Mr Ian Pearce shows how NICE Quality Standard 45 will help to improve the lives of the growing numbers of men who present with lower urinary tract symptoms
- Male LUTS is one of the commonest reasons for men to seek medical advice
- The majority of men with LUTS tolerate their symptoms under the misconception that they are an integral aspect of advancing age
- A significant number of men with LUTS seek medical advice to receive reassurance that they do not have prostate or bladder cancer
- Initial assessment of a man with LUTS should include a DRE, and a urinary frequency volume chart completed by the patient
- Written advice regarding lifestyle modification represents the most cost-effective management option for men with LUTS that are not bothersome
- Temporary containment products should be offered at the initial assessment on an individualised basis
- Timely review of pharmacotherapy saves time and reduces the financial burden to the NHS
- TURP remains one of the ten most common inpatient surgical procedures in the UK, with over 25,000 being performed annually—surgery should only be offered to those who are likely to benefit.
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Lower urinary tract symptoms (LUTS)1 describe a constellation of symptoms that may occur in either sex, at any age, as a consequence of a variety of urological pathologies (see Table 1, below).
The prevalence and severity of male LUTS increase in proportion to advancing age, and in an ageing society, are likely to become an ever-increasing burden to individual patients, the population as a whole, and the NHS. Currently, it is thought that bothersome LUTS can occur in up to 30% of men aged over 65 years.2
Indeed, LUTS occur in most men who reach their eighth decade,3 and although voiding symptoms remain the most common aspect of male LUTS, storage symptoms are reported to cause the greatest reduction in quality of life, and the greatest anxiety. The most significant of these symptoms is urinary incontinence, which not only adds to the social and financial burden of patients and the NHS alike, but is also one of the leading factors contributing to a shift from independent to dependent living; it may also result in a series of potential life-threatening consequences (e.g. fractured neck of femur, due to people falling as a result of wet floors or having vasovagal attacks on getting out of bed at night).
Of the vast number of patients who have LUTS, only a minority will seek medical intervention because most believe that LUTS are an integral aspect of ageing. Many men who do seek intervention do so because they and their partner want reassurance that the symptoms are not signs of a sinister, life-shortening pathology.
Despite this, advice about LUTS remains one of the most common reasons for men consulting in primary care, and a small group of individuals will see their symptoms improve with lifestyle advice or pharmacotherapy. Finally, the smallest proportion of men will undergo surgery, most commonly transurethral resection of the prostate (TURP), because symptoms are severe and resistant to other interventions. According to the most recent hospital episode statistics, around 24,000 TURP procedures were carried out in 2012–2013.4 The success rate from TURP is excellent, despite a number of infrequent complications.
|Slow flow||Urinary frequency|
|Straining to void|
Quality standard on lower urinary tract symptoms in men
The publication in 2010 of NICE Clinical Guideline (CG) 97 on Lower urinary tract symptoms: the management of lower urinary tract symptoms in men2 created, for the first time, a comprehensive, evidence-based, cost-effective rationale for the management of LUTS, from first presentation in primary care to surgery in secondary or tertiary care. The healthcare community welcomed the guidance, and in 2012, LUTS in men was chosen as the first area in adult urology to be the subject of a NICE quality standard, developed by an appointed Topic Expert Group (TEG). The result was NICE Quality Standard (QS) 45 on Lower urinary tract symptoms in men (see publications.nice.org.uk/lower-urinary-tract-symptoms-in-men-qs45).5 It should be noted that NICE CG97 and QS45 relate to non-neurological LUTS; guidance for urinary incontinence in neurological disease can be found in NICE CG148 (see www.nice.org.uk/guidance/CG148).6
The TEG decided on eight statements as the basis for the quality standard (see Table 2, below). This selection was made not just on the perceived importance of each individual statement, but rather on the collective view of the TEG, which considered:
- the impact each statement would have on delivering optimal patient care with regard to efficacy, cost-effectiveness, and practicality
- the perceived baseline level of guidance uptake and implementation of NICE CG97: those aspects of LUTS care thought to be poor throughout the UK were considered as a greater priority for inclusion in the standard.
