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Lower urinary tract symptoms in men overview

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Lower urinary tract symptoms in men

About

What is covered

This pathway covers the management of lower urinary tract symptoms in men.
Lower urinary tract symptoms are storage, voiding and post-micturation symptoms affecting the lower urinary tract. Lower urinary tract symptoms can significantly reduce men's quality of life, and may point to serious pathology of the urogenital tract. Bothersome lower urinary tract symptoms can occur in up to 30% of men older than 65 years. Uncertainty and variation exist in clinical practice, so this pathway gives clear recommendations on assessing, monitoring and treating lower urinary tract symptoms.

Updates

Updates to this pathway

24 November 2015 Sacral nerve stimulation for idiopathic chronic non-obstructive urinary retention (NICE interventional procedure guidance 536) added to surgery for voiding symptoms.
09 October 2015 Minor maintenance update.
15 September 2015 UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia (NICE medical technology guidance 26) added to surgery for voiding symptoms.
7 July 2015 Minor maintenance update.
22 June 2015 Minor maintenance update.
2 June 2015 A new recommendation on phosphodiesterase-5 inhibitors has been added to drug treatment as the NICE guideline on the management of lower urinary tract symptoms in men has been updated (CG97).
24 February 2015 The TURis system for transurethral resection of the prostate (NICE medical technology guidance 23) added to surgery for voiding symptoms.
11 August 2014 Minor maintenance update.
18 February 2014 Minor maintenance update.
21 January 2014 Minor maintenance update.
17 September 2013 Quality standard added to the pathway.
19 August 2013 Minor maintenance update.
2 July 2013 Mirabegron for treating symptoms of overactive bladder (NICE technology appraisal guidance 290) added to drug treatment.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

The management of lower urinary tract symptoms in men

What is covered

This pathway covers the management of lower urinary tract symptoms in men.
Lower urinary tract symptoms are storage, voiding and post-micturation symptoms affecting the lower urinary tract. Lower urinary tract symptoms can significantly reduce men's quality of life, and may point to serious pathology of the urogenital tract. Bothersome lower urinary tract symptoms can occur in up to 30% of men older than 65 years. Uncertainty and variation exist in clinical practice, so this pathway gives clear recommendations on assessing, monitoring and treating lower urinary tract symptoms.

Updates

Updates to this pathway

24 November 2015 Sacral nerve stimulation for idiopathic chronic non-obstructive urinary retention (NICE interventional procedure guidance 536) added to surgery for voiding symptoms.
09 October 2015 Minor maintenance update.
15 September 2015 UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia (NICE medical technology guidance 26) added to surgery for voiding symptoms.
7 July 2015 Minor maintenance update.
22 June 2015 Minor maintenance update.
2 June 2015 A new recommendation on phosphodiesterase-5 inhibitors has been added to drug treatment as the NICE guideline on the management of lower urinary tract symptoms in men has been updated (CG97).
24 February 2015 The TURis system for transurethral resection of the prostate (NICE medical technology guidance 23) added to surgery for voiding symptoms.
11 August 2014 Minor maintenance update.
18 February 2014 Minor maintenance update.
21 January 2014 Minor maintenance update.
17 September 2013 Quality standard added to the pathway.
19 August 2013 Minor maintenance update.
2 July 2013 Mirabegron for treating symptoms of overactive bladder (NICE technology appraisal guidance 290) added to drug treatment.

Sources

NICE guidance and other sources used to create this pathway.
Lower urinary tract symptoms (2010 updated 2015) NICE guideline CG97
Improving outcomes in urological cancers (2002) NICE cancer service guidance
Mirabegron for treating symptoms of overactive bladder (2013) NICE technology appraisal guidance 290
Prostate artery embolisation for benign prostatic hyperplasia (2013) NICE interventional procedure guidance 453
Laparoscopic augmentation cystoplasty (including clam cystoplasty) (2009) NICE interventional procedure guidance 326
Laparoscopic prostatectomy for benign prostatic obstruction (2008) NICE interventional procedure guidance 275
Sacral nerve stimulation for urge incontinence and urgency-frequency (2004) NICE interventional procedure guidance 64
Holmium laser prostatectomy (2003) NICE interventional procedure guidance 17
Transurethral electrovaporisation of the prostate (2003) NICE interventional procedure guidance 14
The TURis system for transurethral resection of the prostate (2015) NICE medical technology guidance 23
Lower urinary tract symptoms in men (2013) NICE quality standard 45

Quality standards

Quality statements

Initial assessment – physical examination

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) are offered a full physical examination, including a digital rectal examination, as part of their initial assessment.

