EAU-Guidelines-on-Non-Neurogenic-Male-LUTS-2025-2
EAU Guidelines on Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS)
J.N. Cornu (Chair), M. Gacci, H. Hashim, T.R.W. Herrmann, S. Malde, C. Netsch, C. De Nunzio, M. Rieken, V. Sakalis, M. Tutolo Guidelines Associates: M. Baboudjian, N. Bhatt, M. Creta, M. Karavitakis, L. Moris Guidelines Office: N. Schouten © European Association of Urology 2025
Table of Contents
INTRODUCTION
1.1 Aim and objectives
1.2 Panel composition
1.3 Available publications
1.4 Publication history
METHODS
2.1 Introduction
2.2 Review
2.3 Patients to whom the guidelines apply
EPIDEMIOLOGY, AETIOLOGY AND PATHOPHYSIOLOGY
DIAGNOSTIC EVALUATION
4.1 Medical history
4.2 Symptom score questionnaires
4.2.1 The International Prostate Symptom Score (IPSS)
4.2.2 The International Consultation on Incontinence Questionnaire for Male LUTS (ICIQ-MLUTS)
4.2.3 Danish Prostate Symptom Score (DAN-PSS)
4.2.4 The Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN-SI-10)
4.3 Frequency volume charts and/or bladder diaries
4.4 Physical examination and digital-rectal examination
4.4.1 Digital-rectal examination and prostate size evaluation
4.5 Urinalysis
4.6 Prostate-specific antigen
4.6.1 Prostate-specific antigen and the prediction of prostatic volume
4.6.2 Prostate-specific angtigen and the probability of PCa
4.6.3 Prostate-specific antigen and the prediction of BPO-related outcomes
4.7 Renal function measurement
4.8 Post-void residual urine
4.9 Uroflowmetry
4.10 Imaging
4.10.1 Upper urinary tract
4.10.2 Prostate
4.10.2.1 Prostate size and shape
4.11 Urethrocystoscopy
4.12 Urodynamics
4.12.1 Diagnosing bladder outlet obstruction
4.12.2 Videourodynamics
4.13 Non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS
4.13.1 Prostatic configuration/intravesical prostatic protrusion
4.13.2 Bladder/detrusor wall thickness and ultrasound-estimated bladder weight
4.13.3 Non-invasive pressure-flow testing
4.13.4 The diagnostic performance of non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS compared with pressure-flow studies
4.14 Novel assessment
4.14.1 Visual prostate symptom score
4.14.2 Micro-RNA
DISEASE MANAGEMENT
5.1 Conservative treatment
5.1.1 Watchful waiting
5.1.2 Behavioural and dietary modifications
5.1.3 Practical considerations
5.2 Pharmacological treatment
5.2.1 α1-Adrenoceptor antagonists (α1-blockers)
5.2.2 5α-reductase inhibitors
5.2.3 Muscarinic receptor antagonists
5.2.4 Beta-3 agonist
5.2.5 Phosphodiesterase 5 inhibitors
5.2.6 Plant extracts – phytotherapy
5.2.7 Combination therapies
5.2.7.1 α1-blockers + 5α-reductase inhibitors
5.2.7.2 α1-blockers + muscarinic receptor antagonists
5.2.7.3 α1-blockers + Beta-3 agonist
5.2.7.4 α1-blockers + Phosphodiesterase 5 inhibitors
5.3 Surgical treatment of benign prostatic obstruction
5.3.1 Resection of the prostate
5.3.1.1 Monopolar and bipolar transurethral resection of the prostate
5.3.1.2 Holmium laser resection of the prostate
5.3.1.3 Thulium:yttrium-aluminium-garnet laser vaporesection of the prostate
5.3.1.4 Transurethral incision of the prostate
5.3.2 Enucleation of the prostate
5.3.2.1 Open prostatectomy
5.3.2.2 Bipolar transurethral enucleation of the prostate
5.3.2.3 Holmium laser enucleation of the prostate
5.3.2.4 Thulium:yttrium-aluminium-garnet laser enucleation of the prostate
5.3.2.5 Diode laser enucleation of the prostate
5.3.2.6 Enucleation techniques under investigation
5.3.2.6.1 Minimal invasive simple prostatectomy
5.3.2.6.2 532 nm (‘Greenlight’) laser enucleation of the prostate
5.3.3 Vaporisation of the prostate
5.3.3.1 Bipolar transurethral vaporisation of the prostate
5.3.3.2 532 nm (‘Greenlight’) laser vaporisation of the prostate
5.3.3.3 Vaporisation techniques under investigation
5.3.3.3.1 Diode laser vaporisation of the prostate