|1||Initial assessment—physical examination
Men with lower urinary tract symptoms (LUTS) are offered a full physical examination, including a digital rectal examination, as part of their initial assessment.
|2||Initial assessment—urinary frequency and volume chart
Men with bothersome lower urinary tract symptoms (LUTS) are asked to complete a urinary frequency and volume chart, as part of their initial assessment.
|3||Initial assessment—advice on lifestyle interventions
Men with lower urinary tract symptoms (LUTS) whose symptoms are not bothersome or complicated are given written advice on lifestyle interventions, as part of their initial assessment.
|4||Conservative management—temporary containment products
Men with lower urinary tract symptoms (LUTS) who have urinary incontinence are offered a choice of temporary containment products, as part of their initial assessment.
|5||Conservative management—urethral milking
Men with lower urinary tract symptoms (LUTS) who have post-micturition dribble are given information about how to perform urethral milking.
Men with lower urinary tract symptoms (LUTS) who are prescribed drug treatments to manage symptoms receive a timely medication review.
|7||Specialist assessment—flow rate and post-void residual volume
Men with lower urinary tract symptoms (LUTS) are offered a measurement of flow rate and post-void residual volume, as part of their specialist assessment.
|8||Surgery for voiding symptoms
Men with voiding symptoms are offered surgery only if voiding symptoms are severe or if drug treatment and conservative management have been unsuccessful or are not appropriate.
|NICE (2013) QS45. Quality standard for lower urinary tract symptoms in men. Available at: www.nice.org.uk/guidance/QS45. Reproduced with permission.|
Initial assessment—statements 1–3
The first three quality statements relate to the patient’s initial assessment within primary care, typically with their GP, practice nurse, continence advisor, or other appropriately trained healthcare professional. This consultation is the key to accurate diagnosis and effective management. Rather than being a single point of contact, it is part of a process, spanning perhaps two or three individual consultations.5
Full physical examination including digital rectal examination
Quality statement 1 highlights the importance of a full physical examination, including a digital rectal examination (DRE) as part of the initial assessment of a man presenting with LUTS. It is expected that a DRE should become a universal and integral part of this assessment.5
A DRE allows the assessment of prostatic volume, which in itself may guide management and serve as a means of detecting potential prostatic malignancy. An abnormal DRE should prompt a serum prostate-specific antigen (PSA) test, with the patient being referred for secondary care urological advice. Acute prostatitis or a prostatic abscess may also be detected by DRE, and will influence first-line patient management.
Urinary frequency and volume chart
Quality statement 2 recommends that men presenting with ‘bothersome LUTS’ are asked to complete a urinary frequency and volume chart, as part of their initial assessment. ‘Bothersome LUTS’ are defined in QS45 as symptoms that are worrying, troublesome, or have an impact on a man’s quality of life.5
A urinary frequency and volume chart (voiding or bladder diary) is a patient-recorded document detailing the volumes and number of times that urine is passed (day and night), along with the volumes and times of fluid consumed, over a 3-day period. This is an essential part of the initial assessment as it allows the healthcare professional to consider, confirm, or refute potential differential diagnoses (e.g. nocturnal polyuria or overactive bladder). The process is non-invasive, although it does rely on a degree of patient compliance, which in turn is influenced by the degree of explanation offered by the healthcare professional. Quality statement 2 recommends the use of a urinary frequency and volume chart because this is a highly useful part of the initial assessment of men with bothersome LUTS;5 the chart is, however, seldom used in primary care. This may be owing to practitioners’ general lack of knowledge and experience to interpret the information in it, which may need to be addressed at a local level by the provision of suitable training.
