• To establish what type or combination of types of lower urinary tract symptoms (LUTS) the man has, ask about:
• Storage (irritative) symptoms: urgency, daytime urinary frequency, nocturia, urinary incontinence, and feeling the need to urinate again just after passing urine.
• Specifically ask about bedwetting, as this can be a sign of chronic urinary retention.
• Voiding (obstructive) symptoms: hesitancy, weak or intermittent urinary stream sometimes causing splitting or spraying, straining, intermittency, incomplete emptying, and terminal dribbling.
• Post-micturition symptoms: post-micturition dribble, and the sensation of incomplete emptying.
• If the man has bothersome LUTS, storage symptoms, or nocturia ask him to complete a urinary frequency-volume chart. This is essential to distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.

• A urinary frequency–volume chart is used to help distinguish and diagnose:
• Frequency: high frequency with normal 24-hour volume suggests that the bladder capacity is diminished (the male bladder normally holds 300–600 mL urine comfortably).
• Polyuria: passing more urine than usual (up to 3 L of urine in 24 hours is normal).
• Nocturia: waking at night to urinate.
• Nocturnal polyuria: passing, at night, more than 35% of the 24-hour urine production.
• A urinary frequency–volume chart (pdf) formatted for printing or downloading is available from CKS.

These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010] and are based on expert opinion [Reynard et al, 2006; NICE, 2010].

• The NICE systematic review found no studies assessing whether the completion of frequency-volume charts affects outcomes.

• If it is practical, ask the man to complete the International Prostate Symptom Score (IPSS) questionnaire to assess symptom severity and degree of bother.
• Severity of symptoms and degree of bother often do not correlate closely, and are therefore assessed separately.
• Establish the man's chief concerns. For example, is he worried that his symptoms:
• Are bothersome?
• Could progress to acute urinary retention?
• Could be due to cancer?

• The International Prostate Symptom Score (IPSS) is a tool for classifying the severity of lower urinary tract symptoms as mild, moderate, or severe; and to assess how bothersome the symptoms are.
• The IPSS questionnaire is intended to be completed by the man. It assesses symptoms (by adding the score of seven separate questions) and degree of bother (one question):
• Severity of symptoms questions — each is scored from 0 (best) to 5 (worst).
• Incomplete emptying. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
• Frequency. Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
• Intermittency. Over the past month, how often have you found you stopped and started again several times when you urinated?
• Urgency. Over the last month, how difficult have you found it to postpone urination?
• Weak stream. Over the past month, how often have you had a weak urinary stream?
• Straining. Over the past month, how often have you had to push or strain to begin urination?
• Nocturia. Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?
• The IPSS severity score is the total of the seven individual symptom scores, and is interpreted as:
• Score 0–7: mildly symptomatic.
• Score 8–19: moderately symptomatic.
• Score 20–35: severely symptomatic.
• Question about quality-of-life due to urinary symptoms — scored from 0 (best) to 6 (worst).
• If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?

These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010] and are based on expert opinion [Reynard et al, 2006; NICE, 2010].

• The IPSS includes the American Urological Association severity of symptoms score, which was developed and validated by the multidisciplinary measurement committee of the American Urological Association [Barry et al, 1992].
• The NICE systematic review found no study that assessed whether scoring symptoms affect clinical outcome.
• The NICE guideline development group highlighted the fact that completing the symptom score would be difficult or impossible for people who are blind, cannot read English, or have learning disabilities.

• Examination should be guided by urological and other symptoms.
• Examine the abdomen for signs of a distended bladder such as abdominal distention and suprapubic dullness on percussion.
• Check the external genitalia.
• Perform a digital rectal examination to assess the prostate for size, consistency, nodules, and tenderness.

These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010] and are based on expert opinion [Reynard et al, 2006; NICE, 2010].

• The NICE systematic review found no study that assessed the effectiveness (in terms of clinical outcomes) of examining the abdomen and external genitalia, or performing a digital rectal examination.

