info re luts

8/20/2019 info re luts

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Guidelines on theManagement of Non-Neurogenic

Male Lower UrinaryTract Symptoms

(LUTS), incl

!enign "rostatic

#$struction (!"#)19. Gravas (Chair), T. Bach, A.

Bachmann, M. Drake, M. Gacci, C. Gratzke, S.

Madersbacher, C. Mamoulakis, .A.!. Tikkinen


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" #uro$ean Association o% &rolo' *+

T%!L& #' #NT&NTS "%G&

+. - T/!D&CT-! 0+.+ Aim 0+. 1ublication histor 0+.2 1anel com$osition 0

. M#T3!DS 0.+ 1atients to 4hom the 'uidelines a$$l

2. T3# G&-D#5- #2A #1-D#M-!5!G6, A#T-!5!G6 A D 1AT3!136S-!5!G62B D-AG !ST-C #7A5&AT-! 8

2B.+ Medical 3istor 82B. S m$tom score 9uestionnaires :

2B. .+ The -nternational 1rostate S m$tom Score (-1SS) : 2B. . The -nternational Consultation on -ncontinence ;uestionnaire (-C-;


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2C. . 1lant e>tracts < $h tothera$ 22C. .8 7aso$ressin analo'ue < desmo$ressin2C. .: #mer'in' thera$ies 8

2C. .:.+ Beta


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2C.2.+.+ Modi%ications o% T&/1 bi$olar T&/1 2+2C.2. !$en $rostatectom 222C.2.2 Transurethral micro4ave thera$ 20 2C.2.0 Transurethral needle ablation o% the $rostate 2 2C.2. 5aser treatments o% the $rostate 28

2C.2. .+ 3olmium laser enucleation and holmium laser resection o% the $rostate 28

2C.2. . 2 nm (EGreenli'htF) laser va$orisation o% $rostate 2: 2C.2. .2 Diode laser va$orisation o% the $rostate 2?2C.2. .0 Thulium ttrium


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1. NT*#+U T #N1.1 %im5o4er urinar tract s m$toms (5&TS) are a common com$laint in adult men 4ith a ma or im$act on9ualit o% li%e (;o5), and substantial $ersonal and societal e>$enditures. The $resent Guidelines o%%er$ractical evidence


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here $ossible, recommendations are based on the stron'est clinicall relevant data. henrecommendations are 'raded, there is no automatic relationshi$ bet4een the 5# and G/. The availabili t o%randomised controlled trials (/CTs) ma not necessaril translate into a Grade A recommendation i% there aremethodolo'ical limitations or a dis$arit in $ublished results, uncertaint about the balance o% desirable andundesirable e%%ects, uncertaint or variabilit in $atientsF values and $re%erences, or uncertaint about 4hetherthe intervention re$resents a 4ise use o% resources. Alternativel , lack o% hi'h$erience and consensus, or situations 4herecorroboratin' studies cannot be $er%ormed, $erha$s %or ethical, %inancial or other reasons. Such a situationis indictated in the te>t 4ith an asterisk to denote Eu$'raded based on 1anel consensusF. The 9ualit o%the scienti%ic evidence is a ma or %actor, but it has to be balanced a'ainst bene%its, burdens, $ersonalvalues and $re%erences 4hen a Grade o% /ecommendation is assi'ned.

The orkin' 1anel intends to u$date the content and recommendations re'ularl , accordin'to the 'iven structure and classi%ication s stems.

2.1 "atients to whom the guidelines apply/ecommendations a$$l to men a'ed 0* ears or older 4ho seek $ro%essional hel$ %or 5&TS in various non<neuro'enic and nonts o% 5&T disease (e.'.concomitant neurolo'ical diseases, oun' a'e, $rior 5&T disease or sur'er ) usuall re9uire a more e>tensive

4ork


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+etrusor LUTSunderacti1ity

%nd others

+istalureteralstone

!ladder tumour

Neurogenic $ladder dysfunction

Urinary tract infection

'oreign$ody

"r ostatitis

Urethralstrictur e

!

