This article outlines recently published NICE guidance on the management of lower urinary tract symptoms (LUTS) and its implications for nursing practice
Keywords Lower urinary tract symptoms, Continence, Guideline
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Up to 30% of men aged 65 years and above experience lower urinary tract symptoms (LUTS). These can be related to storage and voiding urine and post-micturition problems (Abrams et al, 2002). These symptoms can significantly reduce quality of life and may point to serious pathology of the urogenital tract. Benign prostate enlargement (which causes bladder outlet obstruction), is frequently considered the major cause (Chapple, 1999). However many other conditions can cause LUTS, including detrusor muscle weakness or overactivity, prostatitis, urinary tract infection, malignancy, as well as neurological disease.
Acknowledging the non-specific nature of LUTS in adult men, the NICE (2010) guideline makes recommendations for best practice in managing this condition, based on a review of the evidence. In particular, the guideline has a specific focus on LUTS associated with benign prostatic disease.
Treatment and care of men with LUTS should take into account individual needs and preferences. Good communication is essential to allow men to reach informed decisions about their care, supported by evidence-based information.
The recommendations from NICE are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When only minimal evidence is available, the Guideline Development Group used the experience and expertise of its healthcare professionals to ascertain what makes good practice.
There are many areas of the guideline which aim to help nurses ensure that they are delivering the highest possible quality of care to their patients; particularly at their initial assessments and when providing advice about the various conservative management techniques, outlined below.
- Men with LUTS should be offered an assessment of their general medical history to identify possible causes and any associated co-morbidities. Current medication should be reviewed, including herbal and over-the-counter medicines, to identify drugs that may be contributing to the problem.
- A physical examination should be offered, guided by urological symptoms and other medical conditions, as well as an examination of the abdomen and external genitalia and a digital rectal examination.
- Men with bothersome LUTS should complete a urinary frequency and volume chart.
- They should be referred for specialist assessment if their symptoms are complicated by recurrent or persistent urinary tract infection, retention, renal impairment or if lower urinary tract dysfunction or urological cancer are suspected.
- Those with storage LUTS associated with urinary incontinence should be offered temporary containment products such as pads or collecting devices to achieve social continence until a diagnosis and management plan have been discussed.
- If storage LUTS is suggestive of overactive bladder supervised bladder training should also be offered, as well as advice on their fluid intake and lifestyle.
Surgery for voiding symptoms
- Men requiring surgery for voiding LUTS presumed secondary to benign prostate enlargement (BPE) should be offered monopolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). HoLEP should be performed at centres specialising in technique, or with mentorship arrangements in place.
- If offering surgery for managing voiding LUTS presumed secondary to BPE, do not offer minimally invasive treatments as an alternative to TURP, TUVP or HoLEP.
Make sure men with LUTS have access to care that can help with their emotional and physical conditions and relevant physical, emotional, psychological, sexual and social issues.
Men with storage LUTS (particularly incontinence) should be provided with containment products at point of need and advice about relevant support groups.
The NICE guideline gives a comprehensive overview of how to manage and treat adult men with LUTS, covering the key priorities for the initial assessment, conservative treatment, surgery and the importance of providing appropriate information to patients. Nurses will find the recommendations regarding initial assessment and conservative management of particular interest.
For more information about the NICE guideline on The management of lower urinary tract symptoms in adult men visit: www.nice.org.uk/CG97
AUTHOR Angela Billington, RGN, SCM, Dip HV, is director of continence services Bournemouth and Poole Community Health Services
Abrams P et al (2002) The standardisation of terminology of lower urinary tract function: report from the standardisation Sub-committee of the International Continence Society. Neurourology Urodynamics; 21:2, 167-78.
Chapple CR (1999) BPH disease Management. Introduction and concluding remarks. European Urology; 3: Suppl 3, 1-6.
NICE (2010) The Management of Lower Urinary Tract Symptoms in Adult Men. London: NICE. http:// www.nice.org.uk/CG9