Lower Urinary Tract Symptoms (LUTS) in Men
NICE Clinical guideline [CG97] Lower urinary tract symptoms in men: management. Last updated: Jun 2015.
NICE CKS LUTS in men. Last revised: Jun 2025.
Background information added accordingly.
Date: 15/12/25
Background Information
Definition
LUTS refers to a group of symptoms related to dysfunction of the bladder / urethra / prostate. LUTS can be grouped as following:
| Obstructive (voiding) LUTS |
Some sources classify the following as post-micturition symptoms:
|
| Storage (irritative) LUTS |
|
Aetiology
Causes of the type of LUTS:
| Obstructive (voiding) LUTS |
|
| Storage (irritative) LUTS | Causes of overactive bladder:
Nocturnal polyuria can be caused by:
Stress urinary incontinence (due to urethral sphincter malfunction) can be caused by:
|
Diagnosis
Investigation and Diagnosis
It is more important to appreciate what assessments are done routinely initially, and what other ones are only offered by a specialist. Exam questions don’t expect one to learn the exact indications, but one would be expected to be able to distinguish between a routinely offered initial test and a specialist-only test (e.g. urine dipstick vs flow-rate measurement).
Initial Assessment (Primary Care)
Tests for ALL patients:
| Test | Purpose |
|---|---|
| Urinalysis | Important differential diagnoses to exclude:
|
| IPSS assessment | To classify the severity of LUTS and the impact on quality of life
Allows baseline assessment and assesses treatment effectiveness |
| Urinary frequency volume chart | To give an indication of the voiding pattern, the severity of symptoms, and the impact on the person’s daily life |
Additional tests to consider:
- Offer PSA testing (if prostate is abnormal on DRE / patient is concerned about prostate cancer / symptoms suggest bladder outlet obstruction secondary to BPH)
- Only if renal impairment is suspected → offer serum creatinine and eGFR
Further Assessment (Secondary Care)
- Flow-rate measurement – routine
- Post-void residual volume – routine
- Multichannel cystometry – if surgery is considered
- Cystoscopy – only if indicated
- Imaging of the upper urinary tract – only if indicated
Management
Storage Symptoms
Approach (step up if ineffective):
- Step 1: conservative management
- Step 2: pharmacological management
- Step 3: invasive management
Conservative Management
Advise on the following:
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Specific training for urinary incontinence:
- Urge incontinence (overactive bladder) → bladder retraining
- Stress incontinence → pelvic floor muscle training for at least 3 months
Offer temporary containment products (for example, pads or collecting devices) if there is urinary incontinence
Pharmacological Management
All patients:
- 1st line: anti-cholinergic (e.g. oxybutynin, tolterodine, darifenacin)
- 2nd line: beta-3 receptor agonist (e.g. mirabegron, vibegron)
If the patient also experiences bothersome nocturia, consider:
- Late afternoon loop diuretic (off-label)
- Desmopressin
- Glaucoma
- Patient of old age / at risk of cognitive impairment / with cognitive impairment
- Known myasthenia gravis
Invasive Management
Consider the following:
- Botulinum toxin A injection (patient must be willing and able to self-catheterise)
- Augmentation cystoplasty (patient must be willing and able to self-catheterise)
- Implanted sacral nerve stimulation
- Artificial sphincter implantation (for stress incontinence)
- Last resort: urinary diversion
Voiding Symptoms
Approach (step up if ineffective):
- All patients should be offered conservative management
- Consider pharmacological management in all patients (as per indications below)
- Last resort (if pharmacological management failed): invasive management
Conservative Management
Advise on the following:
- Regulate fluid intake
- Avoid bladder stimulants (e.g. caffeine)
- Urethral milking – if there is post-micturition dribbling
Pharmacological Management
2 main drug classes are used to manage obstructive LUTS:
| Drug class | MoA | Examples | Indications |
|---|---|---|---|
| Alpha blocker | Block α1-adrenergic receptors in prostatic and bladder-neck→ smooth muscle relaxation → improve urinary flow | Doxazosin, tamsulosin |
|
| 5-alpha reductase inhibitor | Reduce conversion of testosterone into dihydrotestosterone → reduction in prostate volume → improve obstruction | Finasteride |
|
If the patient meets BOTH criteria above, offer combination therapy (an alpha-blocker AND a 5-alpha reductase inhibitor)
As mentioned above, an enlarged prostate (>30 g) is the indication to start a 5-alpha reductase inhibitor. There are 2 ways to estimate the prostate size:
- PSA level correlates with prostate volume (>1.4 ng/mL is approximately >30g)
- Imaging (often trans-rectal ultrasound) can be used to measure prostate volume – this is widely used in clinical practice but not explicitly mentioned in NICE guideline
Note that an alpha blocker gives rapid symptomatic relief (within days to weeks), while a 5-alpha reductase inhibitor has a slow onset of action, with clinically significant effects typically taking 3-6 months to manifest.
Invasive Management
1st line:
- Transurethral resection of the prostate (TURP) – most widely used
- Transurethral vaporisation of the prostate (TUVP)
Other options:
- If prostate <30g → transurethral incision of the prostate (TUIP)
- If prostate >80g → open prostatectomy is preferred
If surgery is not appropriate (e.g. patient does not wish to undergo surgery, surgery is contraindicated):
- 1st line: intermittent bladder catheterisation
- 2nd line: indwelling urethral / suprapubic catheterisation