+ %GN#ST&2%LU%T #NTests ar e use%

ul % or d

ia'no

sis, monitor

in', assessin

' the $r

o'nos

is o% diseas

e $r o'r ession

, tr eatm

ent $

lannin', and

the $r edicti

on o% tr

ea

s

T

#A&

Guidelines onthemana'ement o% a$$licableconditionsshouldbe%ollo4edin thesecases.

T

d asc

er tain tr eat

mento$tions a

nd ident

i% men at risk o% disease$ro'ression.

! / Medical istoryThe im$ortance o% assessin' the $atientFshistor is 4ell


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5&TS and $r ostate c

ancer (1Ca) H+

, +2I. As $

ar t o% the ur olo'ical

sur 'ical histor

,

a sel% <com$leted validate

d s

m$tom 9uestionnai

r e (see section 2B.

) should be assessed to

ob

ecti%

and 9uanti%

5&TS. 7oidin' dia

r ies ar e $ar ticular l

ben

e% icial 4hen assessin

'


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*ecommendation L& G* A medical histor must al4a s be taken %rom men 4ith 5&TS. 0 AK*Upgraded based on Panel consensus. LUTS = lower urinary tract symptoms.

! 3 Symptom score 4uestionnaires All $ublished 'uidelines %or male 5&TS B13 recommend usin' validated s m$tom score 9uestionnaires H0, +*,

++I. Several 9uestionnaires have been develo$ed 4hich are sensitive to s m$tom chan'es and can be used tomonitor treatment H+0< *I. S m$tom scores are hel$%ul in 9uanti% in' the $atientFs 5&TS and in identi% in' 4hicht $e o% s m$toms are $redominant, et the are not diseaseternal 'enitalia, the $erineum and lo4er limbs. &rethral dischar'e, meatal stenosis, $himosisand $enile cancer must be identi%ied i% $resent.

3B.$.1 Di ital-rectal e!amination an" prostate si#e e$aluationDi'italamination (D/#) is the sim$lest 4a to assess $rostate volume, but correct estimation is noteas to achieve. ;ualit


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MA AG#M# T != ! < #&/!G# -C MA5# 5! #/ &/- A/6T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+ :


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! 9 *enal function measurement/enal %unction ma be assessed b serum creatinine or estimated 'lomerular %iltration rate (eG=/).3 drone$hrosis, renal insu%%icienc or urinar retention are more $revalent in $atients 4ith si'ns ors m$toms o% B1! H 0I. #ven thou'h B1! ma be res$onsible %or these com$lications, there is noconclusive evidence on the mechanism H I.

!ne stud re$orted ++J o% men 4ith 5&TS had renal insu%%icienc H 0I. either s m$tom score nor;o5 4as associated 4ith the serum creatinine concentration, and diabetes mellitus or h $ertension 4ere themost likel causes o% the elevated creatinine concentration. Comiter et al. H 8I re$orted that nonand eG=/ in middle


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! /< maging

3B.1-.1 Upper urinary tract /outine ima'in' o% the u$$er urinar tract in men 4ith 5&TS is not recommended, as the are not at increasedrisk %or u$$er tract mali'nanc or other abnormalities 4hen com$ared to the overall $o$ulation H :, : H:@I. -11 alsoseems to $redict success%ul outcome o% trial 4ithout catheter (T !C) a%ter acute urinar retention H?*, ?+I. oin%ormation 4ith re'ard to intra< or inter


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a'reement 4ith 1=S H80I. Threshold values o% .*, . , or .@ mm %or D T in $atients 4ith 5&TS isable to identi% ?+J, ?@J, and +**J o% $atients 4ith B!!, res$ectivel H?0I.

All studies %ound that B T or D T measurements have a hi'her dia'nostic accurac %or detectin'

B!! than ; ma> or ; ave o% %ree uro%lo4metr , measurements o% 17/, $rostate volume, or s m$tom severit .!ne stud could not demonstrate an di%%erence in B T bet4een $atients 4ith normal urod namics, B!!or detrusor overactivit O ho4ever, the stud did not use a s$eci%ic bladder %illin' volume %or measurin'B T H? I. Disadvanta'es o% the method include the lack o% standardisation, and lack o% evidence toindicate 4hich measurement (B T D T) is $re%erable H?8I. Measurement o% B T D T is there%ore notrecommended %or the dia'nostic 4ork


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There are no $ublished /CTs in men 4ith 5&TS and $ossible B1! that com$are the standard$ractice investi'ation (uro%lo4metr and 17/ measurement) 4ith 1=S, but one such stud is on'oin' in the & .

