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Lower urinary tract symptoms in men, age-related (including symptoms of benign prostatic hyperplasia/hypertrophy) - Management
How do I manage predominantly voiding (obstructive) symptoms?

  • If it is practical, assess the baseline severity of symptoms and degree of bother with a validated symptom scoring system such as the IPSS (International Prostate Symptom Score). Symptom scores are used to guide treatment choice and to assess future changes in symptoms.
  • Exclude or manage causes of obstructive symptoms, for example drugs, neurological conditions, urethral stricture, and cancer (prostate, bladder, rectum).
  • First-line management options include:
    • Active surveillance — reassurance and lifestyle advice without immediate treatment and with regular follow up.
    • Conservative management — pelvic floor muscle training, bladder training, post-void milking, prudent fluid intake, maintaining a healthy lifestyle, and containment products (such as pads, waterproof pants, external sheath, and catheters). Consider referring the man to, or obtaining advice from, a continence nurse, continence physiotherapist, or urologist.
      • To find the local continence service, telephone the Bowel and Bladder Foundation on 01536 533 255.
  • If active surveillance is not appropriate and conservative management fails:
    • If the man has moderate-to-severe voiding lower urinary tract symptoms (LUTS) (which would correspond to an IPSS score of 8 or more), offer an alpha-blocker (such as alfuzosin, doxazosin, tamsulosin, or terazosin).
      • Review at 4–6 weeks and then every 6–12 months. Assess symptoms, quality-of-life, and adverse effects.
      • See Alpha-blockers for voiding symptoms for detailed prescribing information, including the choice of drug.
    • If the man has an enlarged prostate and is considered to be at high risk of progression, offer a 5-alpha reductase inhibitor (dutasteride or finasteride).
      • The prostate is considered to be enlarged if it weighs more than 30 g. Prostatic enlargement can be estimated clinically by digital rectal examination, or indirectly with the prostate specific antigen (PSA) test — PSA higher than 1.4 nanogram/mL is a sign of an enlarged prostate. (Although ultrasonography most accurately estimates prostate size, this is not recommended for guiding the decision to offer a 5-alpha reductase inhibitor.)
      • The risk of progression of symptoms from benign prostatic enlargement is higher in older men, and is higher in men with poorer urine flow, higher symptoms score, evidence of bladder decompensation (such as chronic urinary retention), larger prostate, or higher PSA level.
      • Review symptoms, quality-of-life, and adverse effects at 3–6 months, and then every 6–12 months.
      • See 5-alpha reductase inhibitors for voiding symptoms for detailed prescribing information, including the choice of drug.
    • If the man has bothersome moderate-to-severe voiding LUTS and prostatic enlargement, consider offering a combination of an alpha-blocker and a 5-alpha reductase inhibitor.
  • If the man continues to have storage (irritative) symptoms after treatment with an alpha-blocker alone, consider adding an antimuscarinic (anticholinergic).
    • For example oxybutynin — initially 5 mg two to three times daily, increased if necessary to a maximum of 5 mg four times daily. Elderly men require lower doses.
    • Review every 4–6 weeks until symptoms are stable, and then every 6–12 months. Assess symptoms, quality-of-life, adverse effects, and the need to continue treatment.
    • For full prescribing information and choice of antimuscarinic drug, see Antimuscarinics for overactive bladder.
  • If treatment fails to adequately relieve symptoms:
    • Discuss and decide if active surveillance or further active intervention is appropriate.
    • Consider offering referral to a urologist for assessment and further management.

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