5.3.4 Alternative ablative techniques
5.3.4.1 Aquablation – image guided robotic waterjet ablation: AquaBeam
5.3.4.2 Prostatic artery embolisation
5.3.4.3 Alternative ablative techniques under investigation
5.3.4.3.1 Convective water vapour energy (WAVE) ablation: The Rezum system
5.3.5 Non-ablative techniques
5.3.5.1 Prostatic urethral lift
5.3.5.2 Intra-prostatic injections
5.3.5.3 Non-ablative techniques under investigation
5.3.5.3.1 (i)TIND
5.4 Patient selection for LUTS/BPO treatment
5.5 Management of Nocturia in men with lower urinary tract symptoms
5.5.1 Diagnostic assessment
5.5.2 Medical conditions and sleep disorders Shared Care Pathway
5.5.3 Treatment for Nocturia
5.5.3.1 Antidiuretic therapy
5.5.3.2 Medications to treat LUTD
5.5.3.3 Other medications
5.6 Management of male urinary incontinence
5.6.1 Epidemiology and Pathophysiology
5.6.2 Diagnostic Evaluation
5.6.3 Conservative treatment
5.6.3.1 Simple clinical interventions
5.6.3.1.1 Lifestyle interventions
5.6.3.1.2 Treatment of co-morbidities
5.6.3.1.3 Constipation
5.6.3.1.4 Containment
5.6.3.2 Behavioural and Physical therapies
5.6.3.2.1 Prompted or timed voiding
5.6.3.2.2 Bladder training
5.6.3.2.3 Pelvic floor muscle training
5.6.3.2.4 Electrical stimulation
5.6.3.2.5 Posterior tibial nerve stimulation
5.6.4 Pharmacological management
5.6.4.1 Drugs for urgency urinary incontinence
5.6.4.2 Drugs for stress urinary incontinence
5.6.5 Surgical treatment for stress urinary incontinence
5.6.5.1 Bulking agents in men
5.6.5.2 Male Slings
5.6.5.2.1 Non-adjustable slings
5.6.5.2.2 Adjustable slings in males
5.6.5.2.3 Autologous slings
5.6.5.3 Compression devices in males
5.6.5.3.1 Artificial urinary sphincter
5.6.5.3.2 Non-circumferential compression device (ProACT®)
5.6.6 Surgical treatment for urgency urinary incontinence
5.6.6.1 Bladder wall injection of botulinum Toxin-A
5.6.6.2 Sacral nerve stimulation (neuromodulation)
5.6.6.3 Cystoplasty/urinary diversion
5.7 Management of underactive bladder
5.7.1 Epidemiology and Pathophysiology
5.7.2 Diagnostic Evaluation
5.7.2.1 Medical history and physical examination
5.7.2.2 Questionnaires
5.7.2.3 Uroflowmetry
5.7.2.4 Ultrasound scan and post-void residual measurement
5.7.2.5 Urodynamics
5.7.3 Conservative management
5.7.3.1 Behavioural interventions
5.7.3.2 Pelvic floor muscle relaxation training with biofeedback
5.7.3.3 Clean intermittent self-catheterisation (see section 5.6.3.1.4)
5.7.3.4 Indwelling catheters
5.7.3.5 Intravesical electrical stimulation
5.7.3.6 Extracorporeal Shock Wave Therapy
5.7.4 Pharmacological management
5.7.4.1 Parasympathomimetics
5.7.4.2 Alpha-adrenergic blockers
5.7.4.3 Prostaglandins
5.7.4.4 Other drugs
5.7.5 Surgical treatment for underactive bladder
5.7.5.1 Surgery for benign prostatic obstruction
5.7.5.2 Sacral neuromodulation
5.7.6 Follow-up
FOLLOW-UP
6.1 Watchful waiting (behavioural)
6.2 Medical treatment
6.3 Surgical treatment
REFERENCES
CONFLICT OF INTEREST
CITATION INFORMATION
COPYRIGHT AND TERMS OF USE
Introduction
Lower urinary tract symptoms (LUTS) are common in adult men, significantly impacting quality of life (QoL) and creating a substantial economic burden. These guidelines provide evidence-based guidance on assessing and treating non-neurogenic benign LUTS. The focus is on LUTS rather than Benign Prostatic Hyperplasia (BPH). BPH is considered inappropriate as Benign Prostatic Obstruction (BPO) should be the target of treatment which significantly causing LUTS. Clinical guidelines present experts' best available evidence. Due to individual patients having different responses, guideline adherence does not guarantee optimal outcomes. These guidelines suggest treatment decisions, while considering individual patient values, preferences, and circumstances. They are not mandates or a legal standard of care.