Due to the invasive nature o% the test, a urod namic investi'ation is 'enerall onl o%%ered i%conservative treatment has %ailed. The Guidelines 1anel attem$ted to identi% s$eci%ic indications %or 1=S basedon a'e, %indin's %rom the other dia'nostic tests, and $revious treatments. The 1anel allocated a di%%erent de'reeo% obli'ation %or 1=S in men L ?* ears and men * ears, 4hich ma re%lect the lack o% evidence. -n addition,there 4as no consensus 4hether 1=S should or ma be $er%ormed 4hen considerin' sur'er in men 4ith

bothersome $redominantl voidin' 5&TS and ; ma> L +*m5 s, althou'h the 1anel reco'nised that 4ith

; ma> +* m5 s, B!! is likel and 1=S are not necessaril needed.1atients 4ith neurolo'ical disease, includin' those 4ith $revious radical $elvic sur'er

should be assessed accordin' to the #A& Guidelines on euro H+*8I and $rostatic urethral an'le H+*:I have also been $ro$osed,but are still e>$erimental.

*ecommendations L& G*1=S should be $er%ormed onl in individual $atients %or s$eci%ic indications $rior to sur'er or 2 B4hen evaluation o% the underl in' $atho$h siolo' o% 5&TS is 4arranted.1=S should be $er%ormed in men 4ho have had $revious unsuccess%ul (invasive) treatment %or 2 B5&TS.

hen considerin' sur'er , 1=S ma be used %or $atients 4ho cannot void L + * m5. 2 C

hen considerin' sur'er in men 4ith bothersome, $redominantl voidin' 5&TS, 1=S ma be 2 C$er%ormed in men 4ith a 17/ L 2** m5.

hen considerin' sur'er in men 4ith bothersome, $redominantl voidin' 5&TS, 1=S ma be 2 C$er%ormed in men a'ed L ?* ears.

hen considerin' sur'er in men 4ith bothersome, $redominantl voidin' 5&TS, 1=S should 2 Bbe $er%ormed in men a'ed * ears.

LUTS = lower urinary tract symptoms P S = pressure(#low studies4 P & = post(/oid residual.

+ MA AG#M# T != ! < #&/!G# -C MA5# 5! #/&/- A/6 T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+


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'igure 30 %ssessment algorithm of LUTS in men aged 5< years or older /eaders are stron'l recommended to read the %ull te>t that hi'hli'hts the current $osition o% each test in detail.

Male 5&TS

3istor ( se>ual %unction) S m$tom score9uestionnaire &rinal sis

1h sical e>amination1SA (i% dia'nosis o% 1Ca 4ill chan'e the mana'ementt

%&' = digital(rectal e)amination+ = #re"uency /olume c art

LUTS = lower urinary tractsymptoms P+a = prostate cancerPS, = prostate speci#ic antigenP & = post(/oid residual US =ultrasound.

+ S&%S&M%N%G&M&NT

/

onser1ati1etreatment3+.1.1

atch%ul*aitin Manmen4ith5&TSare nottroubled

enou'hbtheir

s m$toms toneeddru'treatmentorsur'icalinter vention.

Allmen4ith5&TSshould be%ormallassessed$rior

toan

allocation o% treatment in order toestablish s m$tom severit and todi%%erentiate bet4een men 4ithuncom$licated (the ma orit ) and

com$licated 5&TS. atch%ul 4aitin'( ) is a viable o$tion %or man men4ith nonimatel ? J o% men 4ithmild 5&TS 4ere stable on at one

ear H+++I. A lar'e stud com$arin'

and transurethral resection o%the $rostate (T&/1) in men 4ithmoderate 5&TS sho4ed the sur'ical'rou$ had im$roved bladder %unction(%lo4 rates and 17/ volumes),es$eciall in those 4ith hi'h levels o% botherO 28J o% $atients crossedover to sur'er 4ithin %ive ears,leavin' 80J doin' 4ell in the 'rou$ H++ , ++2I. -ncreasin's m$tom bother and 17/ volumesare the stron'est $redictors o% clinical%ailure. Men 4ith mild


