EAU 2025 Guidelines: Non-neurogenic Female LUTS

What This Guideline Covers

The EAU 2025 Non-neurogenic Female LUTS guideline provides evidence-based recommendations across 65 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.

• Take a complete medical history including symptoms and comorbidities, and perform a focused physical examination in the evaluation of women with LUTS.

• Use a validated symptom score questionnaire including bother and quality of life assessment during the initial assessment of female LUTS and for re-evaluation during and/or after treatment.

• Ask patients with LUTS to complete a bladder diary as part of the standardised initial assessment and follow-up of female LUTS.

• Use a bladder diary with a duration of ≥ 3 days.

• Perform urinalysis as a part of the initial assessment of patients with LUTS.

• If a urinary tract infection is present with LUTS, reassess the patient after treatment.

• Do not routinely treat asymptomatic bacteriuria in elderly patients with the aim of improving urinary incontinence.

• Measure post-void residual volume (PVR) in patients with LUTS during initial assessment.

• Use ultrasound to measure PVR volume.

• Monitor PVR in patients receiving treatments that may cause or worsen voiding dysfunction.

• Adhere to good urodynamic practice standards as described by the International Continence Society when performing urodynamics in patients with LUTS.

• Do not routinely carry out urodynamics when offering treatment for uncomplicated stress urinary incontinence.

• Do not routinely carry out urodynamics when offering first-line treatment to patients with uncomplicated overactive bladder symptoms.

• Do not use urethral pressure profilometry or leak point pressure to grade severity of urinary incontinence.

• When pad test is performed, use a standardised duration and activity protocol.

• Do not routinely carry out imaging of the upper or lower urinary tract (apart from post-void residual volume estimation) as part of the initial assessment of female LUTS.

• Do not routinely use urinary biomarkers or estimation of the urinary microbiome in the diagnosis and management of LUT disease in women.

• Request that patients complete at least a three-day bladder diary at initial evaluation for overactive bladder (OAB).

• Do not routinely carry out urodynamics when offering first-line treatment to patients with uncomplicated OAB symptoms.

• Take a history of current medication use from all patients with OAB.

• Review any new medication associated with the development or worsening of OAB symptoms.

• Use a shared decision-making process involving both clinicians and patients when selecting the appropriate conservative management for OAB.

• Ensure that women with overactive bladder (OAB) and/or their carers are informed regarding available treatment options before deciding on urinary containment alone.

• Offer incontinence pads and/or containment devices for management of OAB wet, either for temporary symptom control or when other treatments are not planned or possible.

• Offer prophylactic antibiotics to patients with recurrent urinary tract infections only, after discussion regarding the risk of increasing antimicrobial resistance.

• Advise adults with overactive bladder (OAB) that reducing caffeine intake may improve symptoms of urgency and frequency, but not incontinence.

• Encourage overweight and obese adults with OAB/urinary incontinence to lose weight and maintain weight loss.

• Provide smoking cessation strategies to patients with OAB who smoke.

• Offer prompted voiding to adults with overactive bladder (OAB) who are cognitively impaired.

• Offer bladder training as a first-line therapy to adults with OAB/urgency urinary incontinence (UUI).

• Ensure that pelvic floor muscle training programs are as intensive as possible.

• Offer posterior tibial nerve stimulation as an option for symptomatic improvement of OAB/UUI.

• Use a shared decision-making process involving both clinicians and patients when selecting the appropriate pharmacotherapy for overactive bladder (OAB).

• Offer anticholinergic drugs to women with OAB who fail conservative management.

• Consider extended-release formulations of anticholinergic drugs whenever possible.

• If an anticholinergic treatment proves ineffective, consider dose escalation, offering an alternative anticholinergic formulation, or the use of a beta-3 agonist (alone or in combination with an anticholinergic).

• Encourage early review (of efficacy and side effects) of patients on anticholinergic medication for OAB.

• Offer beta-3 agonists to women with overactive bladder who fail conservative management.

• Long-term anticholinergic treatment should be used with caution in elderly women, especially those who are at risk of, or have pre-existing cognitive dysfunction.