Panel composition
The EAU Non-neurogenic Male LUTS Guidelines Panel comprises international experts in urology and clinical epidemiology. Panel member disclosures of potential conflicts of interest are available on the EAU website (Uroweb).
Available publications
Pocket Guidelines (abridged version)
EAU Guidelines App for iOS and Android (Pocket Guidelines, algorithms, calculators, decision support tools, cheat sheets, and links to extended guidelines).
Publication history
First published in 2000.
Updated based on annual literature assessments.
Next update is scheduled for 2026.
Summary of changes (2024 Update):
All chapters updated based on the 2022 version.
References added throughout the document.
New section 4.2.4: Symptoms of Lower Urinary Tract Dysfunction Research Network.
Update in section 4.8: bladder voiding efficiency.
New section 5.2.7.4: α1-blockers + Phosphodiesterase 5 inhibitors (evidence and recommendations).
New recommendation in section 5.3.1.1: open prostatectomy.
New section in 5.6.2.1: urodynamic testing for male urinary incontinence management.
New algorithm for men presenting with urinary incontinence.
Two new summary of evidence statements in section 5.6.5.3.
New subchapter on the management of underactive bladder, section 5.7.
Methods
The 2025 edition is a reprint of the 2024 version. The guidelines development involved:
Literature search: A structured search of Medline, EMBASE, and Cochrane Libraries was conducted (May 1st 2021 – May 1st 2023).
Inclusion criteria: Systematic reviews, meta-analyses, randomized controlled trials (RCTs), and prospective non-randomized comparative studies in English.
A total of 3,608 unique records screened for relevance.
The search strategies are available online.
Recommendations are determined considering:
Overall quality of evidence.
Magnitude of effect.
Certainty of results (precision, consistency, heterogeneity).
Balance between desirable and undesirable outcomes.
Impact and certainty of patient values and preferences.
Strong recommendations: High-quality evidence and/or favorable benefit-harm balance.
Weak recommendations: Lower quality evidence and/or equivocal benefit-harm balance.
Review
The guidelines underwent peer review prior to publication in 2016, with the new section on underactive bladder peer reviewed prior to publication in 2024.
Patients
Recommendations apply to men seeking professional help for LUTS, including BPO, detrusor overactivity (DO)/overactive bladder (OAB), urinary incontinence, and/or nocturnal polyuria. More extensive work-up may be needed for concomitant neurological diseases, young age, prior LUT disease or surgery. Other EAU guidelines cover Neuro-Urology, Urological Infections, Urolithiasis, or malignant diseases of the LUT, available online.
Epidemiology, Aetiology and Pathophysiology
LUTS can be divided into storage, voiding, and post-micturition symptoms. Increased awareness and management options are needed to improve QoL. LUTS are associated with ageing and modifiable risk factors (e.g., metabolic syndrome). Men with moderate-to-severe LUTS may have an increased risk of major adverse cardiac events. Most elderly men have at least one LUTS, but symptoms are often mild. LUTS can progress, persist, or remit dynamically.
Traditionally, LUTS have been related to bladder outlet obstruction (BOO) and histological BPH progressing through benign prostatic enlargement (BPE) to BPO. However, studies show LUTS are often unrelated to the prostate. Bladder dysfunction (detrusor overactivity/OAB, detrusor underactivity (DU)/underactive bladder (UAB)), structural or functional abnormalities may also cause LUTS. Prostatic inflammation appears to play a role in BPH pathogenesis and progression. Many non-urological conditions also contribute to urinary symptoms, especially nocturia.
