Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Initial assessment f lwer urinary tract symptms (LUTS) Hw shuld I characterize the type f lwer urinary tract symptms (LUTS)? T establish what type r cmbinatin f types f lwer urinary tract symptms (LUTS) the man has, ask abut: Strage (irritative) symptms: urgency, daytime urinary frequency, ncturia, urinary incntinence, and feeling the need t urinate again just after passing urine. Specifically ask abut bedwetting, as this can be a sign f chrnic urinary retentin. Viding (bstructive) symptms: hesitancy, weak r intermittent urinary stream smetimes causing splitting r spraying, straining, intermittency, incmplete emptying, and terminal dribbling. Pst-micturitin symptms: pst-micturitin dribble, and the sensatin f incmplete emptying. If the man has bthersme LUTS, strage symptms, r ncturia ask him t cmplete a urinary frequency-vlume chart. This is essential t distinguish between urinary frequency, plyuria, ncturia, and ncturnal plyuria. Urinary frequency-vlume chart A urinary frequency vlume chart is used t help distinguish and diagnse: Frequency: high frequency with nrmal 24-hur vlume suggests that the bladder capacity is diminished (the male bladder nrmally hlds 300 600 ml urine cmfrtably). Plyuria: passing mre urine than usual (up t 3 L f urine in 24 hurs is nrmal). Ncturia: waking at night t urinate. Ncturnal plyuria: passing, at night, mre than 35% f the 24-hur urine prductin. A urinary frequency vlume chart (pdf) frmatted fr printing r dwnlading is available frm CKS. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Reynard et al, 2006; NICE, 2010]. 1
The NICE systematic review fund n studies assessing whether the cmpletin f frequency-vlume charts affects utcmes. Hw shuld I assess symptm severity, bther, and cncerns in a man presenting with lwer urinary tract symptms (LUTS)? If it is practical, ask the man t cmplete the Internatinal Prstate Symptm Scre (IPSS) questinnaire t assess symptm severity and degree f bther. Severity f symptms and degree f bther ften d nt crrelate clsely, and are therefre assessed separately. Establish the man's chief cncerns. Fr example, is he wrried that his symptms: Are bthersme? Culd prgress t acute urinary retentin? Culd be due t cancer? Internatinal Prstate Symptm Scre (IPSS) The Internatinal Prstate Symptm Scre (IPSS) is a tl fr classifying the severity f lwer urinary tract symptms as mild, mderate, r severe; and t assess hw bthersme the symptms are. The IPSS questinnaire is intended t be cmpleted by the man. It assesses symptms (by adding the scre f seven separate questins) and degree f bther (ne questin): Severity f symptms questins each is scred frm 0 (best) t 5 (wrst). Incmplete emptying. Over the past mnth, hw ften have yu had a sensatin f nt emptying yur bladder cmpletely after yu finish urinating? Frequency. Over the past mnth, hw ften have yu had t urinate again less than 2 hurs after yu finished urinating? Intermittency. Over the past mnth, hw ften have yu fund yu stpped and started again several times when yu urinated? Urgency. Over the last mnth, hw difficult have yu fund it t pstpne urinatin? Weak stream. Over the past mnth, hw ften have yu had a weak urinary stream? Straining. Over the past mnth, hw ften have yu had t push r strain t begin urinatin? 2
Ncturia. Over the past mnth, many times did yu mst typically get up t urinate frm the time yu went t bed until the time yu gt up in the mrning? The IPSS severity scre is the ttal f the seven individual symptm scres, and is interpreted as: Scre 0 7: mildly symptmatic. Scre 8 19: mderately symptmatic. Scre 20 35: severely symptmatic. Questin abut quality-f-life due t urinary symptms scred frm 0 (best) t 6 (wrst). If yu were t spend the rest f yur life with yur urinary cnditin the way it is nw, hw wuld yu feel abut that? Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Reynard et al, 2006; NICE, 2010]. The IPSS includes the American Urlgical Assciatin severity f symptms scre, which was develped and validated by the multidisciplinary measurement cmmittee f the American Urlgical Assciatin [Barry et al, 1992]. The NICE systematic review fund n study that assessed whether scring symptms affect clinical utcme. The NICE guideline develpment grup highlighted the fact that cmpleting the symptm scre wuld be difficult r impssible fr peple wh are blind, cannt read English, r have learning disabilities. Hw shuld I examine a man presenting with lwer urinary tract symptms (LUTS)? Examinatin shuld be guided by urlgical and ther symptms. Examine the abdmen fr signs f a distended bladder such as abdminal distentin and suprapubic dullness n percussin. Check the external genitalia. Perfrm a digital rectal examinatin t assess the prstate fr size, cnsistency, ndules, and tenderness. 3
Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Reynard et al, 2006; NICE, 2010]. The NICE systematic review fund n study that assessed the effectiveness (in terms f clinical utcmes) f examining the abdmen and external genitalia, r perfrming a digital rectal examinatin. What investigatins shuld I d fr a man presenting with lwer urinary tract symptms (LUTS)? Investigatins shuld be guided by the symptms, histry, and examinatin. Dipstick test the urine t check fr bld, glucse, prtein, leuccytes, and nitrites. Measure serum creatinine and egfr (estimated glmerular filtratin rate) if clinically indicated, fr example when there is any f the fllwing: Chrnic high pressure urinary retentin suggested by bedwetting, r enlarged bladder detected n abdminal palpatin r percussin. Recurrent urinary tract infectin. Histry f renal stnes. Test fr prstate specific antigen (PSA) nly after discussing the indicatins fr the test and the interpretatin f the results, and prviding sufficient time fr the man t decide if he wishes t have the test. PSA testing is indicated nly: If symptms suggest bladder utlet bstructin due t benign prstatic enlargement the test result can guide drug treatment. If the man is cncerned abut prstate cancer r if the prstate feels abnrmal n digital rectal examinatin the test result can guide assessment f the risk f prstate cancer. Delay testing if any f the fllwing causes f a transiently increased serum PSA level are present: Vigrus exercise delay testing fr 2 days. Digital rectal examinatin delay testing fr 1 week. 4