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3+.1.2 'eha$ioural an" "ietary mo"i%ications-t is customar %or this t $e o% mana'ement to include the %ollo4in' com$onents

1• education (about the $atientFs condition)O2• reassurance (that cancer is not a cause o% the urinar s m3• $eriodic monitorin'O

4• li%est le advice H++*, +++, ++0, ++ I such as1• reduction o% %luid intake at s$eci%ic times aimed at re inconvenient (e.'. at ni'ht or 4hen 'oin' out in $ublic)O

2• avoidance moderation o% intake o% ca%%eine or alcohol, e%%ect, thereb increasin' %luid out$ut and enhancin'%re9uenc , ur'enc and nocturiaO

3• use o% rela>ed and doubleists evidence (5# +b) that sel%


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e>ist in di%%erent %ormulations (see su$$lementar online material Table S.2). Althou'h di%%erent %ormulations

+0 MA AG#M# T != ! < #&/!G# -C MA5# 5! #/ &/- A/6T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+


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result in di%%erent $harmacokinetic and tolerabilit $ro%iles, the overall clinical im$act o% thedi%%erent %ormulations is modest.

'##icacy -ndirect com$arisons bet4een α +


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Ta$le 30 *andomised, place$o-controlled trials with α +-$loc@ers in men with LUTS

Trials +uration Treatment "atients hange in hange in "2* L&(wee@s) (daily dose) (n) symptoms

?ma6 change

(B) (mLAs) (B)Qardin et al. 0 1lacebo 8:


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3+.2.2 . α -/e"uctase inhi&itors:ec anism o# action Andro'en e%%ects on the $rostate are mediated b dih drotestosterone (D3T), 4hichis converted %rom testosterone b the enz me α tra$rostatic tissues, such as skin and liver.2• α $ression and activit in the $rostate.

T4o α


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Ta$le 0 *andomised trials with 7 α -reductase inhi$itors in men with LUTS and $enignprostatic enlargement due to !"

Trials +uration Treatment (daily dose) "atients hange in hange in hange in L&(wee@s) (n) symptoms

?ma6 prostate

(B "SS) (mLAs) 1olume (B)5e$or et al. 1lacebo 2* m' 2+*


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+? MA AG#M# T != ! < #&/!G# -C MA5# 5! #/&/- A/6 T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+


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Muscarinic rece$tors are also $resent on other cell t $es, such as bladder urothelial cells, e$ithelial cellso% the salivar 'lands, or the $eri$heral or central nervous s stem. =ive muscarinic rece$tor subt $es(M+ but nin h drochloride (o> but nin)O $ro$iverine h drochloride ($ro$iverine)Osoli%enacin succinate (soli%enacin)O tolterodine tartrate (tolterodine)O tros$ium chloride.

'##icacy Antimuscarinics 4ere mainl tested in %emales in the $ast, because it 4as believed that 5&TS inmen are caused b the $rostate, so should be treated 4ith $rostate scores H+?2I.

MA AG#M# T != ! < #&/!G# -C MA5# 5! #/ &/- A/6

T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+ +@


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Ta$le 50 Trials with antimuscarinic drugs only in elderly men with LUTS, predominantlywith #%! symptoms

Trials +uration Treatment n 2oiding Nocturia Urgency "SS L&(wee@s) fre4uency (B) incontinence (B)

(B) (B)

a$lan et al. Tolterodine + 02


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3+.2.$ Phospho"iesterase . inhi&itors:ec anism o# action? 1D# t $e inhibitors (1D# -s) increase intracellular c clic 'uanosine mono$hos$hate, thus reducin' smooth muscle tone o% the detrusor, $rostate and urethra. itric o>ide and 1D#s mi'ht also alterre%le> $ath4a s in the s$inal cord and neurotransmission in the urethra, $rostate, or bladder H+?@I. Moreover,chronic treatment 4ith 1D# - seems to increase blood $er%usion and o> 'enation in the 5&T H+@*I. =inall ,1D# -s could reduce chronic in%lammation in the $rostate and bladder H+@+I.