Definitions:
Acute retention of urine: Painful, palpable, or percussible bladder with inability to pass urine.
Chronic retention of urine: Non-painful, palpable or percussible bladder after urination; may be incontinent.
Bladder outlet obstruction: Increasing detrusor pressure and reduced urine flow rate, diagnosed by invasive urodynamic studies.
Benign prostatic obstruction: A form of BOO caused by BPE.
Benign prostatic hyperplasia: A typical histological pattern.
Detrusor overactivity: Involuntary detrusor contractions during the filling phase, associated with OAB syndrome (urgency, with or without UUI, increased daytime frequency, and nocturia) without proven infection or other pathologies.
Detrusor underactivity: Decreased detrusor voiding pressure, leading to reduced urine flow rate and underactive bladder syndrome, characterized by voiding symptoms similar to those caused by BPO.
Many factors can be present in any man complaining of LUTS.
Diagnostic Evaluation
Tests aid in diagnosis, monitoring, risk assessment, treatment planning, and predicting outcomes. Objectives:
Identify differential diagnoses.
Define the clinical profile (including risk of disease progression).
Medical history
A patient's medical history includes potential causes and co-morbidities, including medical and neurological diseases. Current medication, lifestyle habits, emotional and psychological factors must be reviewed. The Panel recognizes the need to discuss LUTS and the therapeutic pathway from the patient’s perspective, including reassuring the patient that there is no definite link between LUTS and prostate cancer (PCa), Self-completed validated symptom questionnaires (see section 4.2) should be obtained to objectify and quantify LUTS. Bladder diaries or frequency volume charts (FVC) are beneficial. Sexual function should also be assessed, preferably with questionnaires like the International Index of Erectile Function (IIEF).
Summary of Evidence:
A medical and surgical history is an integral part of a patient’s medical evaluation. A medical and surgical history aims to identify the potential causes of LUTS as well as any relevant co-morbidities and to review the patient’s current medication and lifestyle habits.
Recommendation:
Take a complete medical history from men with LUTS. (Strong)
Symptom score questionnaires
All published guidelines for male LUTS recommend using validated symptom score questionnaires to monitor treatment, quantify LUTS, and identify predominant symptom types. However, they are not disease-, gender-, or age-specific. A SR evaluating the diagnostic accuracy of individual symptoms and questionnaires, compared with urodynamic studies (the reference standard), for the diagnosis of BOO in males with LUTS found that individual symptoms and questionnaires for diagnosing BOO were not significantly associated with one another
IPSS
The IPSS is an eight-item questionnaire, consisting of seven symptom questions and one QoL question. The IPSS score is categorized as ‘asymptomatic’ (0 points), ‘mildly symptomatic’ (1-7 points), ‘moderately symptomatic’ (8-19 points), and ‘severely symptomatic’ (20-35 points). Limitations include a lack of assessment of incontinence, post-micturition symptoms, and bother caused by each separate symptom.
ICIQ-MLUTS
The ICIQ-MLUTS was created from the International Continence Society (ICS) Male questionnaire. It is a widely used and validated patient completed questionnaire including incontinence questions and bother for each symptom. [27]. It contains thirteen items, with subscales for nocturia and OAB, and is available in 24 languages. The ICIQ-MLUTS explore more deeply the subtypes of males LUTS.
DAN-PSS
The DAN-PSS is a symptom score used mainly in Denmark and Finland. The DAN-PSS has twelve questions divided into parts A and B with questions on incontinence and measures the bother of each individual LUTS.
LURN-SI-10
The LURN-SI-10 correlates strongly with the IPSS but identifies additional important symptomatology including incontinence and bladder pain in men with LUTS
Summary of Evidence:
Symptom questionnaires are sensitive to symptom changes. Symptom scores can quantify LUTS and identify which types of symptoms are predominant; however, they are not disease- or age-specific.
