NICE has published Referral Advice - A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered recurrent sore throat in the under-15s. In this issue we reproduce the advice on urinary tract 'outflow' symptoms ('prostatism') in men. The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

For a summary of the consensus statements click here.


Lower urinary tract symptoms include frequency, urgency, hesitancy, reduced flow, dribbling, nocturia, incontinence and incomplete emptying of the bladder.

In addition, patients may have dysuria, haematuria, and sometimes pelvic pain. Some patients develop acute retention. Others develop chronic retention with overflow incontinence and, on rare occasions, renal failure.

Symptoms can severely disrupt day-to-day activity, but the extent of the disruption depends very much on the individual person. Around one-third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia (BPH). The numbers affected increase with age.

Once symptoms arise their progress is variable and unpredictable with around one-third of patients improving, one-third remaining stable and one-third deteriorating.

Primary care

Management should include reassurance, watchful waiting, advice on lifestyle and a review of current medication. Symptoms may be alleviated by, for instance, reducing intake of fluids in the evening, preventing constipation and abstaining from caffeine.

Drug treatment may include alpha-blockers, 5-alpha-reductase inhibitors, and occasionally anticholinergics. Antibiotics may be needed for the treatment of urinary tract or prostatic infection.

Assessment should include measurement of plasma creatinine, MSU (or dipstick) and rectal examination. Patients should be offered a PSA test with the reasons for doing the test explained, and the patient counselled with regard to the possible consequences of the result.

Patient information on PSA tests can be obtained from the National Electronic Library for Cancer (

Specialist services

These are in a position to:

  • supplement, where necessary, advice on self-management given to patients in primary care
  • investigate, establish or confirm the diagnosis using ultrasound and flow studies, imaging, prostate biopsy and/or cystoscopy
  • provide advice on management and undertake medical treatment as necessary
  • relieve acute urinary retention by catheterisation and then, if appropriate, undertake a trial without a catheter (TWOC)
  • assess the need for, and carry out, minimally invasive or surgical interventions.

Referral Advice

Most men with evidence of urinary tract ïoutflowÍ symptoms can be managed in primary care. However, referral to a specialist service is advised if:

they develop acute urinary retention

they have evidence of acute renal failure

they have visible haematuria
there is a suspicion of prostate cancer based on the findings of a nodular or firm prostate, and/or a raised PSA
they have culture-negative dysuria
they develop chronic urinary retention with overflow or night-time incontinence
they have a recurrent urinary tract infection
they develop microscopic haematuria
the symptoms have failed to respond to treatment in primary care and are severe enough to affect quality of life. This is best assessed by the patient using a symptom scoring system such as WHOÍs International Prostate Symptom Score
they have evidence of chronic renal failure or renal damage
The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.

The complete document can be downloaded from the NICE webste

Guidelines in Practice, October 2002, Volume 5(10)
© 2002 MGP Ltd
further information | subscribe