Rationale

It is important to carry out a full physical examination so that abnormalities of the abdomen and external genitalia are not missed and left untreated. Performing a digital rectal examination is essential to assess the size of the prostate and to detect abnormalities that might indicate malignancy. It is also good practice to identify abnormalities, such as prostatitis (inflammation of the prostate) and associated conditions, which might affect bladder function.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS are offered a full physical examination, including a digital rectal examination, as part of their initial assessment.
Data source: Local data collection.
Process
Proportion of men with LUTS who receive a full physical examination, including a digital rectal examination, as part of their initial assessment.
Numerator – the number of men in the denominator who receive a full physical examination, including a digital rectal examination, as part of their initial assessment.
Denominator – the number of men who present with LUTS.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to provide a full physical examination, including a digital rectal examination, for men with LUTS, as part of their initial assessment.
Healthcare professionals ensure that they offer men with LUTS a full physical examination, including a digital rectal examination, as part of their initial assessment.
Commissioners ensure that they commission services with local arrangements to offer men with LUTS a full physical examination, including a digital rectal examination, as part of their initial assessment.

What the quality statement means for patients, service users and carers

Men with LUTS are offered a full physical examination, which includes the healthcare professional feeling inside the rectum to check the prostate gland, as part of their initial assessment.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.1.2 (key priority for implementation).

Definitions of terms used in this quality statement

Physical examination
An examination of the abdomen and external genitalia, and a digital rectal examination. NICE clinical guideline 97 recommends physical examination at initial assessment guided by urological symptoms and other medical conditions.
Digital rectal examination
A routine test that is used to detect abnormalities of the prostate gland. The doctor or nurse inserts a gloved and lubricated finger (digit) into the man's rectum, which lies just behind the prostate gland.
Initial assessment
Initial assessment refers to the first assessment within the assessment process, carried out in any setting by a healthcare professional without specific training in managing LUTS in men. Initial assessment may involve a range of assessments as outlined in NICE clinical guideline 97 depending on the presenting symptoms. Based on expert consensus, the initial assessment may involve more than 1 consultation but normally no more than 3 consultations.

Equality and diversity considerations

When offering a digital rectal examination, healthcare professionals should provide information about the examination that reflects any religious, ethnic, transgender or cultural needs and takes into account learning disabilities, or difficulties in communication or reading.
Men provided with information should have access to an interpreter or advocate if needed.

Initial assessment – urinary frequency and volume chart

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with bothersome lower urinary tract symptoms (LUTS) are asked to complete a urinary frequency and volume chart, as part of their initial assessment.

Rationale

Urinary frequency and volume charts add important information to the medical history. They can also help the healthcare professional to make an accurate diagnosis and to distinguish nocturnal polyuria (greater than a third of daily urine output during the night) from detrusor overactivity (normal urine production but increased urinary frequency with urgency and small volumes of urine passed each time).

Quality measures

Structure
Evidence of local arrangements to ensure that men with bothersome LUTS are asked to complete a urinary frequency and volume chart, as part of their initial assessment.
Data source: Local data collection.
Process
Proportion of men with bothersome LUTS who complete a urinary frequency and volume chart, as part of their initial assessment.
Numerator – the number of men in the denominator who complete a urinary frequency and volume chart, as part of their initial assessment.
Denominator – the number of men who present with bothersome LUTS.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place to ask men with bothersome LUTS to complete a urinary frequency and volume chart, as part of their initial assessment.
Healthcare professionals ensure that they ask men with bothersome LUTS to complete a urinary frequency and volume chart, as part of their initial assessment.
Commissioners ensure that they commission services with local arrangements to ask men with bothersome LUTS to complete a urinary frequency and volume chart, as part of their initial assessment.

