LUTS is a very common problem affecting the older male. This guideline is intended to help with the diagnosis, treatment and monitoring of LUTS in men.
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LUTS is a very common problem affecting the older male. This guideline is intended to help with the diagnosis, treatment and monitoring of LUTS in men.
Prostate Specific Antigen (PSA) is not a specific test for prostate cancer and levels can be raised in a variety of conditions. Many aspects of diagnosis and treatment of early prostate cancer remain controversial and unless there is clinical suspicion of prostate cancer, PSA testing should only be done after patient counselling, preferably with written information and consent. Early prostate cancer generally has a very good prognosis and its diagnosis in men with life expectancy less than 10yrs in unlikely to be of benefit and may do more harm than good.
When is a PSA blood test indicated?
PSA is not indicated:
Please repeat the PSA level if considering referral unless the prostate is grossly abnormal.
Referral to urology is indicated for the following:
*Age related ranges for PSA and indication for referral
Age (yrs) |
PSA (ng/ml) |
40-49 |
greater than 2.0 |
50-59 |
greater than 3.0 |
60-69 |
greater than 4.0 |
70-75 |
greater than 6.0 |
over 75 |
greater than 6.5 |
In the presence of UTI, if prostate cancer is suspected, treat the UTI and check or repeat the PSA test after 4 weeks.
*Please note that PSA levels below the age related range should not be regarded as ‘normal’, but simply imply a lower risk of an individual having or developing a significant prostate cancer.
Consider when nocturia occurs 3 or more times per night. Complete a detailed voiding diary.
Large prostate (greater than 30cc) or high PSA (greater than 1.4ng/ml)
LUTS BPH progression
A number of predictive risk factors for both symptom progression and acute urinary retention (AUR) have been identified. |
These risk factors include: |
|
The most common form of disease progression is symptom progression; a 3 or 4 point increase in the IPSS. 5% of symptomatic patients progress each year. Progression to AUR is less common: 2% of patients in secondary care studies. Patients with a number of risk factors are at considerable risk of progression. |
Men with LUTS and small or moderate sized prostates will improve appreciably with lifestyle advice and alpha blocker therapy. Men with LUTS and large prostates are at significant risk of disease progression particularly if they have additional risk factors such as aged over 70 years or flow rate of less than 12mls/sec (see progression note). These men will therefore benifit from treatment with lifestyle advice and 5-alpha reductase inhibitors (5-ARIs). 5-ARIs reduce the risk of acute urinary retention and the likelihood of prostatectomy by 50 to 60 percent compared with placebo. An alpha blocker alone could be substituted in a man with bothersome symptoms, without additional risk factors, if he preferred rapid symptom relief. The combination of 5-ARI and alpha blocker is more effective in delaying the clinical progression of the disease and in improving LUTS and maximal urinary flow rate, than either drug alone. After six months of treatment with a 5-ARI, PSA levels will be reduced by 50 percent. Therefore PSA values for patients on long-term therapy should be doubled to allow appopriate interpretation and avoid masking the early detection of localized prostate cancer.
Abbreviation | Meaning |
DRE | Digital rectal exam |
MSU | Midstream sample of urine |
U+Es | Urea and Electrolytes |
UTI | Urinary Tract Infection |
Last reviewed: 31 August 2015
Next review: 31 August 2017
Author(s): Consultant Urologist
Version: 1.2
Approved By: high-uhb.tam@nhs.net
Reviewer Name(s): Dr Ian Wilson