EAU Guidelines for Male Lower Urinary Tract Symptoms (2023)
Initial Assessment
All men presenting with LUTS require a structured baseline evaluation including medical history, International Prostate Symptom Score (IPSS) with quality-of-life assessment, digital rectal examination, urinalysis, post-void residual (PVR) measurement, and uroflowmetry 1.
Additional assessments should be targeted:
- Frequency-volume charts for men with prominent storage symptoms or nocturia
- PSA measurement only when prostate cancer diagnosis would alter management or when assessing risk of symptom progression
- Renal function if hydronephrosis, suspected renal impairment, or considering surgery
- Prostate imaging when selecting drug therapy or planning surgery
- Pressure-flow studies reserved for specific indications before surgery or when pathophysiology evaluation is essential
Conservative and Medical Management
Mild Symptoms
Offer watchful waiting to men with mild/moderate symptoms who are minimally bothered 1. All patients should receive lifestyle advice and self-care information prior to or concurrent with treatment 1.
Moderate-to-Severe Symptoms
For rapid symptom relief, offer α1-blockers (tamsulosin, silodosin) as first-line therapy 1. These improve IPSS by 30-40% with quick onset but are more effective in prostates <40 ml 1. Common adverse effects include asthenia, dizziness, orthostatic hypotension, and ejaculatory dysfunction, particularly with selective agents 1.
For men with prostate volume >40 ml and risk of progression, use 5α-reductase inhibitors (finasteride, dutasteride) 1. These reduce IPSS by 15-30%, decrease prostate volume by 18-28%, and reduce relative risk of acute urinary retention by 57-68% and surgery by 55-64% at 4 years 1. Counsel patients about slow onset (12 weeks minimum) and sexual side effects including reduced libido, erectile dysfunction, and ejaculatory disorders 1.
Storage Symptoms Predominant
Use muscarinic receptor antagonists in men with moderate-to-severe storage LUTS 1. Do not prescribe if PVR >150 ml 1. These improve urgency, urge incontinence, and frequency but require regular PVR monitoring 1.
Beta-3 agonists (mirabegron) can be used for storage symptoms 1, with improvements in frequency, urgency, and incontinence episodes 1. Contraindicated in severe uncontrolled hypertension 1.
Combination Therapy
Offer α1-blocker plus 5-ARI combination to men with moderate-to-severe LUTS and prostate volume >40 ml 1. This provides superior efficacy but higher adverse event rates and should be intended for long-term use 1.
Use α1-blocker plus muscarinic antagonist for persistent storage symptoms after monotherapy 1. Do not use if PVR >150 ml 1. This combination improves urgency, incontinence, frequency, and nocturia without affecting voiding parameters 1.
Consider α1-blocker plus mirabegron for persistent storage LUTS after α1-blocker monotherapy 1.
Additional Options
Phosphodiesterase-5 inhibitors (tadalafil 5 mg) can be used for moderate-to-severe LUTS with or without erectile dysfunction 1. These provide small IPSS reductions and improve erectile function 1.
Hexane-extracted Serenoa repens may be offered to men wanting to avoid sexual side effects, though efficacy magnitude is modest 1.
Surgical Management
Indications
Surgery is indicated for absolute indications (recurrent urinary retention, recurrent UTIs, bladder stones, renal insufficiency due to BPO, large bladder diverticula) or moderate-to-severe LUTS refractory to medical treatment 1.
Prostate Size-Based Algorithm
For prostates <30 ml without middle lobe:
- First choice: Transurethral incision of the prostate (TUIP) 1
- Alternatives: TURP, laser vaporization, prostatic urethral lift 1
For prostates 30-80 ml:
- First choice: Bipolar or monopolar TURP 1
- Strong alternatives:
- Weak alternatives: Thulium laser resection (ThuVARP), bipolar enucleation, thulium enucleation, diode laser enucleation, bipolar vaporization, aquablation 1
For prostates >80 ml:
- First choice: Open prostatectomy (if HoLEP and bipolar enucleation unavailable) 1
- Strong alternative: HoLEP 1
- Weak alternatives: Bipolar enucleation, thulium enucleation 1
Special Populations
For patients on anticoagulation/antiplatelet therapy:
- Offer thulium laser enucleation 1
- Offer laser vaporization (80-W KTP, 120-W or 180-W LBO) for prostates <80 ml 1
For patients prioritizing ejaculatory preservation:
- Offer prostatic urethral lift (Urolift) for prostate volume <70 ml without middle lobe 1
- Retreatment rate is 13.6% at 5 years with low sexual side effects 1
Alternative Techniques
Prostatic artery embolization (PAE) may be offered to men accepting less optimal outcomes than TURP 1. Perform only in units with urologist-interventional radiologist collaboration 1.
Aquablation can be offered for prostate volume 30-80 ml but inform patients about bleeding risk and lack of long-term data 1.
Do not offer intraprostatic botulinum toxin-A injection—no clinical benefits versus placebo 1.
Follow-Up
Review patients on watchful waiting at 6 months, then annually 1.
Review patients on pharmacotherapy at 4-6 weeks to assess response and adverse effects 1. For adequate symptom control, continue treatment with 6-month and annual reviews 1. Patients on 5-ARIs require review at 12 weeks and 6 months, with PSA re-evaluation at 6 months 1.
Review surgical patients at 4-6 weeks post-catheter removal 1. If symptomatic relief achieved without adverse effects, no further reassessment necessary 1.
Recommended follow-up tests include history, IPSS, uroflowmetry, and PVR volume 1. Use frequency-volume charts for OAB or nocturia assessment 1.