Recommendation:
Use a validated symptom score questionnaire including bother and quality-of-life assessment during initial assessment and re-evaluation. (Strong)
Frequency volume charts and/or bladder diaries
Recording volume and time of each void by the patient is referred to as an FVC. Inclusion of additional information such as fluid intake, use of pads, activities during recording, or which grades symptom severity and bladder sensation, is termed a bladder diary [3]. Parameters include daytime and nighttime voiding frequency, total voided volume, nocturnal polyuria index, and volume of individual voids. FVCs are particularly relevant in nocturia to categorize underlying mechanisms.
FVC duration needs to be long enough to avoid sampling errors but short enough to avoid non-compliance.
Summary of Evidence:
Frequency volume charts (FVC) and/or bladder diaries provide real-time documentation of urinary function and reduce recall bias. Three day FVCs provide reliable measurement of urinary symptoms in patients with LUTS similar to seven days and without losing the diagnostic accuracy.
Recommendation:
Use a bladder diary in male LUTs with a storage component, especially nocturia. (Strong)
Tell the patient to complete a bladder diary for at least three days. (Strong)
Physical examination and digital-rectal examination
Physical examination focusing on the suprapubic area, external genitalia, the perineum, and lower limbs should be performed to exclude urethral discharge, meatal stenosis, phimosis, and penile cancer.
DRE is the simplest way to assess prostate volume, but the correlation to prostate volume is poor. TRUS is more accurate in determining prostate volume than DRE. The underestimation increases with increasing TRUS volume, particularly where the volume is > 30 mL. One study concluded that DRE was sufficient to discriminate between prostate volumes > or < 50 mL
Summary of Evidence:
Physical examination is an integral part of a patient’s medical evaluation. Digital-rectal examination can be used to assess prostate volume and texture; however, the correlation to actual prostate volume is poor.
Recommendation:
Perform a physical examination including digital rectal examination in the assessment of male LUTS. (Strong)
Urinalysis
Urinalysis (dipstick or microscopy) must be included in the primary evaluation of any patient presenting with LUTS to identify conditions, such as urinary tract infections (UTI), microhaematuria and diabetes mellitus.
Summary of Evidence:
Urinalysis (dipstick or microscopy) may indicate a UTI, proteinuria, haematuria, or glycosuria requiring further assessment. The benefits of urinalysis outweigh the costs.
Recommendation:
Use urinalysis (by dipstick or microscopy) in the assessment of male LUTS. (Strong)
Prostate-specific antigen
PSA and the prediction of prostatic volume
Pooled analysis of RCTs showed that PSA has a good predictive value for assessing prostate volume, with areas under the curve (AUC) of 0.76-0.78 for various prostate volume thresholds (30 mL, 40 mL, and 50 mL). Age-specific criteria for detecting men with prostate glands exceeding 40 mL are PSA > 1.6 ng/mL, > 2.0 ng/mL, and > 2.3 ng/mL, for men with BPH in their 50s, 60s, and 70s, respectively
A PSA threshold value of 1.5 ng/mL could best predict a prostate volume of > 30 mL, with a positive predictive value (PPV) of 78%.
PSA and the probability of PCa
The role of PSA in the diagnosis of PCa is presented by the EAU Guidelines on Prostate Cancer. Potential benefits and harms of using serum PSA testing to diagnose PCa in men with LUTS should be discussed with the patient.
PSA and the prediction of BPO-related outcomes
Serum PSA is a stronger predictor of prostate growth than prostate volume and predicted the changes in symptoms, QoL/bother, and maximum flowrate (Qmax). Serum PSA predicted the risk of acute urinary retention (AUR) and BPO-related surgery. The risk for treatment was higher in men with a baseline PSA of > 1.4 ng/mL. PPV of PSA for the detection of BPO was 68%. Elevated free PSA levels could predict clinical BPE, independent of total PSA levels.
Summary of Evidence:
Prostate-specific antigen (PSA) has a good predictive value for assessing prostate volume and is a strong predictor of prostate growth. Baseline PSA can predict the risk of AUR and BPO-related surgery.
Recommendations:
Measure prostate-specific antigen (PSA) if a diagnosis of prostate cancer will change management. (Strong)
Measure PSA if it assists in the treatment and/or decision-making process. (Strong)
Counsel patients about PSA testing and the implications of a raised PSA test. (Strong)
Renal function measurement
Renal function may be assessed by serum creatinine or estimated glomerular filtration rate (eGFR). Hydronephrosis, renal insufficiency or urinary retention are more prevalent in patients with signs or symptoms of BPO. One study reported that 11% of men with LUTS had renal insufficiency
Decreased Qmax and a history of hypertension and/or diabetes are associated with CKD. Patients with renal insufficiency are at an increased risk of developing post-operative complications.
