The NICE clinical guideline on lower urinary tract symptoms in men (LUTS) states that LUTS comprise storage, voiding and post-micturition (after urination) symptoms affecting the lower urinary tract. There are many possible causes of LUTS, such as abnormalities or abnormal function of the prostate, urethra, bladder or urinary sphincters. In men, one of the most common causes is benign prostate enlargement, which obstructs the bladder outlet. Benign prostate enlargement occurs when the number of cells in the prostate increases: a condition called benign prostatic hyperplasia.
The NICE pathway on LUTS in men advises conservative management after initial assessment of LUTS. If overactive bladder is suspected, supervised bladder training, advice on fluid intake, lifestyle advice and containment products are recommended.
The full guideline for LUTS defines bothersome symptoms as symptoms that are worrying, troublesome or have an impact on quality of life from the patient's perspective. For men with bothersome symptoms and when conservative management options have been unsuccessful or are not appropriate, the NICE pathway on LUTS in men advises offering drug treatments, but did not make any recommendations around the use of phosphodiesterase type 5 inhibitors such as tadalafil. The recommended drug treatment options vary depending on the specific symptoms and their severity and include:
An alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) for moderate to severe LUTS.
An anticholinergic for overactive bladder symptoms.
A 5-alpha reductase inhibitor for LUTS and prostate enlargement greater than 30 g or prostate specific antigen greater than 1.4 nanograms/ml, and high risk of progression.
Combination of alpha blocker and a 5-alpha reductase inhibitor for bothersome moderate to severe LUTS and prostate enlargement greater than 30 g or prostate specific antigen greater than 1.4 nanograms/ml.
Combination of alpha blocker and an anticholinergic for men with storage symptoms despite treatment with an alpha blocker alone.
Late afternoon loop diuretic (off-label) for men with nocturnal polyuria.
Oral desmopressin (off-label) for men with nocturnal polyuria if other medical causes have been excluded and they have not benefited from other treatments.
If LUTS do not respond to conservative management or drug treatment, next steps include discussion of active surveillance (reassurance and lifestyle advice without immediate treatment and with regular follow-up) or active intervention (conservative management or surgical options).