Advice on lifestyle interventions
Quality statement 3 states that advice on lifestyle interventions should be given, in writing, to men presenting with LUTS, as part of their initial assessment.5 Lifestyle habits are extremely influential in LUTS, with nicotine and caffeine universally reported as the two most significant bladder irritants.7–12 All men with LUTS should be advised, as part of their initial assessment, to eliminate both nicotine and caffeine from their lifestyle.7–12 This will not only improve their symptoms but also, in the case of anticholinergic therapy, improve a patient’s symptomatic response.
Other lifestyle modifications that have been shown to offer significant improvement in men with LUTS, include:13
- weight loss for patients with a body mass index >30 kg/m2
- pelvic floor exercises
- bladder training
- fluid manipulation
- avoidance of certain foods/drinks that can irritate the bladder (e.g. carbonated drinks).
Written information is specified in quality statement 3 because it is commonly reported that patients remember only a small fraction of the verbal information they receive during medical consultations.5,14Lifestyle advice almost certainly represents the most cost-effective management strategy for men with LUTS that are neither bothersome nor complicated. Useful patient information, including advice on lifestyle interventions, can be found at www.patient.co.uk/health/lower-urinary-tract-symptoms-in-men
Conservative management—statements 4–5
Temporary containment products
Temporary containment products, including absorbent pads and collecting devices, offer an immediate solution for men with LUTS who are experiencing urinary incontinence. Quality statement 4 states that men should be offered a choice of temporary containment products at their initial assessment.5 Such products should suit the individual, and the practitioner should ensure that men are offered the most appropriate and effective product for them. Containment products can help men to continue their normal daily activities, restore dignity, and have a positive impact on quality of life. They are, however, a ‘temporary fix’ and should not generally be considered as a substitute for the definitive management of LUTS.5 The availability of containment products is subject to huge geographical variation across the UK, with most men being offered a very limited choice, at best. Ill-fitting or inappropriate products often compound the issue and may promote secondary pathology, for example, ammoniacal dermatitis and skin integrity problems.15
Men with LUTS often experience urinary dribbling, which may be of two varieties:16
- terminal dribbling, which occurs towards the end of the urinary stream
- post-micturition dribbling, which occurs after voiding is complete and is secondary to pooling of urine in the proximal urethra.
Post-micturation dribble is a common cause of small volume urinary incontinence and a significant cause of embarrassment and lifestyle restriction. The application of digital pressure on the urethra posterior to the scrotum, with an anterior milking action while the penis is in the dependent position, is the most simple and effective method of dealing with the problem, and is easily and swiftly described. Advice about the technique, however, is not consistently delivered by healthcare professionals, and quality statement 5 seeks to redress this situation by advising that men are given information, both verbally and in writing, about urethral milking. The information can be presented in a combination of formats including leaflets, pictures, and through demonstration (including online materials).5
Medication review—statement 6
The pharmacological management of men with LUTS comprises two classes of medication:
- alpha blockers (e.g. alfuzosin, tamsulosin)
- 5-alpha reductase inhibitors (5-ARI) (e.g. dutasteride, finasteride).
The pharmacokinetics of the above two drug classes differ vastly from one another: alpha blockers have a rapid onset of action (24–48 hours), while 5-ARIs take up to 3–6 months to reach peak effectiveness.17 Men are often placed on dual therapy with both classes of drug, leading to irregular and sub-optimal medication review at times that are inappropriate for both. Prolonged, ineffective pharmacotherapy wastes patient time and national resources, and invites possible complications (e.g. sexual dysfunction, gynaecomastia). It is imperative, therefore, that men with LUTS who are receiving pharmacotherapy are given a timely medication review. Quality statement 6 states that men with LUTS receiving alpha blockers and/or 5-ARI therapy should have their medication reviewed as follows:5
- alpha blockers—after 4 to 6 weeks
- 5-ARI therapy—after 3 to 6 months.
Specialist assessment—statement 7
Men should be referred for specialist opinion whenever:2
- symptoms persist despite conservative and pharmacological intervention
- there is diagnostic doubt
- there are red-flag symptoms (e.g. haematuria)
- the patient requests it.