,/ailable drugs Althou'h clinical trials o% several selective oral 1D# -s have been conducted in men4ith 5&TS, onl tadala%il ( m' once dail ) has been licensed %or the treatment o% male 5&TS.

'##icacy Several /CTs have demonstrated that 1D# -s reduce -1SS, stora'e and voidin' 5&TS, and ;o5

(Table ). ; ma> increases in a dose and more severe 5&TS $ro%it the most %rom treatment 4ith 1D# -s H+@ I.

5on'$erience 4ith tadala%il in men 4ith 5&TS is limited to one trial H+@0I, andthere%ore conclusions about its e%%icac or tolerabilit L+ ear are not $ossible. There is limitedin%ormation about reduction o% $rostate size and none about disease $ro'ression.

*ecommendations L& G*1D# -s reduce moderate


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Ta$le 70 &fficacy of "+&7 s in adult men with LUTS who participated in high le1el clinical trials

Trials +uration Treatment "atients "SS?

ma6 "2* L&(wee@s) (mLAs) (mL)

"+&7 s in monotherapyMc7ar et al. + 1lacebo +?* *ualintercourse

Mc7ar et al. + 1lacebo +02 * m' da *@ < . .*


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3+.2. Plant e!tracts - phytotherapy :ec anism o# action 3erbal dru' $re$arations are made o% roots, seeds, $ollen, bark, or %ruits o% a sin'le $lant(monotracts o% t4o or more $lants to one $ill (combination $re$arations).The most 4idel used $lants are +ucurbita pepo ($um$kin seeds), Eypo)is rooperi (South A%rican star 'rass),Pygeum a#ricanum (bark o% the A%rican $lum tree), Secale cereale (r e $ollen), Serenoa repens (s n. Sabalserrulata O berries o% the American d4ar% $alm, sa4 $almetto) and Urtica dioica (roots o% the stin'in' nettle).

1ossible relevant com$ounds include $h tosterols, Utracts can have anti 'enase, 'ro4th %actortra$olated to othersH *@I. Batches %rom the same $roducer mi'ht contain di%%erent concentrations o% active in'redientsH +*I. Thus the $harmacokinetic $ro$erties can var si'ni%icantl .

Table 8 $resents the trials 4ith the hi'hest 5# %or each $lant e>tract. -n 'eneral, no$h tothera$eutic a'ent has been sho4n to reduce $rostate size, and no trial has $roven a reduction o%B!! or a decrease in disease $ro'ression. Anal sis o% each dru' class can be %ound in thesu$$lementar online material (see 444. uro4eb.or' 'uidelines).

Cochrane meta


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Ta$le 80 Trials with plant e6tracts in patients with !" -LUTS (selection)

Trials +uration Treatment "atients hange hange "2* L&(wee@s) (n) symptoms

?ma6 (mL)

( "SS) C (mLAs)Bach ( ***) 1lacebo 02 < . S S +b

H +0I +ucurbita pepo 22


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3+.2. ,asopressin analo ue - "esmopressin:ec anism o# action The antidiuretic hormone ar'inine vaso$ressin (A71) re'ulates 4ater homeostasis. -t controls urine $roduction throu'h the 7 rece$tor in the renal collectin' ducts. A71 increases 4ater reimatel *.8


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Ta$le 90 linical trials with desmopressin in adult men with nocturnal polyuria

Trials +uration Treatment (oral daily "atients hange hange Time to L&(wee@s) dose $efore $edtime, (n) nocturnal nocturnal first 1oid

unless otherwise urine 1oids (n) (hours)indicated) 1olume

(mLAmin) As$lund et al. 2 + > *.+ m' 2K ation.

'##icacy Mirabe'ron * m' is the %irst clinicall available beta


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dr mouth and consti$ation in the mirabe'ron 'rou$s 4as notabl lo4er than re$orted in /CTs o% other !ABa'ents or o% the active control tolterodine H 2@I. #valuation o% urod namic $arameters in men 4ith combinedB!! and !AB concluded that mirabe'ron did not adversel a%%ect voidin' urod namic $arameters com$ared

to $lacebo in terms o% ; ma> , detrusor $ressure at ma>imum %lo4 and bladder contractilit inde> H 02I.

