stress urinary ms hypertension. Check BP before treatment, before 2nd y (Not available on FP10) and lifestyle measures 3 months if caused by prostatectomy Se incontinence det prescription and at regular intervals thereafter (6 monthly) Fr ve eri MHRA drug safety update Mirabegron eq re ora ue Continue α- Blocker IP Yes nc te; α-Blockers: Review at 4-6 weeks and then every 6-12 months SS y Review 4-6 weeks ref 20 Review every 6-12 months No First line: Doxazosin Immediate Release Tablets Vo Symptoms er - Symptoms continue to be 1mg OD, double dose at 1-2 weeks intervals, max dose 8mg daily lu improved? 35 Vo Offer an α- Blocker controlled? to Requires careful dose titration to avoid postural hypotension m idi No sec MR preparations are NOT RECOMMENDED in WECCG e No ng on Ch 2nd Line: Tamsulosin modified release capsules: 400mcg OD sy +Prostate >30g OR dar art Yes More uroselective than other alpha-blockers, may be preferred if PSA> 1.4 ng /mL & y ) m patient has CVS morbidity, unable to tolerate hypotension, or High risk of progression ** Yes Review 6 monthly pt Continue 5-α car prone to dizziness Symptoms o reductase inhibitor e Yes controlled? rd ms Review 3-6 months for 3 Line: Alfuzosin modified release tablets: 10mg OD Offer 5-α reductase Requires no dose titration Symptoms No Continue furt inhibitor improved? Consider combination her Yes therapy combination ma 5-α Reductase Inhibitors: Review at 3-6 months and then every 6- therapy: Review in 3 months 12 months (benefits are usually seen after 6 months) nag No α- Blocker & 5-α Symptoms improved em st reductase inhibitor No 1 Line: Finasteride tablets: 5mg OD ent Associated with foetal abnormalities and is excreted in semen. Women of child-bearing age should not handle broken tablets. Storage & Voiding Symptoms Treat Voiding Symptoms α- Blocker Add Anticholinergic for storage symptoms Counsel patients appropriately MHRA Safety Update potential risk of male breast cancer Severe IPSS=20-35 MHRA alert rare reports of depression & suicidal thoughts Patient Information and Leaflets Patient Information and Further Reading Patient UK: https://patient.info/doctor/lower-urinary-tract-symptoms-in-men-pro Bladder & Bowel Community: https://www.bladderandbowel.org/bladder/bladder-conditions-and-symptoms/frequency/ Patient Information on BPH Patient UK: https://patient.info/doctor/benign-prostatic-hyperplasia Bladder & Bowel Community: https://www.bladderandbowel.org/bladder/bladder-conditions-and-symptoms/benign-prostatic-hyperplasia/ Lifestyle Interventions http://www.nhs.uk/Conditions/Incontinen ce-urinary/Pages/Treatment.aspx https://www.bladderandbowel.org/help-information/resources/lifestyle-fluids-and-diet/ Pelvic Floor Exercises Patient UK: http://www.patient.co.uk/health/pelvic-floor-exercises Bladder Training Patient UK: http://www.patient.co.uk/health/overactive-bladder-syndrome Patient Information on OAB drugs NHS Choices: http://www.nhs.uk/Conditions/Incontinence-urinary/Pages/Treatment.aspx References: 1. NICE Clinical Guideline 97 (CG97). Lower Urinary Tract Symptoms in Men: Management. Published May 2010, updated June 2015, accessed November 2017: https://cks.nice.org.uk/luts-in-men 2. NICE Clinical Knowledge Summaries: LUTS in Men. February 2015 Accessed November 2017: https://cks.nice.org.uk/luts-in-men 3. European Association of Urology. Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO, March 2016, accessed November 2017: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Management-of-non-neurogenic-male-LUTS-2016.pdf 4. British National Formulary, 74TH Edition September 2017 London: British Medical Association and The Royal Pharmaceutical Society of Great Britain; Accessed November 2017: https://bnf.nice.org.uk/ Produced by the Medicines Optimisation Team at West Essex CCG Approved by MOPB December 2017, Review Date December 2019 .
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