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Lower urinary tract symptoms in men, age-related (including symptoms of benign prostatic hyperplasia/hypertrophy) - Management
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How do I manage nocturnal polyuria as the predominant symptom?
- Exclude or manage treatable causes of nocturnal polyuria, such as diabetes, renal disease, chronic heart failure, and drugs. However, it is often not possible to identify a specific cause.
- Advise the man to limit his fluid intake in the late afternoon and evening, and offer information on self-help resources.
- If limiting fluid intake in the late afternoon and evening is ineffective, consider offering a loop diuretic to be taken in the late afternoon. For example, furosemide 40 mg (this use is off-label).
- If nocturnal polyuria remains bothersome, refer the man or seek specialist advice about switching to oral desmopressin to be taken at bedtime — this use is off-label.
- Start treatment with the lowest dose — 200 micrograms of oral desmopressin.
- To prevent fluid overload and hyponatraemia, advise the man to drink only enough to satisfy his thirst, to avoid fluids in the last 1–2 hours before bed, and to avoid fluids for 8 hours after taking desmopressin.
- Monitor for dilutional hyponatraemia by measuring serum sodium 3 days after the first dose. If serum sodium decreases below the normal range, stop the desmopressin.
- For detailed prescribing information, see Desmopressin for nocturnal polyuria.
Basis for recommendation
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].
Furosemide
- NICE found only one clinical trial, which reported that diuretics were more effective than placebo in reducing the frequency of night time urinating, but were not more effective in improving symptoms. These results may not be reliable, because there were only 43 participants in the study and the methods of randomization and allocation concealment were not reported [NICE, 2010].
- NICE found no trial-based evidence on potential adverse effects (such as hypovolaemia and orthostatic hypotension), but considered the risk to be small (provided that this risk informs the information that is given to the man and the plans for monitoring) [NICE, 2010].
Desmopressin
- NICE based their recommendation on expert opinion as they found only one crossover study; this was too small to provide reliable evidence [NICE, 2010].
- NICE concluded that bioavailability and pharmacokinetic studies suggest that the nasal formulation of desmopressin may be more potent and more likely to cause hyponatraemia than the oral formulation (15 episodes per 100,000 patient-years with the nasal spray, and six episodes per 100,000 patient-years with the oral product) [NICE, 2010].
What advice should I provide about self-help resources?
Basis for recommendation
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].
- NICE recommends providing men with lower urinary tract symptoms with information and advice on the basis of expert opinion, as they found no relevant clinical trials [NICE, 2010].
What self-care advice should I provide about fluid intake and lifestyle for men with lower urinary tract symptoms?
- Fluid intake should be within the man's usual range, and should not be limited excessively in an attempt to control symptoms — doing this could increase the risk of complications such as urinary tract infection.
- Lifestyle advice may include:
- Avoiding constipation, or treating it (if it is present).
- Maintaining a healthy lifestyle (with respect to body weight, exercise, diet, smoking, and alcohol consumption).
- Limiting intake of tea, coffee, chocolate, artificial sweeteners, and fizzy drinks.
Basis for recommendation
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].
- NICE based these recommendations on expert opinion as they found no relevant clinical trials [NICE, 2010].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Furosemide
Age from 40 years onwards
Furosemide tablets: 40mg each afternoon
Furosemide 40mg tablets
Take one tablet once a day, during the late afternoon.
Supply 28 tablets.
Desmopressin
Age from 40 to 65 years
Start desmopressin tablets: 200micrograms at bedtime
Desmopressin 200microgram tablets
Take one tablet at bedtime.
Supply 30 tablets.
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