• Investigations should be guided by the symptoms, history, and examination.
• Dipstick test the urine to check for blood, glucose, protein, leucocytes, and nitrites.
• Measure serum creatinine and eGFR (estimated glomerular filtration rate) if clinically indicated, for example when there is any of the following:
• Chronic high pressure urinary retention — suggested by bedwetting, or enlarged bladder detected on abdominal palpation or percussion.
• Recurrent urinary tract infection.
• History of renal stones.
• Test for prostate specific antigen (PSA) only after discussing the indications for the test and the interpretation of the results, and providing sufficient time for the man to decide if he wishes to have the test.
• PSA testing is indicated only:
• If symptoms suggest bladder outlet obstruction due to benign prostatic enlargement — the test result can guide drug treatment.
• If the man is concerned about prostate cancer or if the prostate feels abnormal on digital rectal examination — the test result can guide assessment of the risk of prostate cancer.
• Delay testing if any of the following causes of a transiently increased serum PSA level are present:
• Vigorous exercise — delay testing for 2 days.
• Digital rectal examination — delay testing for 1 week.
• Prostate biopsy — delay testing for 6 weeks.
• Interpreting PSA results can be difficult.
• An increased serum PSA level can be present with:
• Prostate enlargement.
• Prostate cancer.
• Infection (prostatitis, urinary tract infection).
• Physical causes, including following vigorous exercise, digital rectal examination, and prostate biopsy.
• A normal prostate.
• A normal serum PSA level can be present with:
• Prostate enlargement.
• Prostate cancer.
• Infection.
• If checking PSA levels in a man using a 5-alpha reductase inhibitor, be aware that:
• A decrease in PSA levels is seen rapidly, within the first few months of treatment.
• After 6 months of treatment with a 5-alpha reductase inhibitor, the PSA value should be doubled to make it comparable to levels in men not treated with a 5-alpha reductase inhibitor.

These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010] and are based on expert opinion [Reynard et al, 2006; NICE, 2010].

Usefulness of urine dipstick tests for excluding bladder cancer, urinary tract infection, and urinary calculi in men with lower urinary tract symptoms (LUTS)

• The NICE systematic review found only one study that assessed the usefulness of urine dipstick tests for excluding bladder cancer, urinary tract infection, and urinary calculi in men with LUTS suggestive of benign prostatic hyperplasia (BPH). The study had serious methodological limitations that make the data unreliable.
• NICE found no trials for urine dipstick tests to exclude diabetes and renal disease in men with LUTS suggestive of BPH.

Serum creatinine to assess renal function

• NICE recommends offering men with LUTS a serum creatinine test to assess for renal impairment only when there are clinical indications of causes of renal impairment. NICE noted that most laboratories now report eGFR (estimated glomerular filtration rate) alongside blood creatinine levels.
• NICE found no trials that assessed clinical outcomes in men who had renal function measured.

PSA test to predict progression of symptoms and clinical outcomes

• The NICE systematic review found no directly relevant studies on the effect of strategies of PSA testing on eventual clinical outcomes.
• The NICE systematic review found six studies that assessed how accurately the PSA test predicts progression of symptoms. The results were inconsistent, and no reliable conclusion could be drawn.

• Check for the underlying cause of the specific type of LUTS.
• Acute urinary retention
• Stress urinary incontinence
• Overactive bladder
• Nocturnal polyuria
• Voiding (obstructive) symptoms
• Exclude or manage other serious causes of lower urinary tract symptoms (LUTS), including:
• Urological cancer
• Alarm signals for urological cancer include a prostate that is hard and irregular, unexplained haematuria, lower back pain, bone pain, and weight loss.
• Marked urinary frequency or urgency, and bladder pain may be signs of bladder cancer.
• If urological cancer is suspected, refer the man with appropriate urgency. For more information, see the CKS topic on Urological cancer - suspected, which covers suspected cancer of the prostate, bladder, kidney, and penis.
• Urological infection
• Alarm signals for urological infection include pain when urinating, pelvic pain, loin pain, fever, and abnormal urine dipstick test findings.
• If urological infection is suspected, confirm and manage accordingly. For more information, see the CKS topics on Prostatitis - acute, Prostatitis - chronic, Pyelonephritis - acute, Urethritis - male, and Urinary tract infection (lower) - men.
• Drugs, including drugs that can cause polyuria and drugs than can cause voiding (obstructive) symptoms.
• If the symptoms could be caused by a drug, consider if the dosage could be decreased, or if the drug could be stopped or replaced by another.
• Sciatica or other neurological disease
• Sciatica causes weakness, numbness, or tingling in a leg. It sometimes causes or aggravates LUTS.
• For information on the diagnosis and management of sciatica, see the CKS topic on Sciatica (lumbar radiculopathy).

These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010] and are based on expert opinion [Reynard et al, 2006; NICE, 2010].

• The sources for the recommendations on checking for specific underlying causes are cited in the linked text.
• Assessing for urologic cancer is discussed in the CKS topic on Urological cancer - suspected, which is based on NICE guidelines.
• Assessing for urological infection is discussed in the CKS topics on Prostatitis - acute, Prostatitis - chronic, Pyelonephritis - acute, Urethritis - male, and Urinary tract infection (lower) - men.
• Assessing for drug causes is discussed in the sections Nocturnal polyuria and Voiding (obstructive) symptoms.
• Assessing for sciatica is discussed in the CKS topic on Sciatica (lumbar radiculopathy).