Prstate bipsy delay testing fr 6 weeks. Interpreting PSA results can be difficult. An increased serum PSA level can be present with: Prstate enlargement. Prstate cancer. Infectin (prstatitis, urinary tract infectin). Physical causes, including fllwing vigrus exercise, digital rectal examinatin, and prstate bipsy. A nrmal prstate. A nrmal serum PSA level can be present with: Prstate enlargement. Prstate cancer. Infectin. If checking PSA levels in a man using a 5-alpha reductase inhibitr, be aware that: A decrease in PSA levels is seen rapidly, within the first few mnths f treatment. After 6 mnths f treatment with a 5-alpha reductase inhibitr, the PSA value shuld be dubled t make it cmparable t levels in men nt treated with a 5-alpha reductase inhibitr. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Reynard et al, 2006; NICE, 2010]. Usefulness f urine dipstick tests fr excluding bladder cancer, urinary tract infectin, and urinary calculi in men with lwer urinary tract symptms (LUTS) The NICE systematic review fund nly ne study that assessed the usefulness f urine dipstick tests fr excluding bladder cancer, urinary tract infectin, and urinary calculi in men with LUTS suggestive f benign prstatic hyperplasia (BPH). The study had serius methdlgical limitatins that make the data unreliable. 5
NICE fund n trials fr urine dipstick tests t exclude diabetes and renal disease in men with LUTS suggestive f BPH. Serum creatinine t assess renal functin NICE recmmends ffering men with LUTS a serum creatinine test t assess fr renal impairment nly when there are clinical indicatins f causes f renal impairment. NICE nted that mst labratries nw reprt egfr (estimated glmerular filtratin rate) alngside bld creatinine levels. NICE fund n trials that assessed clinical utcmes in men wh had renal functin measured. PSA test t predict prgressin f symptms and clinical utcmes The NICE systematic review fund n directly relevant studies n the effect f strategies f PSA testing n eventual clinical utcmes. The NICE systematic review fund six studies that assessed hw accurately the PSA test predicts prgressin f symptms. The results were incnsistent, and n reliable cnclusin culd be drawn. What causes f lwer urinary tract symptms (LUTS) in men shuld I check fr? Check fr the underlying cause f the specific type f LUTS. Acute urinary retentin Stress urinary incntinence Overactive bladder Ncturnal plyuria Viding (bstructive) symptms Exclude r manage ther serius causes f lwer urinary tract symptms (LUTS), including: Urlgical cancer Alarm signals fr urlgical cancer include a prstate that is hard and irregular, unexplained haematuria, lwer back pain, bne pain, and weight lss. Marked urinary frequency r urgency, and bladder pain may be signs f bladder cancer. 6
If urlgical cancer is suspected, refer the man with apprpriate urgency. Fr mre infrmatin, see the CKS tpic n Urlgical cancer - suspected, which cvers suspected cancer f the prstate, bladder, kidney, and penis. Urlgical infectin Alarm signals fr urlgical infectin include pain when urinating, pelvic pain, lin pain, fever, and abnrmal urine dipstick test findings. If urlgical infectin is suspected, cnfirm and manage accrdingly. Fr mre infrmatin, see the CKS tpics n Prstatitis - acute, Prstatitis - chrnic, Pyelnephritis - acute, Urethritis - male, and Urinary tract infectin (lwer) - men. Drugs, including drugs that can cause plyuria and drugs than can cause viding (bstructive) symptms. If the symptms culd be caused by a drug, cnsider if the dsage culd be decreased, r if the drug culd be stpped r replaced by anther. Sciatica r ther neurlgical disease Sciatica causes weakness, numbness, r tingling in a leg. It smetimes causes r aggravates LUTS. Fr infrmatin n the diagnsis and management f sciatica, see the CKS tpic n Sciatica (lumbar radiculpathy). Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Reynard et al, 2006; NICE, 2010]. The surces fr the recmmendatins n checking fr specific underlying causes are cited in the linked text. Assessing fr urlgic cancer is discussed in the CKS tpic n Urlgical cancer - suspected, which is based n NICE guidelines. Assessing fr urlgical infectin is discussed in the CKS tpics n Prstatitis - acute, Prstatitis - chrnic, Pyelnephritis - acute, Urethritis - male, and Urinary tract infectin (lwer) - men. 7
Assessing fr drug causes is discussed in the sectins Ncturnal plyuria and Viding (bstructive) symptms. Assessing fr sciatica is discussed in the CKS tpic n Sciatica (lumbar radiculpathy). Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Urinary retentin (acute, acute n chrnic, chrnic) Hw d I manage acute urinary retentin in a man? If this is the first episde f acute urinary retentin: Admit the man urgently fr catheterizatin and investigatin f the cause. If the expertise and facilities are available, catheterize befre admissin. Fr an episde f recurrent acute retentin, r acute-n-chrnic urinary retentin: Admit the man, r insert a urethral catheter. Discuss and decide n treatment t prevent r manage recurrent urine retentin. Optins include: An alpha-blcker (alfuzsin) start at least 24 hurs befre attempting t remve the catheter. After remving the catheter, cnfirm ver several hurs that the man can vid freely. Cntinue the alphablcker until the man has been fully investigated t determine the cause and t assess renal functin. Fr detailed prescribing infrmatin, see Alpha-blckers fr viding symptms. Intermittent urethral catheterizatin refer the man r his carer t a cntinence nurse fr training in catheterizatin. A lng-term indwelling catheter nly if intermittent catheterizatin is nt apprpriate r practical. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Admissin The recmmendatins t admit men with acute urinary retentin (unless the expertise and facilities are available in primary care) is based n expert pinin in NICE referral guidelines [NICE, 2001]. Alpha-blckers 8
