Guidelines from the European Association of Urology

This article provides a summary of the 2013 European Association of Urology guidelines on the treatment and follow-up of men lower urinary tract symptoms (LUTS).

Men with enlarged prostates often experience bothersome urinary symptoms. These may include increased frequency or urgency of urination, painful urination, frequently waking up at night to urinate, hesitancy, dribbling or an inability to pass urine (urinary retention). These symptoms are often collectively referred to as lower urinary tract symptoms, or LUTS.

According to current guidelines, men with mild LUTS, who are not too bothered by their symptoms, benefit from conservative treatment (also called watchful waiting). Watchful waiting often includes the following: education and reassurance, advice on lifestyle changes, and periodic monitoring. Lifestyle changes which may help resolve LUTS include reduction of fluid intake at specific times of day, avoidance of caffeine or alcohol, use of relaxing techniques, bladder retraining, treating constipation, and changing any medications that may be causing LUTS. All men should be offered appropriate lifestyle advice before beginning drug treatment.

Men with enlarged prostates, especially those >40 ml, profit from 5a-reductase inhibitors (5-ARIs) such as dutasteride (Avodart) and finasteride (Proscar). 5-ARIs cause an 18–28% prostate size reduction and have been shown to slowly reduce LUTS and the probability of urinary retention.

Men with moderate-to-severe LUTS quickly benefit from a1-blockers, such as alfuzosin (Uroxatral), doxazosin (Cardura) and tamsulosin (Flomax). Although improvement of LUTS with a1-blockers may take a few weeks to fully develop, significant improvements were noted within hours to days compared to placebo therapy.

The phosphodiesterase-5 (PDE-5) inhibitor tadalafil (Cialis) can quickly reduce LUTS to a similar extent as a1-blockers, and also improves erectile dysfunction. The combination of a1-blockers with PDE-5 inhibitors was also evaluated, and was found to significantly improve LUTS when compared with the use of a1-blockers alone.

Combined treatment with an a1-blocker and a 5-ARI was also shown to improve LUTS to a greater extent than single drug therapy.

Prostate surgery is indicated in men which do not respond to drug treatment. In severe cases, such as urinary retention (inability to pass urine), kidney failure, or recurrent infections, surgery may be needed to quickly resolve symptoms. A procedure called transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30–80 ml in size. An open surgery (prostatectomy), or laser surgery, are appropriate for men with prostates larger than 80 ml. Other procedures which have been demonstrated as effective alternatives to TURP include transurethral incision of the prostate (TUIP, for glands smaller than 30 ml), transurethral microwave therapy or needle ablation (minimally invasive procedures to destroy prostate tissue), and prostate stents (for men unfit for surgery).