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Introduction
OAB detrusor
overactivity
Benign
Prostatic
Obstruction
(BPO)
And others
...
Distal
ureteral
stone
Nocturnal
polyuria
LUTS
Detrusor
underactivity
Bladder
tumour
Neurogenic
bladder
dysfunction
Urethral
stricture
Urinary
tract
infection
Prostatitis
Foreign
body
Diagnostic evaluation
The high prevalence and the underlying multifactorial pathophysiology mean an accurate assessment of LUTS is critical
to provide best evidence-based care. Clinical assessment of
LUTS aims to differentially diagnose and to define the clinical
profile. A practical algorithm has been developed (Figure 2).
LE
GR
A*
2b
A*
1b
A*
2b
3
B
When considering medical treatment for male
LUTS, imaging of the prostate (either by TRUS
or transabdominal US) should be performed if it
assists the choice of the appropriate drug.
3
B
When considering surgical treatment, imaging of
the prostate (either by TRUS or transabdominal US)
should be performed.
3
B
Urethrocystoscopy should be performed in men
with LUTS to exclude suspected bladder or urethral
pathology and/or prior to minimally invasive/
surgical therapies if the findings may change treatment.
B
PFS should be performed only in individual patients 3
for specific indications prior to surgery or when
evaluation of the underlying pathophysiology of
LUTS is warranted.
3
B
PFS should be performed in men who have had
previous unsuccessful (invasive) treatment for
LUTS.
When considering surgery, PFS may be used for
3
C
patients who cannot void > 150 mL.
3
C
When considering surgery in men with bothersome, predominantly voiding LUTS, PFS may be
performed in men with a PVR > 300 mL.
3
C
When considering surgery in men with bothersome, predominantly voiding LUTS, PFS may be
performed in men aged > 80 years.
3
B
When considering surgery in men with bothersome, predominantly voiding LUTS, PFS should be
performed in men aged < 50 years.
*Upgraded based on Panel consensus.
BPE = benign prostatic enlargement; DRE = digital-rectal
examination; FVC = frequency volume chart; LUTS = lower urinary
tract symptoms; PCa = prostate cancer; PFS = pressure flow
studies; PSA = prostate specific antigen; PVR = post-void residual;
QoL = quality of life; TRUS = transrectal ultrasound;
US = ultrasound.
Non-neurogenic Male LUTS including benign prostatic obstruction (BPO) 133
No
Bothersome symptoms
Yes
Abnormal DRE
Suspicion of neurological
disease
High PSA
Abnormal urinalysis
Evaluate according to
relevant
Guidelines or clinical
standard
Significant PVR
US of kidneys
+/- Renal function
assessment
Medical treatment
according to treatment
algorithm
FVC in cases of
predominant storage
LUTS/nocturia
US assessment of prostate
Uroflowmetry
Benign conditions of
bladder and/or prostate
with baseline values
PLAN TREATMENT
Surgical treatment
according to treatment
algorithm
Treatment
Conservative treatment
Watchful waiting is suitable for mild-to-moderate uncomplicated LUTS. It includes education, re-assurance, lifestyle
advice, and periodic monitoring.
134 Non-neurogenic Male LUTS including benign prostatic obstruction (BPO)
Drug treatment
The level of evidence (LE) and the grade of recommendation
(GR) for each treatment option are summarised below.
Recommendations for the conservative and
medical treatment of male LUTS and follow-up
Men with mild symptoms are appropriate for
watchful waiting.
Men with LUTS should always be offered lifestyle advice prior to or concurrent with
treatment.
1-blockers can be offered to men with
moderate-to-severe LUTS.
5-ARIs can be offered to men who have
moderate-to-severe LUTS and an enlarged
prostate (> 40 mL).
5-ARIs can prevent disease progression with
regard to acute urinary retention and need for
surgery.
Muscarinic receptor antagonists may be used in
men with moderate-to-severe LUTS who mainly
have bladder storage symptoms.
Caution is advised in men with BOO.
PDE5Is reduce moderate-to-severe (storage and
voiding) LUTS in men with or without erectile
dysfunction.
Only tadalafil (5 mg once daily) has been
licensed for the treatment of male LUTS in
Europe.
Vasopressin analogue can be used for the treatment of nocturia due to nocturnal polyuria.
LE
GR
1b
1b
1a
1b
1b
1b
4
1a
C
A
1b
no
Add Muscarinic
Receptor Antagonist
Residual
storage
symptoms
1-blocker/PDE5I
with or without
with or without
Watchful Waiting
no
5-Reductase Inhibitor
1-blocker/PDE5I
with or without
yes
Muscarinic Receptor
Antagonist
with or without
yes
Prostate
volume
> 40 mL?
yes
Storage symptoms
predominant?
no
Long-term
treatment?
Nocturnal
polyuria
predominant
no
no
yes
Bothersome
symptoms?
Male LUTS
with or without
Vasopressin Analogue
yes
Surgical treatment
LE
GR
1a
1a
1a
1a
1a
1b
1b
1a
1a
1a
1b
1b
1b
1b
TUIP (1)
TURP
< 30 mL
TURP (1)
Laser enucleation
Laser
vaporization
TUMT
TUNA
30 - 80
mL
Prostate
volume
low
Open
prostatectomy (1)
HoLEP (1)
Laser
vaporization
TURP
> 80 mL
no
Can stop
anticoagulant/
antiplatelet
therapy?
Laser
vaporization (1)
Laser
enucleation
Can have
surgery under
anaesthesia?
high
yes
yes
High Risk
patients?
Male LUTS
TUMT
TUNA
Stent
no
Follow-up
LE
3-4
GR
C