While specialist assessment of men with LUTS is fairly standard across the UK, there are certain elements that are such a vital part of correct assessment and management as to deserve special mention. Quality statement 7 refers to the measurement of urinary flow rate and post-void residual volume (PVR) as part of the specialist assessment of men with LUTS. Both procedures are non-invasive, time-efficient, and, taken together, allow a significantly greater level of diagnostic accuracy regarding the cause of LUTS (e.g. prostatic obstruction, urethral stricture disease).5
Surgery for voiding symptoms—statement 8
Surgery for LUTS presumed to be secondary to prostatic obstruction is undertaken in all urological units and remains a core urological procedure; TURP remains one of the ten most commonly performed inpatient procedures in the UK.4
The outcomes from surgery for LUTS depend on several factors, including patient or case selection, which in turn is influenced by assessment and diagnostic accuracy, as discussed above. It is of the utmost importance, therefore, that surgery is offered only to those patients who are likely to benefit. Quality statement 8 states that men with voiding symptoms are offered surgery only if their symptoms are severe, or if drug treatment and conservative management have been unsuccessful, or are not appropriate.5 This statement will promote more focused and informed case selection, and in turn improve patient outcomes from surgery.
Men with mild or moderate symptoms should try other treatments before surgery; equally, men with severe symptoms are still eligible for drug treatment and conservative management, provided they have no complications (e.g. hydronephrosis, recurrent urinary tract infections).5
Equality and diversity issues
Particular attention has been paid to equality and diversity issues in this quality standard. Good communication between healthcare professionals and men with LUTS is essential. Treatment, care, and support, and the information provided, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory, or learning disabilities, and to people who do not speak or read English. Men with LUTS should have access to an interpreter or advocate, if needed.5
The aim of the quality standard on LUTS in men is to highlight those aspects of care which, if optimised, would result in the greatest improvement in patient diagnosis, management, and the overall care pathway.5 Implementation requires awareness and use of the standard in conjunction with NICE CG97.2
Initial assessment of men with LUTS will take time, so longer primary care appointment times, or repeated consultations, will be needed. Timely medication reviews will also necessitate more clinic appointments from a system already struggling to meet current demands. Further initiatives may alleviate the situation (e.g. implementation of telephone follow up, or online patient-reported outcome measures designed specifically for alpha-blockade or 5-ARI therapy).
Expertise in the interpretation of urinary frequency voiding charts is essential, and training for healthcare professionals in this will almost certainly be needed.
One of the greatest hurdles to implementation of the quality standard will be the offering of a choice of temporary containment products to men who are incontinent. The available choice is truly vast, and current provision far from standardised throughout the UK. The development of a national procurement body may help, but enhanced continence training will still be needed so that professionals can assess the patient effectively before offering a choice of relevant products.
The Clinical Commissioning Groups Outcome Indicator Set (CCGOIS)18 is a useful tool to aid clinical commissioning groups (CCGs) in their role of providing and promoting quality improvement. The CCGOIS includes indicators derived from NICE standards, and by commissioning services in line with these, CCGs can contribute to improving the quality of care delivered. NICE has developed guidance and support to aid implementation of these indicators.19
Male LUTS are a significant healthcare issue in the UK; because of the ageing population and greater patient awareness (though improved media coverage and patient education, e.g. via the internet), they will be increasingly diagnosed in the future. Optimal management requires thorough assessment aimed at increasing diagnostic accuracy, followed by a step-wise approach including lifestyle advice, pharmacotherapy, and surgical intervention. The LUTS quality standard, used in conjunction with NICE CG97, will improve management of the condition, and enable effective clinical audit through which successful implementation will be achieved (see Autit points, below).