What the quality statement means for patients, service users and carers

Men with bothersome LUTS are asked, as part of their initial assessment, to record how often they pass urine and the amount of urine passed.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.1.3 (key priority for implementation).

Definitions of terms used in this quality statement

Bothersome LUTS
Bothersome LUTS are symptoms at presentation that are worrying, troublesome or have an impact on a man's quality of life. These may vary based on the individual man's circumstances. This quality statement does not cover men who may present seeking reassurance related only to concerns about the risk of prostate cancer.
A urinary frequency and volume chart
A simple, non-invasive tool used as part of the initial assessment of men presenting with LUTS. A urinary frequency and volume chart records voided volumes and times of voiding (day and night) for at least 3 days.
Initial assessment
Initial assessment refers to the first assessment within the assessment process, carried out in any setting by a healthcare professional without specific training in managing LUTS in men. Initial assessment may involve a range of assessments as outlined in NICE clinical guideline 97 depending on the presenting symptoms. Based on expert consensus, the initial assessment may involve more than 1 consultation but normally no more than 3 consultations.

Equality and diversity considerations

All information about the urinary frequency and volume chart should be accessible to men with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Men receiving information should have access to an interpreter or advocate if needed.
Men who have physical, sensory or cognitive impairment may need help to complete the chart. If possible, carers should be instructed in how they can help to complete the chart.
Men should be provided with information that reflects any religious, ethnic, transgender or cultural needs.

Initial assessment – advice on lifestyle interventions

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

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.

Rationale

It is important to offer advice on lifestyle interventions as soon as possible so that the man is aware of all the options that might help to manage his condition. The content of this advice should be holistic and cover the benefits of attaining and maintaining a healthy weight, exercise and healthy eating. Also, the man should be given advice on specific health interventions, such as altering the type, quantity and timing of fluid and food intake, pelvic floor exercises and bladder training.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS whose symptoms are not bothersome or complicated are given written advice on lifestyle interventions, as part of their initial assessment.
Data source: Local data collection.
Process
Proportion of men with LUTS whose symptoms are not bothersome or complicated who are given written advice on lifestyle interventions, as part of their initial assessment.
Numerator – the number of men in the denominator who are given written advice on lifestyle interventions, as part of their initial assessment.
Denominator – the number of men who present with LUTS whose symptoms are not bothersome or complicated.
Data source: Local data collection.
Outcome
Men with LUTS whose symptoms are not bothersome or complicated feel informed about lifestyle options that might help to manage their condition.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place to provide men with LUTS whose symptoms are not bothersome or complicated written advice on lifestyle interventions, as part of their initial assessment.
Healthcare professionals provide men with LUTS whose symptoms are not bothersome or complicated written advice on lifestyle interventions, as part of their initial assessment.
Commissioners ensure that they commission services with local arrangements to provide men with LUTS whose symptoms are not bothersome or complicated written advice on lifestyle interventions, as part of their initial assessment.

What the quality statement means for patients, service users and carers

Men with LUTS whose symptoms are not bothersome or complicated are given written advice, as part of their initial assessment, on diet and fluid intake and avoiding things that can irritate the bladder (for example, certain foods, caffeine and smoking). They are also given information about special exercises to improve their symptoms.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.1.12.

Definitions of terms used in this quality statement

Advice on lifestyle interventions
Advice on lifestyle interventions should be holistic and cover the benefits of attaining and maintaining a healthy weight, exercise and healthy eating. Also, the man should be advised on specific health interventions, such as altering the type, quantity and timing of fluid and food intake and avoiding bladder irritants (for example, certain foods, caffeine and smoking). Advice should also include information about pelvic floor exercises and bladder training.
Initial assessment
Initial assessment refers to the first assessment within the assessment process, carried out in any setting by a healthcare professional without specific training in managing LUTS in men. Initial assessment may involve a range of assessments as outlined in NICE clinical guideline 97 depending on the presenting symptoms. Based on expert consensus, the initial assessment may involve more than 1 consultation but normally no more than 3 consultations.
Written advice
Written advice may be presented in leaflet form, but may also be presented in picture format or demonstrated online.