The recmmendatin n ffering an alpha-blcker befre remval f the urinary catheter in an episde f acute retentin reflects NICE guidelines [NICE, 2010]. The NICE systematic review fund fur randmized cntrlled trials (RCTs) that prvide cnsistent, but imprecise because the studies were small, evidence that alpha-blckers imprve the chance f being able t vid after remving the urinary catheter. Tw f the RCTs fund n significant difference in the need fr recatheterizatin, but the studies lacked statistical pwer and had serius methdlgical limitatins. One ecnmic study cnducted in the UK suggests that the use f an alpha-blcker may be cst-saving, but the study did nt include a full cst-effectiveness analysis. Intermittent r cntinuus urethral catheterizatin These recmmendatins are based n expert pinin, because NICE fund n directly relevant cntrlled trials [NICE, 2010]. Hw d I manage chrnic urinary retentin in a man? Exclude nn-bstructive causes f reduced urine flw (such as chrnic heart failure). Check serum creatinine t assess renal functin. Refer the man fr specialist assessment. Cnsider seeking specialist advice abut arranging imaging f the upper urinary tract and kidneys while the man is waiting t be seen. Management ptins in secndary care depend n renal functin and the man's wishes, and include: N catheterizatin, but fllw up with active surveillance f renal functin, vlume f urinary retentin, and changes in imaging f upper renal tract. Intermittent urethral catheterizatin, perfrmed by the man r his carer. A permanent indwelling catheter. Surgery t divert the urine externally (urstmy). Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Referral fr specialist assessment 9
The recmmendatins abut referral fr specialist assessment are based n expert pinin as NICE fund n directly relevant clinical trials [NICE, 2010]. Assessing renal functin with serum creatinine The indicatins fr measuring serum creatinine (palpable bladder, ncturnal enuresis, recurrent urinary tract infectin, histry f renal stnes) are based n expert pinin, because NICE fund n studies that assessed hw measuring renal functin affects clinical utcmes in men with lwer urinary tract symptms (LUTS) [NICE, 2010]. The NICE guideline develpment grup cnsidered serum creatinine t be the mst reliable rutine test fr renal functin. They highlighted that many labratries reprt egfr (estimated glmerular filtratin rate) whenever serum creatinine is measured, and that (when required) renal functin can be mre accurately assessed by measuring creatinine clearance. The NICE guideline develpment grup cnsidered serum urea t be less reliable than serum creatinine fr assessing renal functin. Assessing renal functin and structure with radilgical imaging The NICE systematic review fund n studies that assessed hw radilgical imaging affects clinical utcmes in men with LUTS. The recmmendatins are therefre based n expert pinin [NICE, 2010]. Prescriptins Fr infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) (http://emc.medicines.rg.uk), r the British Natinal Frmulary (BNF) (www.bnf.rg). Alfuzsin Age frm 40 years nwards Alfuzsin m/r tablets: 10mg nce a day Alfuzsin 10mg mdified-release tablets Take ne tablet nce a day. Supply 30 tablets. Age: frm 40 years nwards NHS cst: 12.51 Patient infrmatin: Sme peple experience side effects such as blurred visin, dizziness, drwsiness, sweating r feeling light headed. If any f these apply, sit r lie dwn until the symptms have disappeared. Tell yur dctr if these symptms cntinue after taking the medicine fr a few days. 10
Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Stress urinary incntinence Hw d I assess the severity and impact f stress urinary incntinence? Assess the severity f stress incntinence and its impact n quality-f-life by asking the man: Hw ften d yu need t pass urine? Hw ften d yu leak urine? What prtectin d yu need t cpe with the leakage? When d accidents happen? What drugs and herbal remedies are yu taking? D yu manage yur diet and fluid intake t try t cntrl the leakage? D yu have pain r discmfrt when passing urine? Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010] and are based n expert pinin [Whitfield, 2006; Ethicn Wmen's Health & Urlgy, 2008]. Hw d I manage stress urinary incntinence? If necessary, ffer a chice f temprary urine cntainment prducts (such as sheath and leg bag, absrbent pads, and absrbent pants) t achieve scial cntinence, and refer the man t the lcal cntinence service. T find the lcal cntinence service, telephne the Bwel and Bladder Fundatin n 01536 533 255. Advise the man n fluid intake and lifestyle and ffer infrmatin n self-help resurces. When stress urinary incntinence is nt caused by prstatectmy, refer the man fr specialist assessment t cnfirm the cause. 11
