EAU 2025 Guidelines: Paediatric Urology

What This Guideline Covers

The EAU 2025 Paediatric Urology guideline provides evidence-based recommendations across 36 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.

• Offer topical corticosteroids (ointment or cream) as first-line treatment in symptomatic phimosis.

• Consider surgical intervention if patient/ caregivers prefer for symptomatic phimosis.

• Offer circumcision in case of balanitis xerotica obliterans (BXO) or phimosis refractory to treatment.

• Offer treatment for asymptomatic phimosis in infants with a risk of recurrent urinary tract infection due to upper urinary tract abnormalities (vesico-ureteral reflux or posterior urethral valves).

• Inform patients about the risk of meatal stenosis in BXO.

• Treat paraphimosis by manual reposition and proceed to surgery if this fails.

• Do not perform simple circumcision if phimosis is associated with other penile anomalies such as buried penis, congenital penile curvature, epispadias or hypospadias.

• Do not offer medical or surgical treatment for retractile testes but undertake close follow-up on a regular basis until puberty.

• Do not offer hormonal therapy in unilateral undescended testes for testicular descent only.

• Perform surgical orchidofunicolysis and orchidopexy before the age of twelve months, and by eighteen months at the latest.

• Perform an endocrinological workup in the setting of bilateral non-palpable testes.

• Perform an exam under anaesthesia and subsequent diagnostic laparoscopy to locate an intra-abdominal testicle.

• High-resolution ultrasound (7.5 – 12.5 MHz), preferably a doppler ultrasound, should be performed to confirm the diagnosis.

• Alpha-fetoprotein should be determined in prepubertal boys with a testicular tumour before surgery.

• Surgical exploration should be done with the option for frozen section.

• Testicular sparing surgery should be performed in all benign tumours.

• Staging (MRI abdomen/CT chest) should only be performed in patients with a malignant tumour to exclude metastases.

• Patients with a non-organ confined tumour should be treated in an multidisciplinary fashion including paediatric oncologists.

• Inform patients and caregivers about the impact of gonadotoxic treatments on future fertility and about fertility preservation options and their risk-benefit balance.

• Discuss the indications and options for fertility preservation in a paediatric multidisciplinary fertility preservation team and consider the toxicity of the planned therapy, the age and pubertal status as well ethical and financial issues.

• Observe hydrocele for twelve months prior to considering surgical treatment.

• Perform early surgery if there is suspicion of a concomitant inguinal hernia or underlying testicular pathology.

• Perform ultrasound in case of doubt about the character of an intrascrotal mass, or suspicion of an abdominoscrotal hydrocele.

• Close the processus vaginalis at the inguinal ring.

• Do not use sclerosing agents in children with hydroceles, because of the risk for chemical peritonitis.

• Testicular torsion is a paediatric urological emergency and requires immediate treatment.

• Base the clinical diagnosis on physical examination. The use of Doppler ultrasound to evaluate acute scrotum is useful, but this should not delay the intervention.

• Manage torsion of the appendix testis conservatively. Perform surgical exploration in equivocal cases and in patients with persistent pain.

• Perform urgent surgical exploration in all cases of testicular torsion as soon as possible.

• Differentiate isolated hypospadias from disorders of sex development at birth.

• Counsel caregivers on functional and aesthetic value of hypospadias corrective surgery and possible complications.

• Use the treatment algorithm (Figure 4) to select the most appropriate surgical technique.

• Ensure long-term follow-up to detect urethral stricture, voiding dysfunction, recurrent penile curvature, ejaculation disorder, and to evaluate patient’s satisfaction.

• Ensure that a thorough medical history is taken, and a full clinical examination done to rule out associated anomalies in boys presenting with congenital penile curvature.

• Request photo documentation of the erect penis from different angles as a pre- requisite in the pre-operative evaluation.

• Perform surgery if the penile curvature has functional implications.

• Perform artificial erection at the beginning as well as at the end of surgery.

• Examine varicocele in the standing position and classify into three grades.

• Use scrotal ultrasound to evaluate testicular volume and to detect venous reflux in the supine and upright position and during Valsalva manoeuvre.

• In all pre-pubertal boys with a varicocele and in all isolated right varicoceles perform standard abdominal ultrasound to rule out a retroperitonal mass.

• Inform caregivers and patients and offer surgery for varicocele associated with a persistent small testis (size difference of > 2 mL or 20%).

• Use some form of optical magnification (microscopic or laparoscopic magnification) for surgical ligation.

• Use lymphatic-sparing varicocelectomy to prevent hydrocele formation.

• Take a detailed medical history, assess clinical signs and symptoms and perform a physical examination in the evaluation of children suspected of having a urinary tract infection (UTI).

• Use bladder catheterisation or suprapubic bladder aspiration to collect urine for urinalysis and cultures in non-toilet-trained children.

• Do not use plastic bags for urine sampling in non-toilet-trained children.

• Use midstream urine in toilet-trained children for analysis and culture.

• Perform renal and bladder US within 24 hours in infants with febrile UTI and acutely ill children to check for abnormalities of the urinary tract.