Equality and diversity considerations

All written advice should be accessible to men with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Men receiving information should have access to an interpreter or advocate if needed.
Men should be provided with information that reflects any religious, ethnic, transgender or cultural needs.

Conservative management – temporary containment products

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

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.

Rationale

Temporary containment products (for example, pads or collecting devices) help manage incontinence, offering security and comfort. These products can help men to continue their normal daily activities, including social activities, and therefore improve quality of life.
It is important that a choice of suitable containment products is offered by a healthcare professional as early as possible, even if there is no definite diagnosis and agreed plan on how to manage the symptoms. Containment products only help manage the urinary incontinence – they are not a cure and should not generally be a long-term solution, unless other treatments don't help or are unsuitable.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS who have urinary incontinence are offered a choice of temporary containment products, as part of their initial assessment
Data source: Local data collection.
Process
Proportion of men with LUTS who have urinary incontinence who receive temporary containment products, as part of their initial assessment.
Numerator – the number of men in the denominator who receive a temporary containment product, as part of their initial assessment.
Denominator – the number of men who present with LUTS and urinary incontinence.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for men with LUTS who have urinary incontinence to be offered a choice of temporary containment products, as part of their initial assessment.
Healthcare professionals ensure that men with LUTS who have urinary incontinence are offered a choice of temporary containment products, as part of their initial assessment.
Commissioners ensure that they commission services with local arrangements to offer men with LUTS who have urinary incontinence a choice of temporary containment products, as part of their initial assessment.

What the quality statement means for patients, service users and carers

Men with LUTS who have urinary incontinence (involuntary leakage of urine) are offered a choice of temporary containment products (for example, absorbent pads or a collecting bag) at their initial assessment to help them manage their symptoms.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendations 1.3.2 (key priority for implementation) and 1.3.3.

Definitions of terms used in this quality statement

Temporary containment products
Containment products are designed to contain or divert the urine leaked during an episode of incontinence and are widely used by men with LUTS and incontinence. Products include absorbent pads (pads worn next to the body, pants with integral pads, bed pads), external collection devices (sheath appliances, pubic pressure urinals), disposable and reusable pads. Based on expert consensus, temporary containment products are used for a maximum of 3 months, by which time their use should be reviewed and a management plan should be in place.
Initial assessment
Initial assessment refers to the first assessment within the assessment process, carried out in any setting by a healthcare professional without specific training in managing LUTS in men. The inclusion of ‘as part of their initial assessment’ in this statement on conservative management is based on expert consensus to reflect the need for containment products to be offered as soon as possible. Based on expert consensus, the initial assessment may involve more than 1 consultation but normally no more than 3 consultations.
Equality and diversity considerations
When offering a choice of temporary containment products as part of the initial assessment, healthcare professionals should provide information about the products that reflects any religious, ethnic, transgender or cultural needs.

Conservative management – urethral milking

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) who have post-micturition dribble are given information about how to perform urethral milking.

Rationale

Urethral milking is a technique that when performed correctly reduces urine loss and can usually be learnt in 1 session by men with LUTS who have post-micturition dribble. Men with LUTS who have post-micturition dribble should be shown urethral milking by a healthcare professional and this demonstration should be reinforced by written information.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS who have post-micturition dribble are given information about how to perform urethral milking.
Data source: Local data collection.
Process
Proportion of men with LUTS and post-micturition dribble who are given information about how to perform urethral milking.
Numerator – the number of men in the denominator who are given information about how to perform urethral milking.
Denominator – the number of men with LUTS who have post-micturition dribble.
Data source: Local data collection.
Outcome
Men with LUTS and post-micturition dribble feel informed about how to perform urethral milking to help them to manage their condition.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for men with LUTS who have post-micturition dribble to be given information about how to perform urethral milking.
Healthcare professionals ensure that men with LUTS who have post-micturition dribble are given information about how to perform urethral milking.
Commissioners ensure that they commission services with local arrangements to give men with LUTS who have post-micturition dribble information about how to perform urethral milking.