- Proportion of men presenting with LUTS who receive:
- a full and comprehensive assessment at their initial consultation
- written lifestyle advice
- Demographics and previous management (as listed below) of men presenting with LUTS who undergo surgery:
- socioeconomic status
- previous pharmacotherapy
- previous conservative therapy
- complications (e.g. urinary retention)
- NICE QS45 on LUTS in men places great emphasis on effective primary care management for this condition, yet none of its statements are recognised or incentivised through the QOF for general practice
- Although general practice is now commissioned by NHS England, in reality general practice does not have enough staff to encourage a quality improvement programme in this area, so instigating a programme of this kind will fall to CCGs
- Using QS45 and NICE CG97, CCGs can, together with local specialist services, design local care pathways for the management of LUTS:
- these care pathways should be supported by written information for GPs to issue to patients, and also identify specialist continence support services
- Commissioners should identify cost-effective pharmacotherapies for LUTS in local formularies, with guidance on timings for medication reviews
- Inevitably, any LUTS pathway will need to interlink with (and be supported by) guidance on the diagnosis, investigation, and referral for suspected prostate cancer, with appropriate information for patients about PSA testing.
- Abrams P. New words for old: lower urinary tract symptoms for ‘prostatism’. BMJ 1994; 308 (6934): 929–930.
- NICE. Lower urinary tract symptoms: The management of lower urinary tract symptoms in men. Clinical Guideline 97. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG97
- Platz E, Joshu C, Mondul A et al. Incidence and progression of lower urinary tract symptoms in a large prospective cohort of US men
J Urol 2012; 188 (2): 496–501.
- Health and Social Care Information website. Hospital episode statistics, admitted patient care, England—2012–13 [NS]. www.hscic.gov.uk/searchcatalogue?productid=13264&topics=0%2fHospital+care&sort=Relevance&size=10&page=2#top (accessed 28 January 2014).
- NICE website. Lower urinary tract symptoms in men. Quality Standard 45. www.nice.org.uk/guidance/QS45 (accessed 28 January 2014).
- NICE. Urinary incontinence in neurological disease: Management of lower urinary tract dysfunction in neurological disease. NICE, 2012. Available at: www.nice.org.uk/guidance/CG148
- Arya L, Myers D, Jackson N. Dietary caffeine intake and the risk for detrusor instability: a case-control study. Obstet Gynecol. 2000; 96 (1): 85–89.
- Lohsiriwat S, Hirunsai M, Chaiyaprasithi B. Effect of caffeine on bladder function in patients with overactive bladder symptoms. Urol Ann 2011; 3 (1): 14–18.
- Koskimäki J, Hakama M, Huhtala H, Tammela T. Association of smoking with lower urinary tract symptoms. J Urol 1998; 159 (5): 1580–1582.
- Nuotio M, Jylhä M, Koivisto A, Tammela T. Association of smoking with urgency in older people. Eur Urol. 2001; 40 (2): 206–212.
- Bump R, McClish D. Cigarette smoking and urinary incontinence in women. Am J Obstet Gynecol 1992; 167 (5): 1213–1218.
- Brownson R, Chang J, Davis J. Occupation, smoking, and alcohol in the epidemiology of bladder cancer. Am J Public Health 1987; 77: 1298–1300.
- Dallosso H, McGrother C, Matthews R et al. The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU Int 2003; 92 (1): 69–77.
- Turner P, Williams C. Informed consent: patients listen and read, but what information do they retain? NZ Med J 2002; 115 (1164): U218.
- Beeckman D, Schoonhoven L, Verhaeghe S et al. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs 2009; 65 (6): 1141–1154.
- Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21 (2): 167–178.
- Naslund M, Miner M. A review of the clinical efficacy and safety of 5alpha-reductase inhibitors for the enlarged prostate. Clin Ther 2007; 29 (1): 17–25.
- NHS England. The CCG outcomes indicator set 2013/2014. NHS England, 2012. Available at: www.england.nhs.uk/wp-content/uploads/2012/12/ois-ataglance.pdf
- NICE website. NICE support for commissioning—lower urinary tract symptoms. www.nice.org.uk/usingguidance/commissioningguides/luts/LUTS.jsp (accessed 10 February 2014). G