Elsevier

European Urology

Volume 64, Issue 1, July 2013, Pages 118-140
European Urology

Guidelines
EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction

https://doi.org/10.1016/j.eururo.2013.03.004Get rights and content

Abstract

Objective

To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS).

Evidence acquisition

We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality.

Evidence synthesis

Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40 ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment–resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30–80 ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80 ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30 ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental.

Conclusions

These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).

Introduction

Lower urinary tract symptoms (LUTS) in elderly men were traditionally attributed to the enlarging prostate. The mechanisms invoked were one or all of the following: histologic benign prostatic hyperplasia (BPH), benign prostatic enlargement (BPE), or benign prostatic obstruction (BPO). However, during the last decade the causal link between the prostate and the pathogenesis of LUTS has come into question [1]. Although the enlarged prostate can contribute to the onset of LUTS in a proportion of men >40 yr of age, other factors are of equal importance. Figure 1 illustrates the many causes of LUTS. In any single person complaining of LUTS, it is common for more than one of these factors to be present. This multifactorial view of the aetiology of LUTS has led most experts to regard the whole urinary tract as a single functional unit. This broader, more complex approach to the pathogenesis of LUTS meant that this guidelines panel modified the title (to reflect the change in perspective) from the former “EAU [European Association of Urology] Guidelines on LUTS Suggestive of BPO (BPH)” [2] to the more contemporary and precise “EAU Guidelines on Non-neurogenic Male LUTS Including BPO.”

Because patients seek help for LUTS and not an underlying attribute of the prostate such as BPH or BPE, these updated guidelines have been written from the perspective of men who complain about a variety of bladder storage, voiding, and/or postmicturition symptoms. The recommendations made within the guidelines are based on the best available evidence. These recommendations apply to men ≥40 yr of age who seek professional help for various forms of non-neurogenic benign forms of LUTS, for example, LUTS/BPO, detrusor overactivity/overactive bladder (OAB), or nocturnal polyuria. EAU guidelines on LUTS due to neurologic diseases [3], urinary incontinence [4], urogenital infections [5], ureteral stones [6], or malignant diseases of the lower urinary tract [7] have been published elsewhere.

Section snippets

Evidence acquisition

The recommendations of these guidelines are based on a literature search using articles in the English language published in the PubMed/Medline, Web of Science, and Cochrane databases between 1966 and 31 October 2012, including the search terms lower urinary tract symptoms, benign prostatic hyperplasia, detrusor overactivity, overactive bladder, nocturia, and nocturnal polyuria in combination with the various treatment modalities and the search limits humans, adult men, review, randomised

Conservative treatment

Many men with LUTS are not bothered enough by their symptoms to need drug treatment or surgical intervention. Most of these men can be managed conservatively by a process known as watchful waiting (WW). All men with LUTS should be formally assessed prior to any allocation of treatment. The aim of this assessment is to establish the severity of LUTS and to discriminate the vast majority of men with so-called uncomplicated LUTS that pose no threat to life expectancy from the more unusual

Conclusions

These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).

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