EAU 2025 Guidelines: Non-Neurogenic Male LUTS

What This Guideline Covers

The EAU 2025 Non-Neurogenic Male LUTS guideline provides evidence-based recommendations across 11 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

Diagnostic evaluation of male LUTS

• Take a complete medical history from men with LUTS.
• Use a validated symptom score questionnaire including bother and quality of life assessment during the initial assessment of male LUTS and for re-evaluation during and/or after treatment.
• Use a bladder diary to assess male LUTS with a prominent storage component or nocturia.
• Tell the patient to complete a bladder diary for at least three days.
• Perform a physical examination including digital rectal examination in the assessment of male LUTS.
• Use urinalysis (by dipstick or microscopy) in the assessment of male LUTS.
• Measure PSA if a diagnosis of prostate cancer will change management.
• Measure PSA if it assists in the treatment and/or decision-making process.
• Counsel patients about PSA testing and the implications of a raised PSA test.
• Assess renal function if renal impairment is suspected based on history and clinical examination, or in the presence of hydronephrosis, or when considering surgical treatment for male LUTS.
• Measure post-void residual in the assessment of male LUTS.
• Perform uroflowmetry prior to medical or invasive treatment.
• Perform imaging of the prostate when considering surgical treatment.
• Do not offer non-invasive tests, as an alternative to urodynamics/PFS, for diagnosing bladder outflow obstruction in men.

Conservative and pharmacological management of male LUTS.

• Offer men with mild/moderate symptoms, minimally bothered by their symptoms, watchful waiting.
• Offer men with LUTS lifestyle advice and self-care information prior to, or concurrent with, treatment.
• Offer α1-blockers to men with moderate-to- severe LUTS.
• Use 5α-reductase inhibitors (5-ARIs) in men who have moderate-to-severe LUTS and an increased risk of disease progression (e.g., prostate volume > 40 mL).
• Counsel patients about the slow onset of action of 5α-5-ARIs.
• Use muscarinic receptor antagonists in men with moderate-to-severe LUTS who mainly have bladder storage symptoms.
• Use phosphodiesterase type 5 inhibitors in men with moderate-to-severe LUTS with or without erectile dysfunction.
• Inform the patient that the magnitude of efficacy may be modest.
• Offer combination treatment with an α1-blocker and a 5-ARIs to men with moderate-to-severe LUTS and an increased risk of disease progression (e.g., prostate volume > 40 mL).

Resection of the prostate

• Offer bipolar- or monopolar-transurethral resection of the prostate (TURP) to surgically treat moderate-to-severe LUTS in men with prostate size of 30-80 mL.
• Offer transurethral incision of the prostate to surgically treat moderate-to-severe LUTS in men with prostate size < 30 mL, without a middle lobe.
• Offer open prostatectomy in the absence of anatomical endoscopic enucleation of the prostate to treat moderate-to-severe LUTS in men with prostate size > 80 mL.
• Offer laser enucleation of the prostate using Ho:YAG laser (HoLEP) to men with moderate-to-severe LUTS as an alternative to TURP or open prostatectomy.
• Offer 80-W 532 nm Potassium-Titanyl- Phosphate (KTP) laser vaporisation of the prostate to men with moderate-to-severe LUTS with a prostate volume of 30-80 ml as an alternative to TURP.
• Offer 120-W 532 nm Lithium Borat (LBO) laser vaporisation of the prostate to men with moderate-to-severe LUTS with a prostate volume of 30-80 ml as an alternative to TURP.
• Offer 180-W 532 nm LBO laser vaporisation of the prostate to men with moderate-to- severe LUTS with a prostate volume of 30-80 mL as an alternative to TURP.
• Inform patients about the risk of bleeding and the lack of long-term follow-up data.
• Perform PAE only in units where the work up and follow up is performed by urologists working collaboratively with trained interventional radiologists for the identification of PAE suitable patients.
• Offer Prostatic urethral lift (Urolift®) to men with LUTS interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe.
• Do not offer intraprostatic Botulinum toxin-A injection treatment to patients with male LUTS.

Treatment of nocturia

• Screen for hyponatremia at baseline, day three and day seven, one month after initiating therapy and periodically during treatment. Measure serum sodium more frequently in patients > 65 years of age and in patients at increased risk of hyponatremia.

• Discuss with the patient the potential clinical benefit relative to the associated risks from the use of desmopressin, especially in men > 65 years of age.

• Take a complete medical history including symptoms and co-morbidities, medications, and a focused physical examination in the evaluation of men with urinary incontinence (UI).

• Use a validated symptom score questionnaire, bladder diary and pad-test to assess UI.

• Measure post-void residual in the assessment of UI.

Simple clinical interventions

• Implement prompted voiding for patients with urinary incontinence (UI) where appropriate.

• Offer antimuscarinic drugs or mirabegron to adults with urgency urinary incontinence who failed conservative treatment.

• Inform patients about the possible adverse events of duloxetine and that its use is off label for this indication in Europe

Bulking agents

• Offer artificial urinary sphincter (AUS) to men with moderate-to-severe stress urinary incontinence.
• Warn men receiving AUS or ProACT© that, although cure can be achieved there is a high risk of complications, mechanical failure, and the need for explantation.

Bladder wall injection of botulinum toxin.

• Warn patients of the limited duration of response, risk of urinary tract infection and the possible prolonged need for clean intermittent self-catheterisation (ensure that they are willing and able to do so).

• Inform patients undergoing augmentation cystoplasty of the high risk of complications; the risk of having to perform clean intermittent self-catheterisation and the need for life-long surveillance.

• Do not routinely recommend parasympathomimetics for treatment of men with underactive bladder.