Practical considerations? 5on'


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Ta$le :0 *andomised trials using α / -$loc@er, 7 α -reductase inhi$itor, and the com$ination of $othdrugs in men with LUTS and $enign prostatic enlargement due to !"

Trials +uration Treatment "atients Symptom hange in hange in L&(wee@s) (daily dose) (n) change ? ma6 (mLAs) prostate

(B "SS) 1olume (B)5e$or et al. 1lacebo 2* +* m' 2* m' 2+* m' 2 ?


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3+.2.J.2 α 1(bloc ers F muscarinic receptor antagonists:ec anism o# action? Combination treatment consists o% an α + *. m' d : *.0 m' d *@ < < *.0 m' d *@ < < < +.@b

o> but nin + > +*.* m' da$lan et al. Tolterodine + > 0.* m' d 02


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α +imum %ollo4 im$rovement ( +8 J), a si'ni%icant reduction in -1SS (


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Practical considerations T&/1 and T&-1 are e%%ective treatments %or moderate


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Ta$le /


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2 MA AG#M# T != ! < #&/!G# -C MA5# 5! #/&/- A/6 T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+


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[ie et al. M


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Ta$le /30 *esults of #" studies for treating !" -LUTS or !"#

Studies +uration "atients hange in hange in hange in hange in L&(wee@s) (n) symptoms

?ma6 "2* prostate

( "SS) 1olume%$solute B mLAs B mL B mL B

untz et al. 8* 2


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Tolerability and sa#ety Treatment is 4ell tolerated, althou'h most $atients e>$erience $erineal discom%ort and urinar ur'enc , and re9uire $ain medication %or thera$ . 1ooled morbidit data com$arin' T&MT and T&/1have been $ublished H @@, 2**, 2*:I. -n the Cochrane /CT


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Most studies 4ere short


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and 3o5#1 in $atients 4ith $rostates L 8* m5 sho4ed com$arable s m$tom im$rovement butsi'ni%icantl hi'her %lo4 rates and lo4er 17/ volume a%ter 3o5#1 H2 ?I. Another /CT on 3o5A1 and?*< 171 sho4ed com$arable %unctional im$rovement 4ithin a median %ollo4imum ener' a$$lication.

'##icacy A meta and -1SS bet4een 171 and T&/1, butonl three /CTs $rovided su%%icient +


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4ith Greenli'ht laser 4ithout takin' anticoa'ulants ( .0J) H2 2I. Sa%et in $atients 4ith urinarretention, or $rostates L ?* m5 4as sho4n in various $ros$ective nonimum %ollo4


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Practical considerations? The limited number o% /CTs and limited %ollo4


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6an' et al. +? :@ Thu5#1 increase H2@ I.The $ooled data %rom studies 4ith $atients 4ho 4ere catheter de$endent sho4ed that ?0J o%

$atients (+0? +:8) re'ained the abilit to void s$ontaneousl a%ter &ro5ume treatment H2@ , [email protected] best data on non


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Ta$le /80 &fficacy of stents0 @ey studies

Stent n Symptoms ? ma6 (mLAs) 'ailure rate L&"re- "ost- "re- "ost- (follow-upoperati1e operati1e operati1e operati1e in months)

&rolume (1) H2?0I @+ +0.+ 0.: @.2 +:.+ !verall 200 / 0.8 / +2.: + . J (+?)

Memotherm (1) H2?:I + 2 0.* 8.+K :.0 +8.+K 0J (0?) 2T-TA (1) H2??I ? + .@_ @.22

+?. @K ++.02

+!verall 2

@ +?.* . + / ++.20 +@J ( 0)S$anner (T) H2? I 2* .2 :.+ ?. ++.8 *J ( ) 2Memokath (T


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T/ACT S6M1T!MS (5&TS) < &1DAT# MA/C3 *+ 0+


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sho4ed no si'ni%icant di%%erence in terms o% -1SS, ;o5, and ; ma> at 4eek + H0+0I. /e$ense o% a lon'er o$erative time (see online Table S.?). -n one stud (notincluded in the s stematic revie4) o% 20 cases o% sin'leual activit (mean Se>ual 3ealth -nventor+ .: $re


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Practical considerations? -t should be underlined that the available evidence comes %rom case seriesand retros$ective com$arative studies %rom selected centers. 3i'h 9ualit studies are needed tocom$are the e%%icac , sa%et , and hos$italisation bet4een M-S1 and both !1 and endosco$icmethods. 5on'$ectations to be metin terms o% s$eed o% onset, e%%icac , side e%%ects, ;o5, and disease $ro'ression. A table 4hich $rovides

di%%erential in%ormation about s$eed o% onset and in%luence on basic $arameters 4ith conservative,medical or sur'ical treatment o$tions is described in the su$$lementar online material, Table S.+*.