When stress urinary incntinence is caused by prstatectmy, ffer referral fr supervised pelvic flr muscle training. Advise that the exercises shuld be perfrmed fr at least 3 mnths befre cnsidering referral t secndary care fr assessment fr ther invasive treatment ptins. Supervised pelvic flr training may be available frm the lcal cntinence nurse, cntinence physitherapist, r urlgy clinic. Secndary care ptins fr treating stress incntinence Optins available in secndary care fr treating stress incntinence include: External cllecting devices such as sheath appliances and pubic pressure urinals. Indwelling catheterizatin. Surgical placement f a urethral artificial sphincter. Urinary diversin as a last resrt, when all ther treatments have failed. Treatments that may be available as part f a clinical trial include intramural injectables, implanted adjustable cmpressin devices, and suburethral synthetic sling. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Prviding infrmatin n stress urinary incntinence and self-help resurces The recmmendatin t prvide infrmatin is based n expert pinin [NICE, 2010]. Referral fr stress urinary incntinence nt caused by prstatectmy The recmmendatin t prvide infrmatin is based n expert pinin [NICE, 2010]. Use f urine cntainment prducts The recmmendatins abut ffering urinary cntainment prducts are based n expert pinin [NICE, 2010]. 12
Pelvic flr muscle training NICE fund 11 relevant randmized cntrlled trials f pelvic flr muscle training [NICE, 2010]. The data may be unreliable because the studies had limitatins in design and precisin (size f study), and the results lacked cnsistency and directness f applicability. Nevertheless, NICE fund evidence that pelvic flr muscle training fr stress incntinence after prstatectmy: Did nt reduce incntinence rates in the first 3 mnths after prstatectmy. Reduced incntinence rates between 4 12 mnths after prstatectmy. Treatments nt recmmended Penile clamps are nt recmmended fr men with urinary incntinence. This is based n the expert pinin f the NICE guideline develpment grup [NICE, 2010]. Electrical stimulatin is nt recmmended because NICE fund n reliable evidence that it is effective [NICE, 2010]. Secndary care treatments The infrmatin n treatments recmmended as ptins in secndary care is frm the NICE guidelines n lwer urinary tract symptms, where the evidence is reviewed [NICE, 2010]. What advice shuld I prvide abut self-help resurces? Advise the man that: NHS Chices prvides nline infrmatin fr peple with urinary incntinence. The Bladder and Bwel Fundatin has a helpline (telephne 01536 533 255), and prvides a range f resurces n their website www.bladderandbwelfundatin.rg. Infrmatin n pelvic flr muscle training is included in their bklet n stress urinary incntinence, which can be rdered frm their nline shp r dwnladed fr printing (pdf). N drug is effective fr stress incntinence in men. Sme infrmatin leaflets cite the use f dulxetine fr stress incntinence; hwever, this is fr wmen nly. Basis fr recmmendatin 13
These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE's recmmendatin t prvide infrmatin and advice was made n the basis f expert pinin, as n relevant clinical trials were fund [NICE, 2010]. What self-care advice shuld I prvide abut fluid intake and lifestyle fr men with lwer urinary tract symptms? Fluid intake shuld be within the man's usual range, and shuld nt be limited excessively in an attempt t cntrl symptms ding this culd increase the risk f cmplicatins such as urinary tract infectin. Lifestyle advice may include: Aviding cnstipatin, r treating it (if it is present). Maintaining a healthy lifestyle (with respect t bdy weight, exercise, diet, smking, and alchl cnsumptin). Limiting intake f tea, cffee, chclate, artificial sweeteners, and fizzy drinks. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE based these recmmendatins n expert pinin as they fund n relevant clinical trials [NICE, 2010]. Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Overactive bladder Hw d I manage a man with veractive bladder as the predminant symptm? Exclude r manage treatable causes f veractive bladder (fr example cancer f the prstate r bladder, neurlgical cnditins, infectin, and bladder stnes). 14
Investigatins t exclude treatable causes f an veractive bladder include urinalysis, renal functin tests, and (depending n the clinical features) PSA (prstate specific antigen) level. It is ften nt pssible t identify a specific underlying cause. If necessary, ffer a chice f temprary urine cntainment prducts (such as sheath and leg bag, absrbent pads, and absrbent pants) t achieve scial cntinence, and refer the man t the lcal cntinence service. T find the lcal cntinence service, telephne the Bwel and Bladder Fundatin n 01536 533 255. Offer referral fr supervised bladder training this may be available frm the lcal cntinence nurse, cntinence physitherapist, r urlgy clinic. Advise the man n fluid intake and lifestyle, and ffer infrmatin n self-help resurces. If bthersme symptms persist, ffer an antimuscarinic (antichlinergic). Fr example xybutynin initially 5 mg tw t three times daily, increased if necessary t a maximum f 5 mg fur times daily. Elderly men require lwer dses. Fr full prescribing infrmatin and chice f antimuscarinic drug, see Antimuscarinics fr veractive bladder. Review every 4 6 weeks until symptms are stable, and then every 6 12 mnths. Assess symptms, quality-f-life, adverse effects, and the need t cntinue treatment. If treatment fails, refer the man fr specialist urlgical assessment and management. Treatment ptins in secndary care include injectin f btulinum int the bladder wall, implanted sacral nerve stimulatin, and cystplasty. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Supervised bladder training, advice n fluid intake, lifestyle advice, cntainment prducts The recmmendatins n supervised bladder training, advice n fluid intake, lifestyle advice, and cntainment prducts are based n expert pinin, as NICE fund n relevant clinical r ecnmic studies [NICE, 2010]. 15
