Podcast - Management of male LUTS: a NICE perspective

This episode makes reference to guidelines produced by the “National Institute for Health and Care Excellence” in the UK, also referred to as “NICE”. Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guidance on the management of lower urinary tract symptoms in men.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The full clinical guideline CG97 on lower urinary tract symptoms in men: management can be found here:

·      https://www.nice.org.uk/guidance/cg97

The International Prostatism Symptom Score calculator can be found here:

·       https://www.uptodate.com/contents/calculator-international-prostatism-symptom-score-ipss

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• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guidance on the management of lower urinary tract symptoms in men, which I have summarised from a Primary Care perspective.

So, let’s jump into it.

And to appreciate fully the importance of this subject, let’s have a look at this anonymous poem:

“As man draws near the common goal

Can anything be sadder

Than he who, master of his soul

Is servant to his bladder‟

And, of course, we know that the prevalence and severity of male lower urinary tract symptoms, also known as LUTS, increase with age and although transurethral resection of the prostate is often effective, about a quarter of men have poor post-surgical outcomes and some failures can be attributed to an incorrect initial diagnosis.

So, let’s start by talking about the conditions that can cause LUTS in men.

And in order to get the correct diagnosis, we should remember the ancient Chinese proverb that says that the “bladder is the mirror of the soul‟ and therefore LUTS can result from not only bladder dysfunction or prostatic pathology but also from a number of other causes, e.g., metabolic, hormonal, cardiac, respiratory, etc. And therefore, effective therapy depends on the accurate diagnosis of the underlying problem.

Although, the most common cause is benign prostate enlargement (BPE), which obstructs the bladder outlet, the term LUTS is an umbrella term introduced to dispel the perception that male urinary symptoms are simply caused by prostate problems.

Because other conditions, for example, detrusor muscle problems, prostatitis, UTIs, prostate cancer and neurological disease, can also cause LUTS.

We also need to be aware of the 3 stages of the bladder cycle, which are:

·      Storage - during which filling of the bladder occurs

·      Voiding - during which the bladder actively expels its contents and

·      Post micturition - immediately after voiding when the bladder returns to storage function.

And as a result, LUTS comprise three different types of symptoms:

·      First, storage symptoms normally causing daytime urinary frequency, nocturia, urgency and urinary incontinence

·      voiding symptoms, causing slow stream, spraying, intermittency, hesitancy, straining, and terminal dribbling and

·      post micturition symptoms, for example, sensation of incomplete emptying, and post micturition dribbling

In the management of male LUTS we need to understand that we are dealing with a complex functional unit comprising the bladder, bladder neck/prostate and urethra. LUTS may result from a combination of factors and, to avoid confusion, we should use the correct clinical terms. So let’s have a look at them:

·      “Benign prostatic hyperplasia” or BPH should be reserved for histopathological prostate hyperplastic changes (i.e. abnormality at the cell level). The prevalence of BPH increases with age and whilst it is often associated with LUTS, only 25% to 50% of men with BPH have symptoms.

·      “Benign prostatic enlargement” or BPE refers to an increase in size of prostate gland due to BPH. But only about half of men with hyperplasia will develop clinical enalrgement.

·      “Bladder outlet obstruction” (BOO) is an urodynamically diagnosed condition characterised by increased detrusor pressure and reduced urine flow rate.

·      “Overactive bladder” presents with urinary urgency, with or without incontinence, usually with frequency and nocturia. OAB does not include stress incontinence due to a weak sphincter or overflow incontinence due to chronic retention.

·      And finally, Detrusor overactivity (DO) is urodynamically characterised by involuntary detrusor contractions during the bladder filling phase and occurs in about two thirds of OAB cases and 50% of those with BOO.

There is also a clear association between LUTS and sexual dysfunction, including erectile dysfunction, ejaculatory dysfunction, decreased sexual activity and decreased sexual desire. However, we will not cover this area in today’s episode.

At initial assessment in General Practice, we will review their current medication and take a history and examination including an examination of the abdomen, genitalia, a digital rectal examination as well as a urine dipstick. 