Recommendation:
Assess renal function if renal impairment is suspected or when considering surgical treatment for male LUTS. (Strong)
Post-void residual urine
PVR can be assessed by US, bladder scan or catheterisation. High PVR volumes can be a consequence of obstruction and/or poor detrusor function/DU. Its measurement, using a PVR threshold of 50 mL, has a PPV of 63% and a NPV of 52% for the prediction of BOO. A large PVR may indicate a poor response to watchful waiting (WW). Monitoring changes in PVR over time may allow identification of patients at risk of AUR. However, baseline PVR is little prognostic value for the risk of BPO-related therapy. Bladder voiding efficiency (BVE; [voided volume/total bladder capacity] × 100) and post-void residual urine ratio (PVR-R) may be measured.
Summary of Evidence:
The diagnostic accuracy of PVR measurement, using a PVR threshold of 50 mL, has a PPV of 63% and a NPV of 52% for the prediction of BOO. Monitoring of changes in PVR over time may allow for identification of patients at risk of AUR.
Recommendation:
Measure post-void residual in the assessment of male LUTS. (Strong)
Uroflowmetry
Key parameters are Qmax, voided volume, PVR, and flow pattern. Uroflowmetry parameters should preferably be evaluated with voided volume > 150 mL. Repeat uroflowmetry measurements if voided volume is < 150 mL, or Qmax or flow pattern is abnormal. Low Qmax can arise as a consequence of BOO, DU, or an under-filled bladder.
Summary of Evidence:
The diagnostic accuracy of uroflowmetry for detecting BOO varies considerably and is substantially influenced by threshold values. Specificity can be improved by repeated flow rate testing.
Recommendations:
Perform uroflowmetry in the initial assessment of male LUTS. (Weak)
Perform uroflowmetry prior to medical or invasive treatment. (Strong)
Imaging
Upper urinary tract
Arguments support the use of renal US in preference to urological computed tomography (UROCT).
Prostate
Imaging is performed by transabdominal US or TRUS. A model of visual aids has been developed to help urologists estimate prostate volume more accurately
Prostate size and shape
Assessment of prostate volume predicts symptom progression and the risk of complications. the presence of a median lobe may guide treatment choice in patients scheduled for a minimally invasive approach. Transrectal US is superior to transabdominal volume measurement
Recommendations
Perform ultrasound of the upper urinary tract in men with LUTS. (Weak)
Perform imaging of the prostate when considering medical treatment for male LUTS, if it assists in the choice of the appropriate drug. (Weak)
Perform imaging of the prostate when considering surgical treatment. (Strong)
Urethrocystoscopy
Patients with a history of microscopic or gross haematuria, urethral stricture, or bladder cancer, who present with LUTS, should undergo urethrocystoscopy during diagnostic evaluation. The evaluation of a prostatic middle lobe should be performed when considering interventional treatments for which the presence of a middle lobe may affect the treatment offered e.g., Urolift.
Appearance (grade of bladder trabeculation and urethral occlusion) can correlate with DO and low compliance. There was no significant correlation between the degree of bladder trabeculation and the pre-operative Qmax value.
Summary of Evidence:
Patients with a history of microscopic or gross haematuria, urethral stricture, or bladder cancer, who present with LUTS, should undergo urethrocystoscopy during diagnostic evaluation. No study clearly identified a strong association between the urethrocystoscopic and urodynamic findings.
Recommendation:
Perform urethrocystoscopy in men with LUTS prior to minimally invasive/surgical therapies if the findings may change treatment. (Weak)
Urodynamics
In male LUTS, filling cystometry and pressure flow studies (PFS) are employed. The major goal of urodynamics (UDS) is to explore the functional mechanisms of LUTS, identify risk factors for adverse outcomes, and provide information for shared decision-making. Most terms and conditions (e.g., DO, low compliance, BOO/BPO, DU) are defined by urodynamic investigation.