Antimuscarinics (antichlinergics) The recmmendatin t cnsider using an antimuscarinic fr veractive bladder symptms is based n expert pinin. The best trial-based evidence is frm ne small randmized cntrlled trial, which reprted the data graphically and withut statistical analysis [NICE, 2010]. Antichlinergics reduced the number f urinary incntinence episdes cmpared with placeb (but nt cmpared with alpha-blckers). There were n ther imprvements nted cmpared with placeb. Reductin in the number f incntinence episdes is an imprtant benefit. Minr adverse effects (such as dry muth) are cmmn. Urinary retentin is a serius pssible adverse effect, but NICE fund n evidence that this risk is clinically imprtant. The recmmendatins n fllw up and mnitring are based n expert pinin, as NICE fund n relevant clinical trials. Secndary care treatments The infrmatin n treatments used in secndary care is frm the NICE guidance [NICE, 2010]. What advice shuld I prvide abut self-help resurces? Advise that: The Bladder and Bwel Fundatin have a helpline (telephne 01536 533 255), and prvide a range f resurces n their website www.bladderandbwelfundatin.rg, which include: A bklet n cping with urgency this can be rdered frm their nline shp r dwnladed fr printing (pdf). The bklet includes detailed infrmatin n bladder retraining. A Just Can't Wait tilet card t use when the need t urinate arises while ut shpping r scializing. Mst shps and facilities are willing t help when they are shwn the card. A small dnatin is requested t cver csts. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE recmmends prviding men with lwer urinary tract symptms with infrmatin and advice n the basis f expert pinin, as they fund n relevant clinical trials [NICE, 2010]. 16
What self-care advice shuld I prvide abut fluid intake and lifestyle fr men with lwer urinary tract symptms? Fluid intake shuld be within the man's usual range, and shuld nt be limited excessively in an attempt t cntrl symptms ding this culd increase the risk f cmplicatins such as urinary tract infectin. Lifestyle advice may include: Aviding cnstipatin, r treating it (if it is present). Maintaining a healthy lifestyle (with respect t bdy weight, exercise, diet, smking, and alchl cnsumptin). Limiting intake f tea, cffee, chclate, artificial sweeteners, and fizzy drinks. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE based these recmmendatins n expert pinin as they fund n relevant clinical trials [NICE, 2010]. Prescriptins Fr infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) (http://emc.medicines.rg.uk), r the British Natinal Frmulary (BNF) (www.bnf.rg). First-line antimuscarinic: xybutynin Age frm 40 years nwards Start xybutynin tablets: 5mg tw t three times a day Oxybutynin 5mg tablets Take ne tablet tw t three times a day. Supply 56 tablets. Age frm 60 years nwards Start xybutynin tablets (elderly): 2.5mg twice a day Age: frm 40 years nwards NHS cst: 7.83 17
Oxybutynin 2.5mg tablets Take ne tablet twice a day. Supply 56 tablets. Age: frm 60 years nwards NHS cst: 7.93 Start xybutynin tablets (elderly): 3mg twice a day Oxybutynin 3mg tablets Take ne tablet twice a day. Supply 56 tablets. Age: frm 60 years nwards NHS cst: 9.15 Secnd-line antimuscarinics: if xybutynin nt tlerated Age frm 40 years nwards Start xybutynin m/r tablets: 5mg nce a day Oxybutynin 5mg mdified-release tablets Take ne tablet nce a day. Supply 30 tablets. Age: frm 40 years nwards NHS cst: 10.81 Start xybutynin patches: apply ne patch twice a WEEK Oxybutynin 3.9mg/24hurs patches Apply ne patch twice a week. Supply 8 patches. Age: frm 40 years nwards NHS cst: 27.20 Patient infrmatin: Apply t clean, dry, unbrken skin n the abdmen, hip, r buttck. Remve after 3 4 days and apply a new patch n a different area (avid using the same area fr 7 days). Start tlterdine m/r capsules: 4mg nce a day Tlterdine 4mg mdified-release capsules Take ne capsule nce a day. Supply 28 capsules. Start tlterdine tablets: 2mg twice a day Tlterdine 2mg tablets Take ne tablet twice a day. Supply 56 tablets. 18 Age: frm 40 years nwards NHS cst: 25.78 Age: frm 40 years nwards NHS cst: 30.56
Start trspium tablets: 20mg twice a day Trspium chlride 20mg tablets Take ne tablet twice a day (n an empty stmach). Supply 60 tablets. Age: frm 40 years nwards NHS cst: 26.00 Start trspium m/r capsules: 60mg nce a day Trspium chlride 60mg mdified-release capsules Take ne capsule nce a day. Supply 28 capsules. Age: frm 40 years nwards NHS cst: 23.05 Start darifenacin m/r tablets: 7.5mg nce a day Darifenacin 7.5mg mdified-release tablets Take ne tablet nce a day. Supply 28 tablets. Age: frm 40 years nwards NHS cst: 20.90 Black triangle Start festerdine m/r tablets: 4mg nce a day Festerdine 4mg mdified-release tablets Take ne tablet nce a day. Supply 28 tablets. Age: frm 40 years nwards NHS cst: 25.78 Black triangle Patient infrmatin: D NOT eat r drink prducts cntaining grapefruit juice whilst taking this medicine. Start slifenacin tablets: 5mg nce a day Slifenacin 5mg tablets Take ne tablet nce a day. Supply 28 tablets. Start prpiverine tablets: 15mg 2 t 3 times a day Prpiverine 15mg tablets Take ne tablet tw t three times a day. Supply 84 tablets. Age: frm 40 years nwards NHS cst: 27.62 Age: frm 40 years nwards 19
NHS cst: 27.00 Start prpiverine m/r capsules: 30mg nce a day Prpiverine 30mg mdified-release capsules Take ne capsule nce a day. Supply 28 capsules. Age: frm 40 years nwards NHS cst: 24.45 Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Ncturnal plyuria Hw d I manage ncturnal plyuria as the predminant symptm? Exclude r manage treatable causes f ncturnal plyuria, such as diabetes, renal disease, chrnic heart failure, and drugs. Hwever, it is ften nt pssible t identify a specific cause. Advise the man t limit his fluid intake in the late afternn and evening, and ffer infrmatin n selfhelp resurces. If limiting fluid intake in the late afternn and evening is ineffective, cnsider ffering a lp diuretic t be taken in the late afternn. Fr example, fursemide 40 mg (this use is ff-label). Fr detailed prescribing infrmatin, see Lp diuretic (fursemide) fr ncturnal plyuria. If ncturnal plyuria remains bthersme, refer the man r seek specialist advice abut switching t ral desmpressin t be taken at bedtime this use is ff-label. Start treatment with the lwest dse 200 micrgrams f ral desmpressin. T prevent fluid verlad and hypnatraemia, advise the man t drink nly enugh t satisfy his thirst, t avid fluids in the last 1 2 hurs befre bed, and t avid fluids fr 8 hurs after taking desmpressin. Mnitr fr dilutinal hypnatraemia by measuring serum sdium 3 days after the first dse. If serum sdium decreases belw the nrmal range, stp the desmpressin. Fr detailed prescribing infrmatin, see Desmpressin fr ncturnal plyuria. 20
Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Fursemide NICE fund nly ne clinical trial, which reprted that diuretics were mre effective than placeb in reducing the frequency f night time urinating, but were nt mre effective in imprving symptms. These results may nt be reliable, because there were nly 43 participants in the study and the methds f randmizatin and allcatin cncealment were nt reprted [NICE, 2010]. NICE fund n trial-based evidence n ptential adverse effects (such as hypvlaemia and rthstatic hyptensin), but cnsidered the risk t be small (prvided that this risk infrms the infrmatin that is given t the man and the plans fr mnitring) [NICE, 2010]. Desmpressin NICE based their recmmendatin n expert pinin as they fund nly ne crssver study; this was t small t prvide reliable evidence [NICE, 2010]. NICE cncluded that biavailability and pharmackinetic studies suggest that the nasal frmulatin f desmpressin may be mre ptent and mre likely t cause hypnatraemia than the ral frmulatin (15 episdes per 100,000 patient-years with the nasal spray, and six episdes per 100,000 patientyears with the ral prduct) [NICE, 2010]. What advice shuld I prvide abut self-help resurces? Advise the man that: The Bladder and Bwel Fundatin have a helpline (telephne 01536 533 255), and prvide a range f resurces n their website www.bladderandbwelfundatin.rg. A bklet n managing bladder prblems can be rdered frm their nline shp, r dwnladed fr printing (pdf). Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. 21
NICE recmmends prviding men with lwer urinary tract symptms with infrmatin and advice n the basis f expert pinin, as they fund n relevant clinical trials [NICE, 2010]. What self-care advice shuld I prvide abut fluid intake and lifestyle fr men with lwer urinary tract symptms? Fluid intake shuld be within the man's usual range, and shuld nt be limited excessively in an attempt t cntrl symptms ding this culd increase the risk f cmplicatins such as urinary tract infectin. Lifestyle advice may include: Aviding cnstipatin, r treating it (if it is present). Maintaining a healthy lifestyle (with respect t bdy weight, exercise, diet, smking, and alchl cnsumptin). Limiting intake f tea, cffee, chclate, artificial sweeteners, and fizzy drinks. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE based these recmmendatins n expert pinin as they fund n relevant clinical trials [NICE, 2010]. Prescriptins Fr infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) (http://emc.medicines.rg.uk), r the British Natinal Frmulary (BNF) (www.bnf.rg). 22
Fursemide Age frm 40 years nwards Fursemide tablets: 40mg each afternn Fursemide 40mg tablets Take ne tablet nce a day, during the late afternn. Supply 28 tablets. Age: frm 40 years nwards NHS cst: 1.03 Licensed use: n - ff-label indicatin Desmpressin Age frm 40 t 65 years Start desmpressin tablets: 200micrgrams at bedtime Desmpressin 200micrgram tablets Take ne tablet at bedtime. Supply 30 tablets. Age: frm 40 years t 65 years NHS cst: 33.72 Licensed use: n - ff-label indicatin Black triangle Patient infrmatin: Desmpressin reduces the amunt f urine prduced at night-time. T avid the bdy becming verladed with fluid, drink n mre than ne mug f liquid frm ne hur befre taking the medicine t eight hurs afterwards. Only drink enugh t satisfy thirst. Avid drinks that cntain caffeine such as tea, cffee, ht chclate, and cla. Stp desmpressin during any episdes f vmiting and/r diarrhea. Lwer urinary tract symptms in men, age-related (including symptms f benign prstatic hyperplasia/hypertrphy) - Management Scenari: Viding (bstructive) symptms Hw d I manage predminantly viding (bstructive) symptms? If it is practical, assess the baseline severity f symptms and degree f bther with a validated symptm scring system such as the IPSS (Internatinal Prstate Symptm Scre). Symptm scres are used t guide treatment chice and t assess future changes in symptms. Exclude r manage causes f bstructive symptms, fr example drugs, neurlgical cnditins, urethral stricture, and cancer (prstate, bladder, rectum). First-line management ptins include: 23
Active surveillance reassurance and lifestyle advice withut immediate treatment and with regular fllw up. Cnservative management pelvic flr muscle training, bladder training, pst-vid milking, prudent fluid intake, maintaining a healthy lifestyle, and cntainment prducts (such as pads, waterprf pants, external sheath, and catheters). Cnsider referring the man t, r btaining advice frm, a cntinence nurse, cntinence physitherapist, r urlgist. T find the lcal cntinence service, telephne the Bwel and Bladder Fundatin n 01536 533 255. If active surveillance is nt apprpriate and cnservative management fails: If the man has mderate-t-severe viding lwer urinary tract symptms (LUTS) (which wuld crrespnd t an IPSS scre f 8 r mre), ffer an alpha-blcker (such as alfuzsin, dxazsin, tamsulsin, r terazsin). Review at 4 6 weeks and then every 6 12 mnths. Assess symptms, quality-f-life, and adverse effects. See Alpha-blckers fr viding symptms fr detailed prescribing infrmatin, including the chice f drug. If the man has an enlarged prstate and is cnsidered t be at high risk f prgressin, ffer a 5-alpha reductase inhibitr (dutasteride r finasteride). The prstate is cnsidered t be enlarged if it weighs mre than 30 g. Prstatic enlargement can be estimated clinically by digital