What the quality statement means for patients, service users and carers

Men with LUTS who have post-micturition dribble (leakage of urine after urination) are given information about how to empty the urethra (urethral milking) and stop urine leakage.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.3.1.

Definitions of terms used in this quality statement

Post-micturition dribble
Post-micturition dribble describes the involuntary loss of urine immediately after passing urine, usually in the first few minutes after leaving the toilet.
Urethral milking
Urethral milking is also known as post-void milking, bulbar urethral elevation or bulbar urethral massage. Urethral milking eliminates post-micturition dribble caused by incomplete emptying of the urethra by the surrounding muscles rather than by obstruction.
Information on urethral milking
Information on urethral milking may be presented in a combination of formats including leaflet form, in picture format and through demonstration (including online materials).

Equality and diversity considerations

All information on urethral milking should be accessible to men with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Men receiving information should have access to an interpreter or advocate if needed.
Men should be provided with information that reflects any religious, ethnic, transgender or cultural needs.

Medication review

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

Men with lower urinary tract symptoms (LUTS) who are prescribed drug treatments to manage symptoms receive a timely medication review.

Rationale

It is important that men with LUTS who are taking drug treatments for their symptoms have a medication review initiated promptly after their treatment has been prescribed. The review of the drugs prescribed to manage LUTS, to timescales recommended in NICE clinical guideline 97, will inform decisions about their continued use, taking into account the effect of these drugs on symptoms and quality of life, as well as any adverse effects.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS receive a timely medication review.
Data source: Local data collection.
Process
a) Proportion of men with LUTS prescribed alpha-blockers who receive an initial medication review at 4–6 weeks.
Numerator – the number of men in the denominator who receive an initial medication review at 4–6 weeks.
Denominator – the number of men with LUTS prescribed alpha-blockers.
Data source: Local data collection.
b) Proportion of men with LUTS prescribed 5 alpha reductase inhibitors who receive an initial medication review at 3–6 months.
Numerator – the number of men in the denominator who receive an initial medication review at 3–6 months.
Denominator – the number of men with LUTS prescribed 5 alpha reductase inhibitors.
Data source: Local data collection.
c) Proportion of men with LUTS prescribed anticholinergics who receive an initial medication review every 4–6 weeks until symptoms are stable.
Numerator – the number of men in the denominator who receive an initial medication review every 4–6 weeks until symptoms are stable.
Denominator – the number of men with LUTS prescribed anticholinergics.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place to provide a timely medication review for men with LUTS.
Healthcare professionals carry out a timely medication review for men with LUTS to assess treatment response.
Commissioners ensure that they commission services with local arrangements to provide a timely medication review for men with LUTS.

What the quality statement means for patients, service users and carers

Men with LUTS taking drug treatments to help manage their symptoms have their drug treatment reviewed at an agreed time soon after they start taking the drugs.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendations 1.4.12, 1.4.13 and 1.4.14.

Specialist assessment – flow rate and post-void residual volume

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

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.

Rationale

Measuring flow rate and post-void residual volume by post-micturition bladder scan allows a healthcare professional with specific training to more accurately determine the cause of the LUTS (for example, prostatic obstruction). Both measurements are performed as part of a specialist assessment and are non-invasive and time efficient.

Quality measures

Structure
Evidence of local arrangements to ensure that men with LUTS are offered a measurement of flow rate and post-void residual volume, as part of their specialist assessment.
Data source: Local data collection.
Process
Proportion of men with LUTS who have flow rate and post-void residual volume measured, as part of their specialist assessment.
Numerator – the number of men in the denominator who have flow rate and post-void residual volume measured at the time of specialist assessment.
Denominator – the number of men with LUTS undergoing specialist assessment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers ensure that there are local arrangements for men with LUTS to be offered a measurement of flow rate and post-void residual volume, as part of their specialist assessment.
Healthcare professionals offer men with LUTS a measurement of flow rate and post-void residual volume, as part of their specialist assessment.
Commissioners ensure that they commission services with local arrangements to offer men with LUTS a measurement of flow rate and post-void residual volume, as part of their specialist assessment.