Diagnosing bladder outlet obstruction
Pressure flow studies are used to diagnose and define the severity of BOO, which is characterized by increased detrusor pressure and decreased urinary flow rate during voiding. Bladder outflow obstruction/ BPO has to be differentiated from DU, which exhibits decreased detrusor pressure during voiding with decreased urinary flow rate. Bladder outlet obstruction is calculated according to the equation (BOO > 40 = obstructed; BOO 20-40 = equivocal; and BOO < 20 = unobstructed), and to assess the contractility of the bladder, BCI is calculated according to the equation (BCI > 150 = strong contractility, 100-150 = normal contractility, and < 100 weak contractility).
Videourodynamics
Videourodynamics provides additional anatomical and functional information. There is only low-level evidence for the addition of imaging to UDS.
Summary of Evidence:
Pressure-flow studies are not tests for routine use prior to prostate surgery for all patients.
Recommendation:
Perform urodynamics (UDS) only in individual patients for specific indications prior to invasive treatment or when further evaluation of the underlying pathophysiology of LUTS is warranted. (Weak)
UDS indications list:
Perform UDS in men who have had previous unsuccessful (invasive) treatment for LUTS prior to further invasive treatment. (Weak)
Perform UDS in men considering invasive treatment who cannot void > 150 mL. (Weak)
Perform UDS when considering surgery in men with bothersome predominantly voiding LUTS and Qmax > 10 mL/s. (Weak)
Perform UDS when considering invasive therapy in men with bothersome, predominantly voiding LUTS with a post-void residual > 300 mL. (Weak)
Perform UDS when considering invasive treatment in men with bothersome, predominantly voiding LUTS aged > 80 years. (Weak)
Perform UDS when considering invasive treatment in men with bothersome, predominantly voiding LUTS aged < 50 years. (Weak)
Non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS
Prostatic configuration/intravesical prostatic protrusion
The sensitivity of PCAR was 77% for diagnosing BPO when PCAR was > 0.8, with 75% specificity ultrasound measurement of intravesical prostatic protrusion (IPP) assesses the distance between the tip of the prostate median lobe and bladder neck in midsagittal plane. There is a cut-off values in > 10mm the sensitivity to predict the TWOC was 0.51 and the specificity 0.79.
Bladder/detrusor wall thickness and ultrasound-estimated bladder weight
A threshold value of 5 mm at the anterior bladder wall with a bladder filling of 150 mL was best at differentiating between patients with or without BOO. Severe LUTS and a high UEBW (> 35 g) are risk factors for prostate/BPO surgery in men on α-blockers.
Non-invasive pressure-flow testing
The data generated with the external condom method correlates with invasive PFS in a high proportion of patients.
The diagnostic performance of non-invasive tests in diagnosing bladder outlet obstruction in men with LUTS compared with pressure-flow studies
Theory, data regarding the diagnostic accuracy of these non-invasive tests is limited by their heterogeneity of the studies. Even though several tests have shown promising results regarding non-invasive diagnosis of BOO, invasive urodynamics remains the modality of choice.
Summary of Evidence
Data regarding the diagnostic accuracy of non-invasive tests is limited by the heterogeneity of the studies as well as the small number of studies for each test. Specificity, sensitivity, PPV and NPV of the non-invasive tests were highly variable.
Recommendation
Do not offer non-invasive tests as an alternative to urodynamics/pressure-flow studies for diagnosing bladder outflow obstruction in men. (Strong)
Novel assessment
Visual prostate symptom score
A novel visual prostate symptom score (VPSS) has been prospectively tested vs the IPPS related positively with the IPSS score. This visual score can be used as an option in men with limited literacy.
Micro-RNA
The use of miR-221 has been shown to have the potential to be used as a biomarker and novel target in the early diagnosis and therapy of BPH.
Disease Management
Conservative Treatment
Watchful waiting
many men with LUTS are not troubled enough by their symptoms to need treatment. Before treatment, symptom severity should be formally assessed to differentiate between uncomplicated and complicated LUTS. WW is a viable option for many men with non-bothersome LUTS, as few will progress to AUR and complications.
Men randomized to three self-care management sessions in addition to standard care had better symptom improvement and QoL than men treated with standard care only, for up to a year had better symptom improvement and QoL than men treated with standard care only, for up to a