• Assess anticholinergic burden and associated comorbidities in women being considered for anticholinergic therapy for overactive bladder syndrome.

• Offer bladder wall injections of onabotulinumtoxinA (100 U) to patients with overactive bladder/urgency urinary incontinence refractory to conservative therapy or drug treatment.

• Warn patients of the limited duration of response, risk of urinary tract infection and possible prolonged need for intermittent catheterisation prior to offering treatment with onabotulinumtoxinA.

• Offer sacral nerve stimulation to patients who have overactive bladder/urgency urinary incontinence refractory to anticholinergic therapy.

• Do not offer vaginal laser therapy to treat overactive bladder symptoms outside of a well-regulated clinical research study.

• Ensure patient counselling and lifelong support both prior to and after major surgery as a treatment for overactive bladder (OAB) is provided by a specialist nurse or equivalent health care provider.

• Inform patients undergoing augmentation cystoplasty of the high risk of intermittent catheterisation (ensure they are willing and able to do so) and that they will need life- long surveillance.

• Offer early follow-up to women who have been commenced on anticholinergic or beta-3 agonist therapy.

• Offer repeat injections of onabotulinumtoxinA, as required, to women in whom it has been effective (refer to the manufacturer’s guidance regarding the minimum timeframe for repeat injections).

• Offer life-long surveillance to women who have a sacral nerve stimulation implant, to monitor for lead displacement, malfunction and battery wear.

• Take a full clinical history and perform a thorough physical examination including standardised cough test, in all women presenting with stress urinary incontinence.

• Use a validated condition-specific questionnaire as part of the standardised assessment of patients with stress urinary incontinence.

• Measure post-void residual (PVR) volume in patients presenting with stress urinary incontinence (SUI), particularly when assessing those with voiding symptoms or complicated SUI.

• When measuring PVR, use ultrasound in preference to catheterisation.

• Monitor PVR in patients scheduled for treatment which may cause or worsen voiding dysfunction, including surgery for SUI.

• Do not use urethral pressure profilometry or leak point pressure to grade severity of incontinence.

• Do not carry out imaging of the upper or lower urinary tract as part of the routine assessment of stress urinary incontinence.

• Encourage overweight and obese women with LUTS/ stress urinary incontinence to lose weight and maintain weight loss.

• Offer supervised intensive pelvic floor muscle training (PFMT), lasting at least three months, as first-line therapy to all women with stress urinary incontinence (SUI) or mixed urinary incontinence (including the elderly and pre- and post- natal women).

• Ensure that PFMT programmes are as intensive as possible.

• Balance the efficacy and lack of adverse events from PFMT against the expected and possible complications from invasive surgery for SUI.

• Do not offer electromagnetic stimulation for stress urinary incontinence (SUI) unless it is a part of a well-regulated and closely monitored research study.

• Offer electroacupuncture in women with SUI.

• Offer vaginal oestrogen therapy to postmenopausal women with stress urinary incontinence (SUI) and symptoms of vulvo-vaginal atrophy.

• In women taking oral conjugated equine oestrogen as hormone replacement therapy (HRT) who develop or experience worsening SUI, discuss alternative HRTs.

• Offer duloxetine (where licensed) to selected patients with stress urinary incontinence unresponsive to other conservative managements and who want to avoid invasive treatment, after counselling carefully about the risk of adverse events.

• Duloxetine should be initiated and withdrawn using dose titration because of the high risk of adverse events.

• Employ a shared decision-making approach when deciding on appropriate treatment for stress urinary incontinence (SUI).

• Offer patients who have explored/failed conservative management options, which should include pelvic floor muscle training, a choice of different surgical procedures, where appropriate, and discuss the advantages and disadvantages of each approach.

• Use new devices for the treatment of SUI only as part of a structured research programme. Their outcomes must be monitored in a registry or as part of a well- regulated research study.

• Offer colposuspension (open or laparoscopic) to women seeking surgical treatment for stress urinary incontinence following a thorough discussion of the risks and benefits relative to other surgical modalities.