What the quality statement means for patients, service users and carers

Men with LUTS are offered tests to measure how fast their urine is flowing and the volume of urine left in the bladder after they have been to the toilet, as part of their specialist assessment.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.2.5.

Definitions of terms used in this quality statement

Flow rate
Flow rate refers to the speed at which the urine is passed in millilitres of urine passed per second (ml/s).
Post-void residual volume
Post-void residual volume can be measured by portable non-invasive ultrasound devices, which scan and calculate the volume of urine in the bladder.
Specialist assessment
Specialist assessment refers to assessment carried out in any setting by a healthcare professional with specific training in the management of LUTS in men.

Surgery for voiding symptoms

This quality statement is taken from the Lower urinary tract symptoms in men quality standard. The quality standard defines clinical best practice in lower urinary tract symptoms care in men and should be read in full.

Quality statement

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.

Rationale

This quality statement aims to ensure the appropriate offer of surgery to men with voiding symptoms.
For some men with voiding symptoms, surgery can improve symptoms. But it should be offered only to men with severe symptoms or to men in whom drug treatment and conservative management have not worked. Men with mild or moderate symptoms should try other treatments before surgery. Men with severe symptoms are still eligible for drug treatment and conservative management.

Quality measures

Structure
Evidence of local arrangements to ensure that 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.
Data source: Local data collection.
Process
Proportion of men with voiding symptoms offered surgery whose symptoms are severe or in whom drug treatment and conservative management have been unsuccessful or are not appropriate.
Numerator – the number of men in the denominator who are offered surgery.
Denominator – the number of men with voiding symptoms whose symptoms are severe or in whom drug treatment and conservative management have been unsuccessful or are not appropriate.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers ensure that local arrangements are in place to offer surgery to men with voiding symptoms only if voiding symptoms are severe or if drug treatment and conservative management have been unsuccessful or are not appropriate.
Healthcare professionals offer surgery to men with voiding symptoms only if voiding symptoms are severe or if drug treatment and conservative management have been unsuccessful or are not appropriate.
Commissioners ensure that they commission services with local arrangements to offer surgery to men with voiding symptoms only if voiding symptoms are severe or if drug treatment and conservative management have been unsuccessful or are not appropriate.

What the quality statement means for patients, service users and carers

Men with voiding symptoms (problems passing urine) are offered an operation only if voiding symptoms are severe or if drug treatment and other management options have been unsuccessful or are not appropriate.

Source guidance

Lower urinary tract symptoms (NICE clinical guideline 97), recommendation 1.5.1.

Definitions of terms used in this quality statement

Voiding symptoms
Voiding symptoms include weak or intermittent urinary stream, straining, hesitancy, terminal dribbling and incomplete emptying. The International Prostate Symptom Score (IPSS) categorises levels of severity. A score of 20–35 is for severe symptoms. A score of 8–19 is for moderate symptoms and a score of 0–8 is for mild symptoms.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

A painful inability to pass urine and the presence of a distended, tender palpable bladder.
Symptoms that that are worrying, troublesome or have an impact on quality of life from the patient's perspective.
For the purposes of this pathway, chronic urinary retention is defined as residual volume greater than 1 litre or presence of a palpable/percussable bladder
High-intensity focused ultrasound
Holmium laser enucleation of the prostate.
Assessment in any setting by a healthcare professional without specific training in managing lower urinary tract symptoms in men.
An International Prostate Symptom Score of 0–7.
An International Prostate Symptom Score of 8–19.
Prostate specific antigen.
An International Prostate Symptom Score of 20–35.
Assessment in any setting by a healthcare professional with specific training in managing lower urinary tract symptoms in men.
Storage symptoms include daytime urinary frequency, nocturia, urgency and urinary incontinence.
Transurethral ethanol ablation of the prostate
Transurethral incision of the prostate.
Transurethral microwave thermotherapy
Transurethral needle ablation
Transurethral resection of the prostate.
Transurethral vaporisation of the prostate.
Transurethral vaporisation resection of the prostate
Voiding symptoms include slow stream, splitting or spraying, intermittency, hesitancy, straining and terminal dribble.

Paths in this pathway

Pathway created: October 2012 Last updated: November 2015

© NICE 2016

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