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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 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.
Treatments available in secondary care
- In secondary care, treatment options for storage (obstructive) symptoms include urethral catheterization and prostate surgery.
- Catheterization
- Urethral catheterization may be intermittent, indwelling urethral, or indwelling suprapubic.
- More invasive options are used only when less invasive options are impractical or have failed.
- Surgery
- Surgical options include:
- Transurethral resection of the prostate (TURP).
- Transurethral vaporization of the prostate (TUVP).
- Holmium laser enucleation of the prostate (HoLEP).
- Transurethral incision of the prostate (TUIP).
- Open prostatectomy.
- The choice of surgery depends on the size of the prostate, the availability of specialized equipment and skills, the man's health, and how he balances the expected benefits against the risks.
- Most operations are performed through the urethra, but open surgery is used for larger prostates (weighing more than 80 g).
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].
Assessment of symptoms and excluding treatable causes
- These recommendations are pragmatic and based on expert opinion as NICE found no relevant clinical trials of assessment and exclusion strategies.
Active surveillance
- The recommendations on active surveillance are based on expert opinion as NICE found no relevant clinical or economic studies [NICE, 2010].
Conservative treatments
- The recommendations on conservative treatments (bladder training, post-void milking, maintaining a healthy lifestyle, containment products, and obtaining advice) are based on expert opinion, as NICE found no relevant clinical or economic studies [NICE, 2010].
Alpha-blockers
- NICE concluded that alpha-blockers are cost-effective for men with moderate-to-severe LUTS, are more cost-effective than 5-alpha reductase inhibitors in men with a normally sized prostate, and their benefits outweigh the adverse effects [NICE, 2010].
- Meta-analysis by NICE of 12 randomized controlled trials (RCTs) found that, compared with placebo, alpha-blockers reduced the symptom score, with a mean difference of –2.55 (95% CI –3.17 to –1.92). Although this difference is statistically significant, the 95% confidence interval includes the minimum clinically important difference.
- Economic studies found that alpha-blockers were cost-effective compared with placebo or no treatment in men with moderate or severe LUTS. NICE assessed the results as having minor limitations and being only partially applicable.
- RCTs found that alpha-blockers are more effective than 5-alpha reductase inhibitors.
- The quality of evidence from studies comparing alpha-blockers with antimuscarinics (anticholinergics) and phosphodiesterase-5 (PDE-5) inhibitors ranged from very low to low.
- RCTs found that more men treated with alpha-blockers than placebo experience dizziness, fatigue (asthenia), postural hypotension, rhinitis, erectile dysfunction, and abnormal ejaculation.
- The recommendations on follow up and monitoring are based on expert opinion as NICE found no relevant clinical trials.
5-alpha reductase inhibitors
- NICE concluded that 5-alpha reductase inhibitors may be cost-effective for men with large prostates, and that their benefits outweigh the adverse effects [NICE, 2010].
- RCTs found that 5-alpha reductase inhibitors were less effective than alpha-blockers in improving symptom scores and maximum urine flow in men with prostates estimated to be less than 30 mL, but were more effective in men with larger prostates (at least 30 mL, and 55 mL on average).
- RCTs found that, compared with alpha-blockers, 5-alpha reductase inhibitors are less likely to cause orthostatic hypotension, dizziness, fatigue or asthenia, and rhinitis, but are more likely to cause decreased libido, impotence, and breast enlargement.
- The recommendations on follow up and monitoring are based on expert opinion as NICE found no relevant clinical trials.
Combination of an alpha-blocker and a 5-alpha reductase inhibitor
- NICE concluded that combined treatment with an alpha-blocker and a 5-alpha reductase inhibitor may be more cost-effective than treatment with an alpha-blocker alone in selected people who are at higher risk of progression because of older age, more severe/bothersome symptoms, or greater prostate size. The recommendation was made on the basis of expert opinion weighing up the evidence on benefits, adverse effects, acceptability, and cost-effectiveness [NICE, 2010].
- RCTs found that alpha-blockers plus 5-alpha reductase inhibitor combinations are more effective than alpha-blockers alone in improving symptom scores at 2–4 years' follow up. The combination was not more effective at 6 months or 1 year.
- Men treated with alpha-blockers plus 5-alpha reductase inhibitor combinations were more likely than men treated with alpha-blockers alone to experience adverse effects (such as decreased libido, ejaculatory abnormalities, and impotence).
Antimuscarinics (anticholinergics)
- The recommendation to consider adding an antimuscarinic for persistent overactive bladder symptoms in men being treated with an alpha-blocker is based on one RCT included in the NICE systematic review [Kaplan et al, 2006; Kaplan et al, 2008], and a more recent RCT [Chapple et al, 2009].
- The first RCT had methodological weaknesses.
- The second RCT, which was placebo-controlled, found that men with bothersome overactive bladder symptoms while taking an alpha-blocker had statistically significantly greater improvements in diary variables, International Prostate Symptom Score (IPSS) storage scores, and symptom bother when an antimuscarinic (tolterodine ER) was added. However, there was no difference in the proportions of men whose Patient Perception of Bladder Condition (PPBC) score improved.
- Minor adverse effects (such as dry mouth) are common with antimuscarinics. Urinary retention is a serious possible adverse effect, but NICE found no evidence that this risk is clinically important.
- The recommendations on follow up and monitoring are based on expert opinion as NICE found no relevant clinical trials.
Referral
- The recommendations on referral are based on expert opinion as NICE found no relevant clinical trials.
Information on specialist treatments
- The information on specialist treatments is from the NICE guideline [NICE, 2010].
What advice should I provide about self-help resources?
- Advise that:
- NHS Choices provides online information for people with prostate enlargement, including information on the management of voiding problems and other lower urinary tract symptoms (LUTS).
- The Bladder and Bowel Foundation has a helpline (telephone 01536 533 255), and provides a range of resources on their website www.bladderandbowelfoundation.org. Information on voiding symptoms is included in their booklet on bladder problems, which can be ordered from their online shop or downloaded for printing (pdf).
- Homeopathy, phytotherapy (such as saw palmetto), and acupuncture are not recommended for treating LUTS in men, because clinical trials have not provided evidence of effectiveness and safety.
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 LUTS 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).
Start immediate-release alpha blocker
Age from 40 years onwards
Start doxazosin tablets: 1mg once a day
Doxazosin 1mg tablets
Take one tablet once a day.
Supply 14 tablets.
Start terazosin: BPH starter pack
Terazosin 5mg tablets and Terazosin 2mg tablets and Terazosin 1mg tablets
Take one tablet once a day. See package insert for full instructions.
Supply 28 tablets.
Start modified-release alpha-blocker
Age from 40 years onwards
Alfuzosin m/r tablets: 10mg once a day
Alfuzosin 10mg modified-release tablets
Take one tablet once a day.
Supply 30 tablets.
Tamsulosin m/r capsules: 400micrograms once a day
Tamsulosin 400microgram modified-release capsules
Take one capsule once a day.
Supply 30 capsules.
Start doxazosin m/r tablets: 4mg once a day
Doxazosin 4mg modified-release tablets
Take one tablet once a day.
Supply 28 tablets.
5-alpha reductase inhibitors
Age from 40 years onwards
Finasteride tablets: 5mg once a day
Finasteride 5mg tablets
Take one tablet once a day.
Supply 28 tablets.
Dutasteride capsules: 500micrograms once a day
Dutasteride 500microgram capsules
Take one capsule once a day.
Supply 30 capsules.
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