We will check creatinine and eGFR if concerned about renal impairment and we will give information about PSA testing if:

·      their LUTS are suggestive of bladder outlet obstruction secondary to benign prostate enlargement (BPE) or

·      their prostate feels abnormal on digital rectal examination or

·      they are concerned about prostate cancer

If there are bothersome LUTS we could ask the patient to complete a urinary frequency volume chart and we will refer if the patient has not responded to the initial management or have complications such as UTIs, retention, renal impairment or suspected urological cancer. 

For uncomplicated LUTS, we will not routinely offer:

·      Cystoscopy

·      Imaging of the upper urinary tract

·      Flow-rate measurement

·      a post-void residual volume measurement

Although these investigations as well as other ones may be carried out following specialist referral.

To assess response to treatment, we should use a validated symptom score (for example, the International Prostatism Symptom Score or IPSS) before and after the intervention. There are online calculators that can facilitate this and I have included a link in the episode description.

As conservative management, we should offer advice on fluid intake and lifestyle measures, for example:

• cut down on fizzy drinks, and/or drinks that contain alcohol or caffeine

• avoid excessive drinking, aiming for between 1.5 and 2 litres of fluid a day and

• avoid constipation

If there is post-micturition dribble, we will advise how to perform urethral milking. 

If LUTS are suggestive of overactive bladder, we should refer to local community continence services for supervised bladder training

We should refer to urology if there is stress urinary incontinence but

If stress urinary incontinence is caused by prostatectomy, we should offer supervised pelvic floor muscle training for at least 3 months, again via local community continence services.

For urinary incontinence:

·      We will give temporary products, for example, pads or collecting devices, while waiting for a definitive management.

·      External collecting devices, for example, sheath appliances, pubic pressure urinals should be used before indwelling catheterisation

·      Intermittent bladder catheterisation should be considered before indwelling catheterisation.

·      Long-term indwelling urethral catheterisation maybe suitable when:

• medical management has failed and surgery is not appropriate and
• the patient is unable to manage intermittent self-catheterisation or
• there are skin problems aggravated by contact with urine or
• the patient is distressed by bed and clothing changes and

We will refer patients with symptoms of urinary retention and ensure that:

·      Men with acute retention are catheterised urgently and that

·      An alpha blocker should be given before removal of the catheter

·      Checking creatinine and imaging of the upper urinary tract is recommended for chronic urinary retention and

·      Surgery or permanent catheterisation will be guided by urology services

Drug treatment will be offered only when conservative management has been unsuccessful, after taking into account comorbidities and current medication.

Drug treatment may be guided by Urology but, in summary, we should be aware of the following:

·      An alpha blocker (like alfuzosin, doxazosin, tamsulosin or terazosin) can be offered to men with moderate to severe LUTS

·      An anticholinergic can be given if there are symptoms of an overactive bladder

·      A 5‑alpha reductase inhibitor such as finasteride can be given if LUTS are present with a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml

·      A combination of an alpha blocker and a 5‑alpha reductase inhibitor can be given if they have both moderate to severe LUTS and a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.

·      An anticholinergic as well as an alpha blocker can be given if there are storage symptoms such as daytime urinary frequency, nocturia, urgency and urinary incontinence after treatment with an alpha blocker alone. 

·      A late afternoon loop diuretic may be offered if there is nocturnal polyuria although this is an unlicensed indication

·      Oral desmopressin may be offered to men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments. This is an unlicensed indication and sodium should be measured 3 days after the first dose and desmopressin should be stopped if sodium is below the normal range.

We need to be aware that 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, and sickle cell anaemia.

Equally, medications that can cause nocturnal polyuria symptoms include calcium channel blockers, diuretics, and SSRIs.

We will review patients regularly to monitor symptoms and medication:

·      We will review men taking alpha blockers at 4 to 6 weeks and then every 6 to 12 months. 

·      We will review men taking 5‑alpha reductase inhibitors at 3 to 6 months and then every 6 to 12 months. 

·      We will review men taking anticholinergics every 4 to 6 weeks until symptoms are stable, and then every 6 to 12 months. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.