• Treat febrile UTIs with four to seven day courses of oral or parenteral therapy.

• Chose parenteral therapy in severely ill patients or if oral treatment is not tolerated.

• Treat complicated febrile UTI with broad- spectrum antibiotics.

• Offer antibacterial prophylaxis in patients at risk of recurrent UTIs.

• Assess bladder and bowel dysfunction and lower urinary tract function in any toilet- trained child with febrile and/or recurrent UTI and treat it.

• Use two-day voiding diaries and/or structured questionnaires for objective evaluation of symptoms, voiding drinking habits and response to treatment.

• Use a stepwise approach, starting with the least invasive treatment in managing daytime lower urinary tract (LUT) conditions in children.

• Provide adequate bowel management as part of the treatment, if bladder bowel dysfunction is present.

• Arrange adequate transition into adult urological care for children with persistent daytime LUT conditions in adolescence.

• Do not treat children less than five years of age in whom spontaneous cure is likely, but inform the family about the involuntary nature, the high incidence of spontaneous resolution and the fact that punishment will not help to improve the condition.

• Use micturition diaries or questionnaires to exclude day-time symptoms.

• Perform a urine test to exclude the presence of infection or potential causes such as diabetes insipidus.

• Offer supportive measures in conjunction with other treatment modalities, of which pharmacological and alarm treatment are the two most important.

• Offer desmopressin in proven night-time polyuria.

• Offer alarm treatment in motivated and compliant families.

• Urodynamic studies should be performed in every patient with spinal dysraphism as well as in every child with a high suspicion of a neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter.

• In all newborns, intermittent catheterisation (IC) should be started soon after birth. In those with a clear underactive sphincter and no overactivity, starting IC may be delayed. If IC is delayed, closely monitor babies for urinary tract infections, upper tract changes (US) and the lower tract (UDS).

• Start early anticholinergic medication in newborns with a suspicion of an overactive detrusor.

• The use of suburothelial or intradetrusoral injection of onabotulinum toxin A is an alternative and less invasive option in children who are refractory to anticholinergics in contrast to bladder augmentation.

• Treatment of bowel emptying problems is important to gain continence and independence. Treatment should be started with regular fluid intake and dietary measures as well as mild laxatives, rectal suppositories, and digital stimulation. If insufficient, transanal irrigation is recommended, and if this is not practicable or feasible, a Malone antegrade colonic enema (MACE)/Antegrade continence enema (ACE) stoma should be discussed.

• Ileal or colonic bladder augmentation is recommended in patients with therapy resistant detrusor overactivity, small capacity and poor compliance, which may cause upper tract damage and incontinence. The risks of surgical and non- surgical complications and consequences outweigh the risk of permanent damage of the upper urinary tract +/- incontinence due to the detrusor.

• A life-long follow-up of renal function should be available and offered to every patient.

• Performing and reporting of urodynamic studies should be done according to ICCS standards.

• Screen for psychological symptoms and disorders with validated, broadband behavioural questionnaires at school entry or whenever indicated clinically.

• If the screening is positive and reveals signs and symptoms of psychological disorders, a full professional mental health assessment should follow.

• If a psychological disorder of clinical relevance and with incapacitation is present, counselling should be offered in every case.

• If a mental health disorder is present and counselling alone is insufficient, treatment according to evidence-based guidelines is recommended.

• Include serial ultrasound (US) and subsequent diuretic renogram and sometimes voiding cystourethrography in post-natal investigations.

Screening

• Inform parents of children with vesicoureteric reflux (VUR) that siblings and offspring have a high prevalence of VUR.

Treatment

• Offer immediate, parenteral antibiotic treatment for febrile breakthrough infections.

• Initially manage all children presenting at age one to five years conservatively.

• Offer close surveillance without antibiotic prophylaxis to children presenting with lower grades of reflux and without symptoms.

• Ensure that a detailed investigation for the presence of lower urinary tract dysfunction (LUTD) is done in all and especially in children after toilet-training. If LUTD is found, the initial treatment should always be for LUTD.

• Offer reimplantation to patients with persistent high-grade reflux and endoscopic correction for lower grades of reflux.

• Offer surgical correction, if parents prefer definitive therapy to conservative management.

• In high-risk patients who already have renal impairment, a more aggressive, multi- disciplinary approach is needed.

• Use plain abdominal X-ray and ultrasound as the primary imaging techniques for the diagnosis and follow-up of stones.

• Use low-dose non-contrast computed tomography in cases with a doubtful diagnosis, especially of ureteral stones or complex cases requiring surgery.

• Perform a metabolic evaluation in any child with urinary stone disease. Any kind of interventional treatment should be supported with medical treatment for the underlying metabolic abnormality, if detected.

• Limit open surgery under circumstances in which the child is very young with large stones, in association with congenital problems requiring surgical correction and/ or with severe orthopaedic deformities that limit positioning for endoscopic procedures.

• Observe infant microlithiasis, unless symptoms occur or size increases significantly.

• Do not delay diagnosis and treatment of any neonate presenting with ambiguous genitalia since salt-loss in a 46XX CAH girl can be fatal.

