What are the European Association of Urology (EAU) guidelines for managing male Lower Urinary Tract Symptoms (LUTS)?

EAU Guidelines on Management of Male LUTS

The 2023 European Association of Urology (EAU) guidelines recommend a structured, evidence-based approach to male LUTS management that begins with proper assessment, followed by conservative measures, medical therapy, and surgical interventions when appropriate. 1

Diagnostic Evaluation

Initial Assessment

• Complete medical history - essential for identifying LUTS etiology and risk factors for progression
• Validated symptom score questionnaire (e.g., IPSS) - to assess symptom severity, bother, and quality of life
• Physical examination including digital rectal examination - to assess prostate size and characteristics
• Urinalysis - to rule out infection or hematuria
• PSA measurement - if diagnosis of prostate cancer would change management or assist in treatment decisions
• Bladder diary (for at least 3 days) - particularly for patients with storage symptoms or nocturia

Additional Testing

• Post-void residual measurement - to assess for urinary retention
• Uroflowmetry - recommended prior to medical or invasive treatment
• Prostate imaging - when considering surgical treatment or when it would assist in medication selection
• Urethrocystoscopy - prior to surgical interventions if findings may change treatment approach
• Urodynamics - selectively for complicated cases or when invasive treatment is considered

Treatment Algorithm

Conservative Management

• Watchful waiting - appropriate for men with mild, non-bothersome LUTS
• Self-management - includes education, reassurance, periodic monitoring, lifestyle advice
• Behavioral modification - should be offered prior to or concurrent with any treatment

Medical Therapy

For Voiding Symptoms (BPO/BPE)

1. Alpha-1 adrenoceptor antagonists (α1-blockers)

   • First-line treatment with rapid onset of action (2-4 weeks)
   • Most effective for smaller prostates (<40 ml)
   • Common side effects: asthenia, dizziness, orthostatic hypotension, ejaculatory dysfunction

2. 5α-Reductase inhibitors (5-ARIs)

   • For men with enlarged prostates (>40 ml) or elevated PSA
   • Slow onset of action (3-6 months)
   • Reduce prostate volume by 18-28% and risk of AUR by 57-68%
   • Side effects: sexual dysfunction including reduced libido and erectile dysfunction

For Storage Symptoms (OAB)

1. Muscarinic receptor antagonists

   • For predominant storage symptoms
   • Use with caution in men with elevated PVR (>150 ml)
   • Side effects: dry mouth, constipation, cognitive effects

2. Beta-3 agonists

   • Alternative for storage symptoms with fewer anticholinergic side effects
   • Contraindicated in severe uncontrolled hypertension

Combination Therapies

• α1-blocker + 5-ARI - for men with moderate-to-severe LUTS and enlarged prostates
• α1-blocker + muscarinic antagonist - for persistent storage symptoms despite α1-blocker therapy
• PDE5 inhibitors - particularly for men with concurrent erectile dysfunction

Surgical Management

Indicated for patients with:

• Absolute indications (refractory urinary retention, recurrent UTIs, bladder stones, renal insufficiency)
• Failure of medical therapy
• Patient preference for definitive treatment

Surgical options are categorized as:

• Resection techniques (TURP remains the standard for prostates 30-80 ml)
• Enucleation techniques (for prostates >80 ml)
• Vaporization techniques
• Alternative ablative techniques
• Non-ablative techniques

Follow-up Recommendations

• Reassess patients 4-12 weeks after initiating treatment
• Use symptom scores to evaluate improvement
• Consider PVR measurement and uroflowmetry during follow-up
• Annual assessment if symptoms are stable

Important Considerations

• The choice of treatment should be based on:

  • Predominant symptom type (storage vs. voiding)
  • Prostate size
  • Patient preferences and expectations
  • Comorbidities
  • Potential side effects

• Common pitfalls to avoid:

  • Failing to distinguish between voiding and storage symptoms
  • Not considering prostate size when selecting medical therapy
  • Overlooking potential complications (e.g., urinary retention, renal impairment)
  • Delaying referral when red flag symptoms are present

By following this structured approach to male LUTS management, clinicians can provide effective, evidence-based care that improves symptoms and quality of life while reducing the risk of complications.