rectal examinatin, r indirectly with the prstate specific antigen (PSA) test PSA higher than 1.4 nangram/ml is a sign f an enlarged prstate. (Althugh ultrasngraphy mst accurately estimates prstate size, this is nt recmmended fr guiding the decisin t ffer a 5- alpha reductase inhibitr.) The risk f prgressin f symptms frm benign prstatic enlargement is higher in lder men, and is higher in men with prer urine flw, higher symptms scre, evidence f bladder decmpensatin (such as chrnic urinary retentin), larger prstate, r higher PSA level. Review symptms, quality-f-life, and adverse effects at 3 6 mnths, and then every 6 12 mnths. See 5-alpha reductase inhibitrs fr viding symptms fr detailed prescribing infrmatin, including the chice f drug. If the man has bthersme mderate-t-severe viding LUTS and prstatic enlargement, cnsider ffering a cmbinatin f an alpha-blcker and a 5-alpha reductase inhibitr. 24
If the man cntinues t have strage (irritative) symptms after treatment with an alphablcker alne, cnsider adding an antimuscarinic (antichlinergic). Fr example xybutynin initially 5 mg tw t three times daily, increased if necessary t a maximum f 5 mg fur times daily. Elderly men require lwer dses. Review every 4 6 weeks until symptms are stable, and then every 6 12 mnths. Assess symptms, quality-f-life, adverse effects, and the need t cntinue treatment. Fr full prescribing infrmatin and chice f antimuscarinic drug, see Antimuscarinics fr veractive bladder. If treatment fails t adequately relieve symptms: Discuss and decide if active surveillance r further active interventin is apprpriate. Cnsider ffering referral t a urlgist fr assessment and further management. Treatments available in secndary care In secndary care, treatment ptins fr strage (bstructive) symptms include urethral catheterizatin and prstate surgery. Catheterizatin Urethral catheterizatin may be intermittent, indwelling urethral, r indwelling suprapubic. Mre invasive ptins are used nly when less invasive ptins are impractical r have failed. Surgery Surgical ptins include: Transurethral resectin f the prstate (TURP). Transurethral vaprizatin f the prstate (TUVP). Hlmium laser enucleatin f the prstate (HLEP). Transurethral incisin f the prstate (TUIP). Open prstatectmy. The chice f surgery depends n the size f the prstate, the availability f specialized equipment and skills, the man's health, and hw he balances the expected benefits against the risks. 25
Mst peratins are perfrmed thrugh the urethra, but pen surgery is used fr larger prstates (weighing mre than 80 g). Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. Assessment f symptms and excluding treatable causes These recmmendatins are pragmatic and based n expert pinin as NICE fund n relevant clinical trials f assessment and exclusin strategies. Active surveillance The recmmendatins n active surveillance are based n expert pinin as NICE fund n relevant clinical r ecnmic studies [NICE, 2010]. Cnservative treatments The recmmendatins n cnservative treatments (bladder training, pst-vid milking, maintaining a healthy lifestyle, cntainment prducts, and btaining advice) are based n expert pinin, as NICE fund n relevant clinical r ecnmic studies [NICE, 2010]. Alpha-blckers NICE cncluded that alpha-blckers are cst-effective fr men with mderate-t-severe LUTS, are mre cst-effective than 5-alpha reductase inhibitrs in men with a nrmally sized prstate, and their benefits utweigh the adverse effects [NICE, 2010]. Meta-analysis by NICE f 12 randmized cntrlled trials (RCTs) fund that, cmpared with placeb, alpha-blckers reduced the symptm scre, with a mean difference f 2.55 (95% CI 3.17 t 1.92). Althugh this difference is statistically significant, the 95% cnfidence interval includes the minimum clinically imprtant difference. Ecnmic studies fund that alpha-blckers were cst-effective cmpared with placeb r n treatment in men with mderate r severe LUTS. NICE assessed the results as having minr limitatins and being nly partially applicable. RCTs fund that alpha-blckers are mre effective than 5-alpha reductase inhibitrs. 26
The quality f evidence frm studies cmparing alpha-blckers with antimuscarinics (antichlinergics) and phsphdiesterase-5 (PDE-5) inhibitrs ranged frm very lw t lw. RCTs fund that mre men treated with alpha-blckers than placeb experience dizziness, fatigue (asthenia), pstural hyptensin, rhinitis, erectile dysfunctin, and abnrmal ejaculatin. The recmmendatins n fllw up and mnitring are based n expert pinin as NICE fund n relevant clinical trials. 5-alpha reductase inhibitrs NICE cncluded that 5-alpha reductase inhibitrs may be cst-effective fr men with large prstates, and that their benefits utweigh the adverse effects [NICE, 2010]. RCTs fund that 5-alpha reductase inhibitrs were less effective than alpha-blckers in imprving symptm scres and maximum urine flw in men with prstates estimated t be less than 30 ml, but were mre effective in men with larger prstates (at least 30 ml, and 55 ml n average). RCTs fund that, cmpared with alpha-blckers, 5-alpha reductase inhibitrs are less likely t cause rthstatic hyptensin, dizziness, fatigue r asthenia, and rhinitis, but are mre likely t cause decreased libid, imptence, and breast enlargement. The recmmendatins n fllw up and mnitring are based n expert pinin as NICE fund n relevant clinical trials. Cmbinatin f an alpha-blcker and a 5-alpha reductase inhibitr NICE cncluded that cmbined treatment with an alpha-blcker and a 5-alpha reductase inhibitr may be mre cst-effective than treatment with an alpha-blcker alne in selected peple wh are at higher risk f prgressin because f lder age, mre severe/bthersme symptms, r greater prstate size. The recmmendatin was made n the basis f expert pinin weighing up the evidence n benefits, adverse effects, acceptability, and cst-effectiveness [NICE, 2010]. RCTs fund that alpha-blckers plus 5-alpha reductase inhibitr cmbinatins are mre effective than alpha-blckers alne in imprving symptm scres at 2 4 years' fllw up. The cmbinatin was nt mre effective at 6 mnths r 1 year. Men treated with alpha-blckers plus 5-alpha reductase inhibitr cmbinatins were mre likely than men treated with alpha-blckers alne t experience adverse effects (such as decreased libid, ejaculatry abnrmalities, and imptence). Antimuscarinics (antichlinergics) 27
