Lower Urinary Tract Symptoms in Men

Lower urinary tract symptoms in men are a group of symptoms arising from the bladder, prostate and urethra: storage (frequency, urgency, nocturia, urge incontinence), voiding (hesitancy, slow or intermittent stream, straining, terminal dribbling) and post-micturition (incomplete emptying, post-void dribbling).

• Prevalence increases with age: about 25 percent of men in their 50s and over 50 percent over 60 have moderate to severe symptoms.
• Causes:
  • Benign prostatic enlargement with bladder outlet obstruction (commonest).
  • Overactive bladder and detrusor underactivity (ageing, diabetes).
  • Nocturnal polyuria (heart failure, sleep apnoea, evening fluids).
  • Urinary tract infection, prostatitis, urethritis.
  • Urethral stricture, meatal stenosis, phimosis.
  • Prostate cancer, bladder cancer, bladder stones.
  • Neurogenic bladder (diabetic neuropathy, Parkinson disease, multiple sclerosis, spinal cord disease, stroke).
  • Constipation, drugs (diuretics, anticholinergics, decongestants, opioids, antidepressants, calcium channel blockers), high fluid intake, caffeine, alcohol, diabetes mellitus and insipidus, hypercalcaemia.
• Complications of obstruction: acute and chronic retention, recurrent urinary infection, bladder stones, haematuria, hydronephrosis and renal impairment.

• Symptoms assessed by the International Prostate Symptom Score (IPSS, 0 to 7 mild, 8 to 19 moderate, 20 to 35 severe) with a bother question.
• History: duration, pattern, haematuria, dysuria, fever, pain, nocturia, fluid and caffeine intake, sexual and ejaculatory function, previous prostate or urethral surgery, instrumentation, urethritis, neurological symptoms, constipation, weight loss, bone pain, family history of prostate cancer, drugs.
• Examination: abdomen (palpable bladder), external genitalia (meatus, phimosis), digital rectal examination (size, consistency, nodules, tenderness, anal tone), neurological (perineal sensation, lower limb), oedema, blood pressure.
• Red flags: visible haematuria, hard irregular prostate or raised PSA for age, back pain, weight loss, bone pain, painful retention, recurrent infections, fever with prostate tenderness (acute prostatitis), renal impairment, palpable bladder with overflow, neurological deficit, saddle anaesthesia.

• Urinalysis (dipstick) and culture if positive; bloods: urea, creatinine, eGFR, glucose or HbA1c, and PSA after counselling on benefits and harms (also useful for prostate size prediction and treatment choice).
• Frequency volume chart for 3 days when nocturia or frequency is prominent.
• Uroflowmetry: peak flow (Qmax) below 10 mL/s suggests obstruction; over 15 mL/s argues against it; voided volume at least 150 mL needed.
• Post-void residual by bladder scan: over 100 to 150 mL suggests incomplete emptying; high residual with renal impairment requires urgent assessment.
• Renal tract ultrasound if haematuria, infection, residual urine, renal impairment, or suspected stones.
• Transrectal or abdominal ultrasound to measure prostate volume (over 30 to 40 mL indicates enlargement).
• Cystoscopy for haematuria or suspected stricture; urodynamics for diagnostic uncertainty or before surgery; multiparametric MRI of the prostate when PSA is raised.
• Differential: prostate cancer, bladder cancer, urethral stricture, detrusor underactivity, neurogenic bladder, overactive bladder.

• Conservative: reassure, watchful waiting for mild symptoms; reduce fluids in the evening; limit caffeine and alcohol; avoid constipation; double voiding and urethral milking; bladder training; review drugs; weight loss and exercise.
• Moderate to severe voiding symptoms: alpha blockers
  • Tamsulosin 400 micrograms orally once daily (modified release, 30 minutes after the same meal each day).
  • Alfuzosin 10 mg modified release orally once daily.
  • Doxazosin 1 mg at night, doubled after 1 to 2 weeks to 2 mg, then 4 mg, up to 8 mg daily (first dose hypotension; take at night).
  • Silodosin 8 mg once daily with food.
  • Side effects: dizziness, postural hypotension, retrograde ejaculation, nasal congestion; tell the ophthalmologist about use before cataract surgery (intraoperative floppy iris syndrome). Assess at 4 to 6 weeks.
• Prostate volume over 30 to 40 mL or PSA over 1.4 ng/mL: add or use a 5-alpha reductase inhibitor
  • Finasteride 5 mg orally once daily or dutasteride 500 micrograms orally once daily; effect takes 3 to 6 months; reduces prostate volume by about 20 to 25 percent; halves PSA (double PSA values for interpretation); side effects: reduced libido, erectile dysfunction, ejaculatory disorders, gynaecomastia. Combination with an alpha blocker lowers risk of progression, retention and surgery.
• Erectile dysfunction with LUTS: tadalafil 5 mg orally once daily (contraindicated with nitrates, and with alpha blockers use only at lower doses with blood pressure caution).
• Persistent storage symptoms with residual urine under 150 mL after alpha blockade: add an antimuscarinic (solifenacin 5 mg daily, tolterodine 2 mg twice daily, or fesoterodine 4 mg daily) or mirabegron 50 mg daily (25 mg if eGFR 15 to 29); check residual volume and blood pressure.
• Nocturnal polyuria: desmopressin melt 50 micrograms sublingually at bedtime in men (check serum sodium at baseline, day 3 and 1 month, and stop if below 130 mmol/L); contraindicated with heart failure, eGFR under 50 mL/min and hyponatraemia.
• Acute retention: catheterise (urethral 12 to 14 Fr; record residual volume) and start tamsulosin 400 micrograms daily; remove the catheter after 2 to 3 days of an alpha blocker to test voiding; refer if it fails.
• Surgery and procedures (urology): transurethral resection or laser enucleation of the prostate, prostatic urethral lift, water vapour thermal therapy, and open prostatectomy for large glands. Indications: retention, recurrent urinary infection, haematuria from the prostate, bladder stones, renal impairment from obstruction, or failure or intolerance of medical therapy. Intradetrusor onabotulinumtoxinA for refractory overactive bladder is a specialist option.
• Review every 6 to 12 months for patients on treatment; reassess symptoms, PSA, and adherence.
• Refer urgently if suspected prostate cancer (hard or irregular gland, raised age specific PSA), visible haematuria, or retention with renal impairment.