Behavioural modi%ications, 4ith or 4ithout medical treatments, are usuall the %irst choice o%thera$ . =i'ure 2 $rovides a %lo4 chart illustratin' treatment choice accordin' to evidence


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Sur'ical treatment is usuall re9uired 4hen $atients have e>$erienced recurrent or re%ractorurinar retention, over%lo4 incontinence, recurrent &T-s, bladder stones or diverticula, treatment


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'igure 50 Treatment algorithm of $othersome LUTS refractory to conser1ati1eAmedical treatmentor in cases of a$solute operation indications The flowchart was stratified $y thepatientFs a$ility to ha1e anaesthesia, cardio1ascular ris@, and prostate siJe

Male LUTSwith a$solute indications for surgery or non-responders to medical treatment or

those who do not want medical therapy $ut re4uest acti1e treatment

low ,igh ris@ highpatientsG

yesan ha1e

nosurgery under anaesthesiaG

an stop

yes anticoagulantA noantiplatelettherapyG

K < mL "rostate H :< mL (+) Current standard %irst choice1olumeThe alternative treatments are $resented oal$habetical order

Gotice /eaders are stron'l recommended

< - :<to read the %ull te>t that hi'hli'hts thecurrent $osition o% each treatment in deta

mL

TU " (/) TU*" (/) #pen Laser TUMTTU*" Laser enucleation prostatectomy (/) 1aporisation (/) TUN%

Laser oL&" (/) Laser Stent1aporisation Laser enucleationTUMT 1aporisationTUN% TU*"

5aser va$orisation includes Green5i'ht, thulium, and diode lasers va$orisationO5aser enucleation includes holmium and thulium laser enucleation.

EoL'P = olmium laser enucleation TU5P = transuret ral incision o# t e prostate TU:T = transuret ralmicrowa/e t erapy TUG, = transuret ral needle ablation TU&P = transuret ral resection o# t e prostate.

+ '#LL#E-U"+ / Eatchful waiting ($eha1ioural)

1atients 4ho elect to $ursue a $olic should be revie4ed at 8 months and then annuall , $rovidedthere is no deterioration o% s m$toms or develo$ment o% absolute indications %or sur'ical treatment. The%ollo4in' are recommended at %ollo4


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at 8 months, and an con%irmed increase in 1SA 4hile on


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12. 6oun' QM, et al. Are men 4ith lo4er urinar tract s m$toms at increased risk o% $rostatecancer A s stematic revie4 and criti9ue o% the available evidence. BQ& -nt, ***. ? (@) $.+*2:


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31. /oehrborn CG, et al. -ntere>aminer reliabilit and validit o% a threeamination and serum $rostate s$eci%ic anti'en inthe estimation o% $rostate volume in communit


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the clinical $ro'ression o% beni'n $rostatic h $er$lasia. #n'l Q Med, **2. 20@( ) $. 2?:<@?. htt$ 444.ncbi.nlm.nih.'ov $ubmed +08?+ *0

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50. /oehrborn CG. Al%uzosin +* m' once dail $revents overall clinical $ro'ression o% beni'n$rostatic h $er$lasia but not acute urinar retention results o% a < ear $lacebo


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68. /e nard QM, et al. The -CSimum %lo4 rate %or dia'nosin' bladder outlet obstruction canbe estimated %rom the -CS nomo'ram. eurourol &rod n, **?. :(+) $. @:


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87. o ima M, et al. &ltrasonic estimation o% bladder 4ei'ht as a measure o% bladder h $ertro$h inmen 4ith in%ravesical obstruction a $reliminar re$ort. &rolo' , +@@8. 0:(8) $. @0


