Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms - Beyond the Abstract

Lower urinary tract symptoms (LUTS) are common, often bothersome and have multifactorial aetiology. Several modifiable factors have been correlated with LUTS, suggesting potential targets for prevention. Herein we present a summary of the current version of the European Association of Urology (EAU) guidelines on the management of non-neurogenic male LUTS. The recommendations are based on a literature search on articles published in the PubMed/Medline, Web of Science, and Cochrane databases between 1966 and May 1st 2021 with a focus on high-level evidence. The recommendations are developed using the Delphi technique consensus approach.

The assessment of men with LUTS should be practical. The main objectives are the identification of LUTS etiology (Figure 1) and the definition of the clinical profile of the patients (including risk of disease progression). A careful medical history and physical examination is essential. Validated symptom scores, urine test, uroflowmetry and post-void urine residual (PVR), as well as frequency volume charts for patients with nocturia or predominately storage symptoms, should be used. Prostate-specific antigen (PSA) should be ordered if a diagnosis of prostate cancer will change the treatment plan. Urodynamics should be reserved only for selected patients. Several non-invasive tests have been proposed to recognize outlet obstruction however, the diagnostic accuracy is limited by heterogeneity and small number of studies.

Men with mild symptoms are candidates for watchful waiting with or without behavioural modification. Men with mild-to-moderate LUTS who are not particularly troubled by their symptoms are also candidates for WW since 85% will remain stable for one year.

Alpha-blockers (irrespective of prostate volume) improve LUTS and has a good safety profile with the most frequently reported adverse events (AE) include asthenia, dizziness and orthostatic hypotension. 5α-reductase inhibitors (for men with prostate >40ml) improve LUTS and reduce the risk of urinary retention and the need for surgery. The AEs of 5-ARIs are related to sexual function and their effect on PSA should be considered in PCa screening. In patients with predominant storage symptoms and PVR <150ml, antimuscarinics or β3-agonists are recommended. Tadalafil is the only PDE5I licensed for the treatment of mLUTS with reported improvements in IPSS and IIEF scores. The Herbal Medicinal Products committee of European Medicine Agency, recommends only hexane-extracted Serenoa repens(HESr) for well-established use. Combination therapy is superior to monotherapy but it is associated with more adverse events.

Surgery is reserved for men with absolute indications, and for patients who fail or prefer not to receive medical therapy. Surgical management has been divided into five sections: resection; enucleation; vaporisation; alternative ablative; and nonablative- techniques. A decision between different surgical treatment modalities should include consideration on the surgeon’s expertise as well as the patient’s characteristics and expectations.

Follow-up after conservative, medical, or surgical treatment is based on empirical data or theoretical considerations and is not evidence-based. Patients receiving pharmacotherapy should be reviewed four to six weeks after treatment initiation to assess treatment response, thereafter every six or twelve months and then annually, provided there is no deterioration of symptoms or development of absolute indications for surgical treatment. All prostate surgery patients, should be reviewed four to six weeks after catheter removal to evaluate treatment efficacy and treatment-related complications. If patients have symptomatic relief and are without AEs, no further re-assessment is necessary.

Written by: Vasileios Sakalis, MSc, PhD, FEBU, FRCS, Consultant Urologist, Department of Urology, Hippokrateion General Hospital, Thessaloniki, Greece

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