EAU 2025 Guidelines: Neuro-Urology

What This Guideline Covers

The EAU 2025 Neuro-Urology guideline provides evidence-based recommendations across 12 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 an extensive general history, concentrating on past and present symptoms.

• Take a specific history for each of the four mentioned functions - urinary, bowel, sexual and neurological.

• Pay special attention to the possible existence of alarm symptoms/signs (e.g., pain, infection, haematuria, fever) that warrant further specific diagnosis.

• Assess quality of life when evaluating and treating neuro-urological patients.

• Use available validated tools for urinary and bowel symptoms in neuro-urological patients.

• Use MSISQ-15 or MSISQ-19 to evaluate sexual function in multiple sclerosis patients.

• Acknowledge individual patient disabilities when planning further investigations.

• Describe the neurological status as completely as possible, sensations and reflexes in the urogenital area must all be tested.

• Test the anal sphincter and pelvic floor functions.

• Perform urinalysis, blood chemistry, bladder diary, post-void residual, incontinence quantification and urinary tract imaging as initial and routinary evaluation.

• Perform a urodynamic investigation to detect and specify lower urinary tract (dys-)function, use same session repeat measurement as it is crucial in clinical decision making.

• Non-invasive testing is mandatory before invasive urodynamics is planned.

• Use video-urodynamics for invasive urodynamics in neuro-urological patients. If this is not available, then perform a filling cystometry continuing into a pressure flow study.

• Use a physiological filling rate and body- warm saline.

• Perform blood pressure and heartrate monitoring during urodynamic investigation and other invasive procedures in patients at risk for autonomic dysreflexia.

• Use antimuscarinic therapy as the first-line medical treatment for neurogenic detrusor overactivity.

• Do not use mirabegron with the intention of reducing urodynamically proven neurogenic detrusor overactivity.

• Prescribe α-blockers to decrease bladder outlet resistance.

• Do not prescribe parasympathomimetics for underactive detrusor.

• Use intermittent catheterisation as a standard treatment for patients who are unable to empty their bladder.

• Thoroughly instruct patients in the technique and risks of intermittent catheterisation.

• Avoid indwelling transurethral and suprapubic catheterisation whenever possible.

• Offer intravesical oxybutynin to neurogenic detrusor overactivity patients with poor tolerance to the oral route.

• Use botulinum toxin injection in the detrusor to reduce neurogenic detrusor overactivity in multiple sclerosis or spinal cord injury patients if antimuscarinic therapy is ineffective.

• Offer bladder augmentation in low bladder compliance and/or refractory neurogenic detrusor overactivity.

• Place an autologous urethral sling as first- line treatment in female patients with neurogenic stress urinary incontinence (SUI) who are able to self-catheterise.

• Insert an artificial urinary sphincter in male patients with neurogenic SUI.

• Consider sacral neuromodulation in selected neuro-urological patients.

• Do not use dipstick urine analysis to screen for urinary tract infection (UTI) in neuro- urological patients.

• Do not screen for or treat asymptomatic bacteriuria in patients with neuro- urological disorders.

• Avoid the use of long-term antibiotics for recurrent UTIs.

• In patients with recurrent UTIs, optimise treatment of neuro-urological symptoms and remove foreign bodies (e.g., stones, indwelling catheters) from the urinary tract.

• Individualise UTI prophylaxis in patients with neuro-urological disorders as there is no optimal prophylactic measure available.

• Prescribe oral phosphodiesterase type 5 inhibitors as first-line medical treatment in neurogenic erectile dysfunction (ED).

• Give intracavernous injections of vasoactive drugs (alone or in combination) as second-line medical treatment in neurogenic ED.

• Offer mechanical devices such as vacuum devices and rings to patients with neurogenic ED.

• Perform vibrostimulation and transrectal electroejaculation for sperm retrieval in men with spinal cord injury.

• Perform microsurgical epididymal sperm aspiration, testicular sperm extraction and intracytoplasmic sperm injection after failed vibrostimulation and/or transrectal electroejaculation in men with spinal cord injury.

• Counsel men with spinal cord injury, at or above Th 6, and fertility clinics about the potentially life-threatening condition of autonomic dysreflexia.

• Do not offer medical therapy for the treatment of neurogenic sexual dysfunction in women.

• Take a multidisciplinary approach, tailored to individual patient’s needs and preferences, in the management of fertility, pregnancy and delivery in women with neurological diseases.

• Assess the upper urinary tract at regular intervals in high-risk patients.

• Perform a physical examination and urine laboratory every year in high-risk patients.

• Any significant clinical changes should instigate further, specialised, investigation.

• Perform urodynamic investigation as a mandatory baseline diagnostic intervention in high-risk patients at regular intervals.