Please register or login to view the chart

LUTS in men

Lower urinary tract symptoms ( LUTS ) in men- storage , voiding and post-micturition symptoms

LUTS can happen due to many causes such as
abnormalities or abnormal function of 

◘ prostate eg prostatitis , cancer
◘ urethra- stricture , foreign body, stone
◘ sphincters -detrusor muscle weakness or overactivity

UTIs and neurological diseases eg neurogenic bladder dysfunction
Foreign body in bladder or urethra
Meatal stenosis or phimosis
Calculus in bladder , distal ureter or urethra
Bladder tumour

Benign Prostatic Enlargement ( BPE ) is the commonest cause

Voiding or 
Obstructive symptoms-Weak or intermittent urinary stream , hesitancy , terminal dribbling and incomplete emptying

( Overactive bladder )-Urgency , frequency , urgency incontinence and nocturia

storage symptoms may indicate an underlying medical condition ( eg diabetes , htension, OSA )

micturition-Post- micturition dribbling and feeling of incomplete emptying.Prevalence increases with age
○ 30 % of men over 50 suffer from moderate to severe LUTS
○ bothersome LUTS can happen in upto 30 % of men > 65 yrs Symptoms increase 9.8 % per decade LUTS are independent risk factor for sexual dysfunction in men over the age of 50

Initial assessment-general medical hx current medications
including herbal medications , otc meds physical examination based on symptoms eg
○ abdomen and external genitalia -check for meatal stenosis , phimosis or hypospadias
○ digital rectal examination – prostate volume and surface consistency
 NICE advice asking patients to fill in a urinary frequency volume chart- available here

These charts can give an objective assessment of bladder performance
Minimum 3 days
 Dipstick -check for blood , glucose ,protein , leucocytes and nitrates PSA – discuss the test / offer advice particularly if
○ BPE suspected
○ abnormal DRE
○ patient is concerned about prostate cancer Us and Es and GFR ( if renal impairment suspected ) Consider an assessment of baseline symptoms using a validated questionnaire for eg
○ International Prostate Scoring system ( IPSS ) 
○ American Urological Association symptom index Do not routinely offer imaging of the upper urinary tract to men with uncomplicated LUTS at initial assessment

conservative management-Weight reduction – can lead to improvement Caffeine – bladder stimulant consider ↓↓ Smoking – ↑↑ ed risk of incontinence Ensure help with emotional and physical conditions Relevant physical ,psychological , sexual and social issues Men with storage LUTS -provide containment products at point of need and advice about relevant support groups Men with overactive bladder
○ offer supervised bladder training
○ adv on fluid intake
○ lifestyle advice Micturition dribble- perform urethral milking

Drug treatment-Only if conservative management fails or are not appropriate Take into account co-morbidities and current treatment Offer an alpha blocker
○ alfuzocin
○ doxazocin
○ tamsulocin
○ terazocin

for moderate to severe LUTS ( IPSS 8 or more )

Alpha blockade of adrenoceptors in the bladder neck and prostate -> relax smooth muscles leading to imrovement in urine flow/rate and reduction in LUTS symptoms
 Offer an anti-cholinergic to manage OAB symptoms Offer a 5-alpha reductase if
○ prostates > 30 g
○ PSA level > 1.4 ng/ml and considered to be high risk progression Consider a combination ie alpha Bl + 5 A Red
moderate to severe LUTS and prostates estimated to be > 30 g Consider offering an anticholinergic + alpha blocker if storage symptoms persist after treatment with an alpha blocker Consider a late afternoon loop diuretic for nocturnal polyuria Consider desmopressin for nocturnal polyuria if
○ other medical cause excluded
○ no benefit from other Rx
○ measure Na level 3 days after the 1st dose and stop Rx if level below the normal range Do not offer phosphodiesterase 5-inhibitors solely for the purpose of treating LUTS symptoms except as a part of randomised controlled trial

Predominantly obstructive symptoms –Exclude and manage cause if identifiable Active surveillance ( lifestyle + regular f/u ) Lifestyle adv ( as on left ). Moderate to severe voiding symptoms-Alpha blocker Review at 4-6 weeks and then every 6-12 months. Enlarged prostate and high risk of progression-5-alpha reductase Review at 3-6 months and then every 6-12 months.Bothersome moderate to severe voiding symptoms and prostatic enlargement-Alpha bocker
 + 5-alpha reductase. Mixed picture storage + voiding and symptoms persist after alpha-Bl Rx-Add an antimuscarinic Review every 4-6 weeks until symptoms stable and then every 6-12 months

Overactive bladder –Offer an antimuscarinic ( anti-cholinergic ) First line Older frail men avoid immediate release oxybutynin Review every 4-6 wks until symptoms stable , then
every 6-12 months Offer Mirabegron if
○ antimuscarinic contraindicated , not tolerated or not effective
○ review at 4-6 weeks

Nocturia -Limit late afternoon/evening fluid intake Late afternoon loop diuretic ( eg furosemide 40 mg ) Consider oral desmopressin if no improvement 
( consider seeking specialist urology adv )

stress incontinence-Offer containment products Refer continence specialist service Refer for specialist assessment if not caused by prostatectomy If secondary to prostatectomy
○ refer for supervised pelvic floor muscle training x 3 months
○ consider referral if no improvement after 3 months

Urinary retention-Acute retention – admit Further management will be guided by urology depending on cause

Referral-Bothersome LUTS that has not responded to conservative management LUTS complicate by
○ recurrent or persistent UTI
○ retention
○ renal impairment that is suspected to be caused by lower UrTr dysfunction or suspected urological cancer Stress urinary incontinence Continence nurse – men with obstructive symptoms Suspected urological cancer Renal impairment that might be due to lower urinary tract dysfunction


  1. Lower urinary tract symptoms in men : management Clinical guideline CG97 NICE May 2010
  2. Management of lower urinary tract symptoms: summary of NICE guidance BMJ 2010 ;340:c2354
  3. Lower urinary tract symptoms in men by Dr Louise Newson GP Online
  4. Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer ? BMJ 2018; 361:k1202
  5. CKS NHS- LUTS in men


Related Charts:

Add Your Comments

Your email address will not be published.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

A4 Medicine  - Search Less and Learn More

Welcome to the A4 medicine community where we are constantly working to provide exceptional educational material to primary health care professionals. Subscribe to our website for complete access to our A4 Charts. They are aesthetically designed charts that contain 300 (plus and adding) common and complex medical conditions with the all information required for primary care in one single page that can help you in consultation/practice and exam.

Additionally, you will get complete access for our Learn From Experts : A4 Webinar Series in which domain experts share the video explainer presentation on one medical condition in one hour for the primary care. And you will also get a hefty discount on our publications and upcoming digital products.

We are giving a lifetime flat 30% discount to our first thousand users, discount code already applied to checkout.