• Offer autologous sling placement to women seeking surgical management for stress urinary incontinence following a thorough discussion of the risks and benefits relative to other surgical modalities.

• Offer urethral bulking agents to women seeking surgical management for stress urinary incontinence (SUI) following a thorough discussion of the risks and benefits relative to other surgical modalities.

• Offer urethral bulking agents to women with SUI who request a low-risk procedure with the understanding that efficacy is lower than other surgical procedures, repeat injections are likely and long-term durability and safety are not established.

• Do not offer autologous fat and hyaluronic acid as urethral bulking agents due to the higher risk of adverse events.

• Do not offer vaginal laser therapy to treat stress urinary incontinence symptoms outside of a well-regulated and closely monitored research study.

• Offer a mid-urethral sling (MUS) to women seeking surgical management for stress urinary incontinence following a thorough discussion of the risks and benefits relative to other surgical modalities.

• Perform cystoscopy to check for intraoperative bladder perforation when inserting a synthetic mid-urethral sling.

• Inform women that long-term outcomes from MUS inserted by the retropubic route are superior to those inserted via the transobturator route.

• Inform women of the complications associated with MUS procedures and discuss all alternative treatments in the light of recent publicity surrounding surgical mesh.

• Inform women who are being offered single incision slings (Ajust® and Altis®), that short-term efficacy appears equivalent compared to conventional MUS.

• Inform women who are being offered a single-incision sling that long-term efficacy remains uncertain.

• Do not offer mechanical devices to women with mild-to-moderate SUI unless it is part of a well-regulated and closely monitored research study.

• Inform women receiving artificial urinary sphincter or adjustable compression device (ACT©) that although cure is possible, even in expert centres, there is a high risk of complications, mechanical failure or a need for explantation.

• Management of complicated stress urinary incontinence (SUI) should only be offered in centres with appropriate experience.

• Base the choice of surgery for recurrent SUI on careful evaluation, including individual patient factors and considering further investigations such as cystoscopy, multichannel urodynamics, as appropriate.

• Do not use adjustable mid-urethral sling for primary surgical management for SUI unless it is part of a well-regulated and closely monitored research study.

• Inform women receiving AUS or ACT® device that, although cure is possible, even in expert centres, there is a high risk of complications, mechanical failure or a need for explantation.

• Complete a thorough history and examination as part of the assessment of mixed urinary incontinence (MUI).

• Use bladder diaries and urodynamics as part of the multimodal assessment of MUI to help inform the most appropriate management strategy.

• Offer bladder training as a first-line therapy to adults with MUI.

• Offer supervised intensive pelvic floor muscle training, lasting at least three months, as a first-line therapy to all women with MUI (including elderly and postnatal women).

• Offer anticholinergic drugs or beta-3 agonists to patients with urgency- predominant MUI.

• Warn women that surgery for MUI is less likely to be successful than surgery for stress urinary incontinence alone.

• Warn women with underactive bladder (UAB) who use abdominal straining to improve emptying about pelvic organ prolapse risk.

• Use intermittent catheterisation (IC) as a standard treatment in patients who are unable to empty their bladder.

• Thoroughly instruct patients in the technique and risks of IC.

• Do not routinely recommend parasympathomimetics for treatment of women with UAB.

• Offer sacral nerve stimulation to women with UAB refractory to conservative management.

• Use standardised classification of bladder outlet obstruction in women (anatomical or functional) and research populations should be fully characterised using such classification.

• Take a full clinical history and perform a thorough clinical examination in women with suspected bladder outlet obstruction (BOO).

• Do not rely on measurements from urine flow studies alone to diagnose female BOO.

• Perform cysto-urethroscopy in women with suspected anatomical BOO.

• Perform urodynamic evaluation (preferably with video fluoroscopy) in women with suspected anatomical BOO.

• Use electromyography when evaluation of pelvic floor muscle or sphincter tone is required.

• Do not offer an intraurethral device to women with BOO.

• Inform women who undergo bladder neck incision on the small risk of developing post operative stress urinary incontinence (SUI), vesico-vaginal fistula or urethral stricture.