• Refer children to experienced centres where neonatology, endocrinology, (paediatric) urology, psychology and transition to adult care are guaranteed.

• Utilise a multi-disciplinary approach and a shared decision model in patients with DSD conditions including: a. Gender assigment b. G enital surgery (in accordance with national regulations) c. Gonadectomy.

• Do not underestimate the significant effects on psychological and psychiatric health, quality of life, personal relationships, and sexual function in individuals with DSD.

• Ensure full disclosure to patients and caregivers that the presence of a Y-chromosome in dysgenetic gonads results in a higher malignancy risk

• Drain the bladder in new-borns with a suspected diagnosis of infravesical obstruction and place on antibiotic prophylaxis.

• Perform a voiding cystourethrogram in patients in whom a diagnosis of PUV is suspected.

• Attempt endoscopic valve ablation after bladder drainage and stabilisation of the child.

• Consider neonatal circumcision as an adjunct to antibiotic prophylaxis to decrease the risk of UTI in those with a posterior urethral valve (PUV), especially in the presence of high grade vesicoureteral reflux.

• Offer prolonged urinary diversion (suprapubic/transurethral) for bladder drainage if the child is too small for valve ablation.

• Use serum creatinine nadir as a prognostic marker.

• Assess split renal function by dimercaptosuccinic acid scan or mercaptoacetyltriglycine clearance.

• Consider high urinary diversion if bladder drainage is insufficient to drain the upper urinary tract, or in the absence of clinico- biochemical improvement.

• Monitor and manage bladder and renal function lifelong.

• Manage asymptomatic urachal remnants (UR) conservatively.

• Remove symptomatic URs either using an open, laparoscopic or robotic approach.

• Ultrasound is the first investigation of choice for the diagnosis of paediatric bladder tumours.

• Cystoscopy should be reserved if a bladder tumour is suspected on imaging for diagnosis and treatment.

• Have a high index of suspicion of eosinophilic cystitis (EC) in protracted urinary tract symptoms unresponsive to regular treatment.

• Remove any possible allergens as the obvious first step in managing EC.

• Manage nephrogenic adenoma (NA) by resection either transuretherally or by open excision.

• Propranolol is currently first-line treatment for infantile hemangiomas.

• Conservative management is the first-line treatment for penile lymphedema.

• Use imaging in all children who have sustained a blunt or penetrating trauma with any level of haematuria, especially when the history reveals a deceleration trauma, direct flank trauma or a fall from a height.

• Use contrast-enhanced scanning with delayed images for diagnostic and staging purposes.

• Manage most injured kidneys conservatively.

• Offer surgical intervention in case of haemodynamic instability and a Grade V renal injury.

• Diagnose suspected ureteral injuries by retrograde pyelogram.

• Use retrograde cystography to diagnose suspected bladder injuries.

• Ensure that the bladder has been filled to its full capacity and an additional film is taken after drainage.

• Manage extra-peritoneal bladder ruptures conservatively with a transurethral catheter left in place for seven to ten days.

• Perform surgical exploration in cases of intra-peritoneal bladder ruptures.

• Assess the urethra by retrograde urethrogram in case of suspected urethral trauma.

• Perform a rectal examination to determine the position of the prostate.

• Manage urethral injuries conservatively initially if a transurethral catheter can be placed.

• Perform a doppler ultrasonography in all patients presenting with priapism.

• In children with ischaemic (low-flow) priapism, perform a full blood count and haemoglobinopathy screen to exclude sickle cell disease or other haematological disorders.

• Adopt a multidisciplinary approach when managing patients with SCD-associated priapism.

• Use a step-wise approach starting with the least invasive therapy in patients with ischaemic (low-flow) priapism.

• Manage neonatal and non-ischaemic (high- flow) priapism conservatively in the initial management period.

• Ensure shorter pre-operative fasting periods for elective surgeries (one hour for clear liquids, three hours for breast milk, four hours for formula milk-based products and six hours for a light meal).

• Start early post-operative oral fluid intake in all patients scheduled for minor surgical procedures.

• Use enhanced recovery after surgery protocols for abdominal surgery in children with pre-existing normal bowel function.

• Prevent/treat pain in children of all ages.

• Evaluate pain using age-compatible assessment tools.

• Use pre-emptive and balanced analgesia in order to decrease opioids requirements.

• Use physical methods for venous thrombo- embolism (VTE) risk reduction in older children and adolescents who are at increased risk of VTE.

• Consider low molecular weight heparin VTE prophylaxis in children, particularly adolescents, with additional risk factors.

• Use pharmacological premedication to decrease anxiety levels in children and monitor for potential side effects.

• Use lower intra-abdominal pressure (6-8 mmHg) during laparoscopic surgery in infants and smaller children.

• Use open access for laparoscopy in infants and smaller children.

• Monitor for laparoscopy-related cardiac, pulmonary and diuretic responses.

• Develop a standardised transition-of- care program and collaborate with adult providers to facilitate safe, successful, and sustainable transition.

• Use a validated transition assessment tool to objectively assess for transition readiness.