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105. 1el QQ, et al. Develo$ment o% a non


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total or transition zone volume o% the $rostate. 1rostate Cancer 1rostatic Dis, **8. @( ) $.+ +< . htt$ 444.ncbi.nlm.nih.'ov $ubmed +82*0 :

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124. /oehrborn CG, et al. The e%%ects o% dutasteride, tamsulosin and combination thera$ on lo4erurinar tract s m$toms in men 4ith beni'n $rostatic h $er$lasia and $rostatic enlar'ement <

ear results %rom the CombAT stud . Q &rol, **?. +:@( ) $. 8+8< +O discussion 8 +.htt$ 444.ncbi.nlm.nih.'ov $ubmed +?*? +8

125. /oehrborn CG, et al. The e%%ects o% combination thera$ 4ith dutasteride and tamsulosin onclinical outcomes in men 4ith s m$tomatic beni'n $rostatic h $er$lasia 0< ear results %rom

the CombAT stud . #ur &rol, *+*. :(+) $. + 2


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140. ilt TQ, et al. Terazosin %or beni'n $rostatic h $er$lasia. Cochrane Database S st /ev,** (0) $. Cd**2? +.

htt$ 444.ncbi.nlm.nih.'ov $ubmed + +@8++

141. ickel QC, et al. A meta


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157. /oehrborn CG, et al. #%%icac and sa%et o% a dual inhibitor o%

166. Andersen QT, et al. =inasteride si'ni%icantl reduces acute urinar retention and need %orsur'er in $atients 4ith s m$tomatic beni'n $rostatic h $er$lasia. &rolo' , +@@:. 0@(8) $.?2@


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174. ono M, et al. Central muscarinic rece$tor subt $es re'ulatin' voidin' in rats. Q &rol, **8.+: (+) $. 2 2


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192. Gacci M, et al. A s stematic revie4 and metauall active men 4ith both conditionsanal ses o% $ooled data %rom %our randomized, $lacebo Med, *+2. +*(?) $. *00< .htt$ 444.ncbi.nlm.nih.'ov $ubmed 2:? 0 @

197. /oehrborn CG, et al. #%%ects o% tadala%il once dail on ma>imum urinar %lo4 rate in men 4ithlo4er urinar tract s m$toms su''estive o% beni'n $rostatic h $er$lasia. Q &rol, *+0. +@+(0)$. +*0 < *. htt$ 444.ncbi.nlm.nih.'ov $ubmed 000 :?

198. Gacci M, et al. The use o% a sin'le dail dose o% tadala%il to treat si'ns and s m$toms o%beni'n $rostatic h $er$lasia and erectile d s%unction. /es /e$ &rol, *+2. $. @@


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209. 3abib = , et al. ot all brands are created e9ual a com$arison o% selected com$onents o%di%%erent brands o% Serenoa re$ens e>tract. 1rostate Cancer 1rostatic Dis, **0. :(2) $. +@ <

**. htt$ 444.ncbi.nlm.nih.'ov $ubmed + ?@?+0

210. Sca'lione =, et al. Com$arison o% the $otenc o% di%%erent brands o% Serenoa re$ens e>tract onal$hatrakt bei B13<bedin'ten Miktionsbesch4erden. &rolo'e B ***. 0* $. 02:on) 4ith %inasteride in the treatment o% beni'n$rostate h $er$lasia a randomized international stud o% +,*@? $atients. 1rostate, +@@8. @(0)$. 2+


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blind, $lacebo$lorator stud . BQ& -nt, +@@@. ?2(8) $. @+< .htt$ 444.ncbi.nlm.nih.'ov $ubmed +* 22 82

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333. #lza at #A, et al. 3olmium laser enucleation o% the $rostate (3o5#1) lon'


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368. 5eonardi /. 1reliminar results on selective li'ht va$orization 4ith the side


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404. 1lante M , et al. 1hase - -- e>amination o% transurethral ethanol ablation o% the $rostate %or thetreatment o% s m$tomatic beni'n $rostatic h $er$lasia. Q &rol, **:. +::(2) $. +*2*< Odiscussion +*2 .htt$ 444.ncbi.nlm.nih.'ov $ubmed +: @80*

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