• Inform women on the possible recurrence of strictures on long-term follow-up after urethroplasty.

• Offer sling revision (release, incision, partial excision, or excision) to women who develop urinary retention or significant voiding difficulty after tape surgery for UI.

• Inform women about the risk for recurrent SUI and the need for a repeat/concurrent anti-UI surgery after sling revision.

• Offer pelvic floor muscle training (PFMT) aimed at pelvic floor muscle relaxation to women with functional bladder outlet obstruction (BOO).

• Prioritise research that investigates and advances understanding of the mechanisms and impact of PFMT on the coordinated relaxation of the pelvic floor during voiding.

• Do not offer sildenafil to women with BOO unless it is part of a well-regulated and closely monitored research study.

• Do not offer thyrotropin-releasing hormone to women with BOO.

• Take a complete medical history from women with nocturia, including screening for sleep disorders.

• Use a three-day bladder diary to assess nocturia in women.

• Consider screening for sleep disorders and performing renal function, thyroid function, HbA1c and calcium level blood tests in the initial workup of women presenting with nocturia as predominant symptom.

• Offer women with LUTS lifestyle advice prior to, or concurrent with, treatment.

• Offer pelvic floor muscle training for nocturia (either individually or in the group setting) to women with urinary incontinence or other storage LUTS.

• Offer women with nocturia and a history suggestive of obstructive sleep apnoea a referral to a sleep clinic for an assessment of suitability for continuous positive airway pressure treatment.

• Offer desmopressin treatment for nocturia secondary to nocturnal polyuria to women, following appropriate counselling regarding the potential benefits and associated risks (including hyponatraemia).

• Carefully monitor serum sodium concentration in elderly patients treated with desmopressin. Avoid prescribing desmopressin to patients with a baseline serum sodium concentration below normal range.

• Offer anticholinergic treatment for nocturia to women with urgency urinary incontinence or other LUTS, following appropriate counselling regarding the potential benefits and associated risks.

• Consider short-term use (up to two-weeks) of melatonin for symptom improvement in women with nocturia associated with sleep disturbance.

• Perform pelvic organ prolapse (POP) reduction test in continent women to identify those with occult stress urinary incontinence (SUI) and counsel them about the pros and cons of additional anti- incontinence surgery at the time of POP surgery.

• Inform women with pelvic organ prolapse (POP), who do not need a vaginal pessary or surgical intervention, about the potential relief from LUTS from pelvic floor muscle training (PFMT).

• Do not offer pre-operative PFMT to improve outcome of LUTS if pessary therapy or surgical intervention is indicated for POP.

Women requiring surgery for bothersome pelvic organ prolapse (POP) who have symptomatic or occult stress urinary incontinence (SUI)

• Offer simultaneous surgery for POP and SUI only after a full discussion of the potential risks and benefits of combined surgery vs. POP surgery alone.

• Inform women of the increased risk of adverse events with combined prolapse and anti-urinary incontinence surgery compared to prolapse surgery alone.

• Inform women that there is a risk of developing de novo SUI after prolapse surgery.

• Do not offer concomitant anti- incontinence surgery at the time of abdominal prolapse surgery.

• Use a detailed description of anatomical and associated features to distinguish between simple and complex fistulae and standardise terminology in this subject area.

• Take a complete medical history and perform a focused physical examination including direct visual inspection for evaluation of women with suspicion of urinary fistula.

• When reporting on outcomes after fistula repair, authors should make a clear distinction between fistula closure rates and post-operative urinary incontinence rates and the time at which the follow-up was organised.

• Do not routinely use ureteric stents as prophylaxis against injury during routine gynaecological surgery.

• Suspect ureteric injury or fistula in patients following pelvic surgery if a fluid leak or pelvicalyceal dilatation occurs post- operatively, or if drainage fluid contains high levels of creatinine.

• Carefully question and investigate patients for coexisting voiding dysfunction and urinary incontinence (UI).

• Counsel patients regarding the possibility of de novo or persistent lower urinary tract symptoms including UI, despite technically successful urethral diverticulectomy.