The recmmendatin t cnsider adding an antimuscarinic fr persistent veractive bladder symptms in men being treated with an alpha-blcker is based n ne RCT included in the NICE systematic review [Kaplan et al, 2006; Kaplan et al, 2008], and a mre recent RCT [Chapple et al, 2009]. The first RCT had methdlgical weaknesses. The secnd RCT, which was placeb-cntrlled, fund that men with bthersme veractive bladder symptms while taking an alpha-blcker had statistically significantly greater imprvements in diary variables, Internatinal Prstate Symptm Scre (IPSS) strage scres, and symptm bther when an antimuscarinic (tlterdine ER) was added. Hwever, there was n difference in the prprtins f men whse Patient Perceptin f Bladder Cnditin (PPBC) scre imprved. Minr adverse effects (such as dry muth) are cmmn with antimuscarinics. Urinary retentin is a serius pssible adverse effect, but NICE fund n evidence that this risk is clinically imprtant. The recmmendatins n fllw up and mnitring are based n expert pinin as NICE fund n relevant clinical trials. Referral The recmmendatins n referral are based n expert pinin as NICE fund n relevant clinical trials. Infrmatin n specialist treatments The infrmatin n specialist treatments is frm the NICE guideline [NICE, 2010]. What advice shuld I prvide abut self-help resurces? Advise that: NHS Chices prvides nline infrmatin fr peple with prstate enlargement, including infrmatin n the management f viding prblems and ther lwer urinary tract symptms (LUTS). The Bladder and Bwel Fundatin has a helpline (telephne 01536 533 255), and prvides a range f resurces n their website www.bladderandbwelfundatin.rg. Infrmatin n viding symptms is included in their bklet n bladder prblems, which can be rdered frm their nline shp r dwnladed fr printing (pdf). Hmepathy, phyttherapy (such as saw palmett), and acupuncture are nt recmmended fr treating LUTS in men, because clinical trials have nt prvided evidence f effectiveness and safety. 28
Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE recmmends prviding men with LUTS with infrmatin and advice n the basis f expert pinin, as they fund n relevant clinical trials [NICE, 2010]. What self-care advice shuld I prvide abut fluid intake and lifestyle fr men with lwer urinary tract symptms? Fluid intake shuld be within the man's usual range, and shuld nt be limited excessively in an attempt t cntrl symptms ding this culd increase the risk f cmplicatins such as urinary tract infectin. Lifestyle advice may include: Aviding cnstipatin, r treating it (if it is present). Maintaining a healthy lifestyle (with respect t bdy weight, exercise, diet, smking, and alchl cnsumptin). Limiting intake f tea, cffee, chclate, artificial sweeteners, and fizzy drinks. Basis fr recmmendatin These recmmendatins are in line with the guideline The management f lwer urinary tract symptms in men frm the Natinal Institute fr Health and Clinical Excellence (NICE) [NICE, 2010]. NICE based these recmmendatins n expert pinin as they fund n relevant clinical trials [NICE, 2010]. Prescriptins Fr infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) (http://emc.medicines.rg.uk), r the British Natinal Frmulary (BNF) (www.bnf.rg). Start immediate-release alpha blcker 29
Age frm 40 years nwards Start dxazsin tablets: 1mg nce a day Dxazsin 1mg tablets Take ne tablet nce a day. Supply 14 tablets. Age: frm 40 years nwards NHS cst: 0.60 Patient infrmatin: Take the first dse befre yu g t bed at night. Sme peple experience side effects such as blurred visin, dizziness, drwsiness, sweating r feeling light headed. If any f these apply, sit r lie dwn until the symptms have disappeared. Tell yur dctr if these symptms cntinue after taking the medicine fr a few days. Usually, yur dctr will increase the dse f this medicine every week r tw during the first mnth r s f treatment, prvided that side effects are nt trublesme. Start terazsin: BPH starter pack Terazsin 5mg tablets and Terazsin 2mg tablets and Terazsin 1mg tablets Take ne tablet nce a day. See package insert fr full instructins. Supply 28 tablets. Age: frm 40 years nwards NHS cst: 10.97 Patient infrmatin: Take the first dse befre yu g t bed at night. Sme peple experience side effects such as blurred visin, dizziness, drwsiness, sweating r feeling light headed. If any f these apply, sit r lie dwn until the symptms have disappeared. Tell yur dctr if these symptms cntinue after taking the medicine fr a few days. Start mdified-release alpha-blcker Age frm 40 years nwards Alfuzsin m/r tablets: 10mg nce a day Alfuzsin 10mg mdified-release tablets Take ne tablet nce a day. Supply 30 tablets. Age: frm 40 years nwards NHS cst: 12.51 Patient infrmatin: Sme peple experience side effects such as blurred visin, dizziness, drwsiness, sweating r feeling light headed. If any f these apply, sit r lie dwn until the symptms have disappeared. Tell yur dctr if these symptms cntinue after taking the medicine fr a few days. Tamsulsin m/r capsules: 400micrgrams nce a day Tamsulsin 400micrgram mdified-release capsules Take ne capsule nce a day. Supply 30 capsules. Age: frm 40 years nwards NHS cst: 4.92 Patient infrmatin: Sme peple experience side effects such as blurred visin, dizziness, drwsiness, sweating r feeling light headed. If any f these apply, sit r lie dwn until the symptms have disappeared. Tell yur dctr if these symptms cntinue after taking the medicine fr a few days. 30