Male Lower Urinary Tract Symptoms (LUTS) History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today about the urinary symptoms you have noticed. I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presenting, for example: “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE) to pick up on later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

Examples of open questions here would be: “Could you describe the symptoms you have noticed?” or “Have you noticed that anything makes these symptoms better or worse?” Examples of closed questions include: “Does it hurt when you pass urine?” or “Have you seen any blood in your urine?”

When taking a history of lower urinary tract symptoms (LUTS), it may be useful to think about the following structure for your questions, as well as what useful information the patient’s answers provide about the likely diagnosis:

• Onset – when did the symptoms start? Have the symptoms changed since the patient first noticed them? Acute-onset LUTS indicate acute pathology (e.g., urinary tract infection or acute prostatitis). Insidious-onset LUTS suggest more chronic conditions (e.g., BPH, overactive bladder syndrome, or chronic prostatitis). Did the symptoms start shortly after a new medication was started or stopped?
• Character – ask the patient to describe the symptoms to you using open questions, and let them describe the symptoms in their own words to understand what sort of LUTS they are experiencing. You can ask about specific LUTS using closed questions later in the history. 
• Timing – are the symptoms worse at a particular time of day? Is the patient experiencing night-time urinary frequency (nocturia)? If so, how many times do they need to pass urine per day or night – or, if severe, how many times per hour?
• Associated symptoms – has the patient experienced any other symptoms of note?
• Exacerbating & relieving factors – does anything make the symptoms better or worse? Caffeine, alcohol, and other diuretics can worsen urinary frequency, urgency, and incontinence. Patients may have tried restricting fluid intake in order to pass urine less often.
• Severity – how are the symptoms affecting the patient’s life, and to what extent? Are the symptoms affecting them at home, at work, or in relationships? The International Prostate Symptom Score (IPSS) is a good tool to quantify the impact of LUTS.

System-specific History

After obtaining further details of the presenting complaint, you need to gather any relevant system-specific information. In this case, the relevant system is the urological system. 

It is important not only to ask about symptoms but also to consider why their presence or absence is significant in narrowing the differential diagnosis. 

Urological symptoms to enquire about include, but are not limited to:

• Dysuria – pain experienced on passing urine.
• Urgency to pass urine, “I need to go now!”
• Frequency – ensure you quantify how many times per day or per hour the patient is passing urine.
• Nocturia – waking in the night to pass urine, ensure to quantify how many times per night they are waking.
• Urinary incontinence – is this stress incontinence, (e.g., leaking on laughing or coughing) or urge incontinence, (e.g., not being able to get to the toilet in time)?
• Hesitancy – difficulty in starting urination.
• Poor urinary flow – may be slow, weak or the stream may split or spray.
• Terminal dribbling – slowing of urinary flow to a dribble at the end of the process of passing urine.
• Incomplete emptying
• Sexual dysfunction – are they able to get and maintain an erection?

It may be helpful to categorise LUTS in terms of voiding symptoms (hesitancy, straining, weak urinary flow, terminal dribbling, or incomplete emptying) and storage symptoms (frequency, urgency, nocturia, or urinary incontinence). Different causes of LUTS may result in predominantly voiding symptoms (e.g., urethral stricture or phimosis) or predominantly storage symptoms (e.g., overactive bladder syndrome), or there may be a mixed picture (e.g, benign prostatic hyperplasia).

Red Flags

It is important to ask about symptoms that may lead you to consider more sinister causes of urinary symptoms in the differential diagnosis, which may require more urgent investigation and management (e.g., to rule out malignancy).

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information, as they might find the symptoms worrying or may not have the same insight into their significance as you do. 

Red flag symptoms to screen for when taking a LUTS history include:

• Visible haematuria
• Unintentional weight loss
• Back pain – especially pain that is new, severe, thoracic, or wakes the patient from sleep at night

Relevant Systems Review

A systems review is a useful tool to ensure no key information from the history has been missed. However, it is important to consider which systems are relevant to review so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of LUTS include the following:

• Endocrine – endocrine conditions, including diabetes mellitus, diabetes insipidus, and hypercalcaemia can all cause polyuria (passing high volumes of urine). Patients with polyuria may present with LUTS, especially urinary frequency and nocturia. Diabetes mellitus is the most common condition, and so it is good practice to screen for its symptoms when someone presents with urinary frequency and/or polyuria (e.g., polydipsia, weight loss, fatigue, or recurrent infection).
• Gastrointestinal – constipation can cause or worsen LUTS, even leading to acute urinary retention, so it is worth asking when the patient last opened their bowels and about the consistency of the stool passed. 

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing these symptoms you’ve told me about?”
• Concerns – “Is there anything that is worrying you about your symptoms?” “Have you read or Googled anything about your symptoms that has made you anxious?”
• Expectations – “Was there anything specific you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note whether an existing condition may be of significance in the context of the presenting complaint of LUTS. For example, a patient who is known to have pre-diabetes and presents with urinary frequency and polyuria may have progressed to type 2 diabetes.

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications they may not think to volunteer (e.g., over-the-counter medications, herbal or alternative remedies, contraception, HRT, or injections such as B12). Check whether the patient is compliant with their medication and taking it as prescribed.

Consider whether the information you are given could be relevant to the differential diagnosis. For example, consider a patient who presents with LUTS and has recently started furosemide for congestive cardiac failure may experience urinary frequency and urgency as a side effect of the diuretic.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, beyond their presenting complaint. Consider asking the following:

• Who do they live with? Do they have a social support network they could depend on if they were to receive a life-changing or life-limiting diagnosis, e.g., malignancy?
• Do they work? Will the patient require time off work to attend appointments, investigations, or treatment? Are their symptoms impacting on their performance at work? Is there good access to toilet facilities in their workplace? Do they need any adaptations to their work duties while their symptoms are brought under control?
• Do they drive? Does their condition affect their ability to drive or to attend appointments? Do they need to inform the DVLA?
• Do they smoke? Smoking is associated with increased risk of malignancy, including bladder cancer.
• Do they drink alcohol? Alcohol is a diuretic and a bladder irritant, so may cause or exacerbate LUTS 
• Do they use recreational drugs? Several recreational substances are associated with urinary symptoms, including opioids which can cause urinary retention, or benzodiazepines which reduce awareness of needing to pass urine therefore may cause urinary incontinence. 

Family History

Does anyone in the family have any urological conditions? Patients with a family history of either BPH or prostate cancer are at increased risk of going on to develop the conditions themselves.

Do any other health conditions run in the family that may be important when thinking about causes of LUTS, e.g., diabetes?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation and imaging.

Last updated June 2025

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