EAU Guidelines for the Diagnosis and Treatment of Lower Urinary Tract Symptoms in Non-Neurogenic Women (Part 1)

The European Association of Urology (EAU) guidelines for the diagnosis and management of lower urinary tract symptoms (FLUTS) in non-neurogenic women evolved from previous guidelines for urinary incontinence (UI)
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The new guidelines (top) focus on the diagnosis of lower urinary tract symptoms in non-neurogenic women, and the management of overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI)
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The EAU expert group summarizes the current best evidence and gives corresponding recommendations.
This article mainly summarizes the main recommendations of the expert group
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RECOMMENDED POINTS—Diagnosis of Lower Urinary Tract Symptoms (LUTS) Take a complete history, including symptoms and complications, and perform a physical examination to evaluate LUTS (Strength of Recommendation: Strong)
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Use a validated and appropriate questionnaire as a standardized assessment of LUTS in women (strength of recommendation: strong)
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Completion of a bladder diary in patients with LUTS should be included as part of a standardized assessment of LUTS in women (strength of recommendation: strong)
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A bladder diary with a duration of 3 days and more should be used (recommended strength: strong)
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Urinalysis may be included as part of the initial assessment of LUTS (strength of recommendation: strong)
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If LUTS has concurrent urinary tract infection (UTI), re-evaluation after treatment is required (strength of recommendation: strong)
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Asymptomatic bacteriuria in the elderly does not require routine treatment to improve incontinence (strength of recommendation: strong)
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The amount of residual urine (PVR) should be measured during the initial evaluation of patients with LUTS (strength of recommendation: strong)
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The amount of PVR should be measured using ultrasound (recommended strength: strong)
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Monitoring the amount of PVR in treated patients may cause or exacerbate voiding dysfunction (strength of recommendation: strong)
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Bladder volume efficiency can be an additional consideration when measuring PVR volume (strength of recommendation: weak)
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Urodynamic testing in patients with LUTS should follow the standards of good urodynamic practice established by the International Advisory Committee on Urinary Incontinence (Strength of Recommendation: Strong)
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Routine urodynamic testing is not required for the treatment of uncomplicated SUI (strength of recommendation: strong)
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Routine urodynamic testing is not required for first-line treatment of OAB symptoms (strength of recommendation: strong)
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Kinetic studies may be performed if diagnostic findings may alter invasive treatment options (strength of recommendation: weak)
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Do not use urethral manometry or leak spot manometry to grade the severity of UI, as these primarily examine urethral function (strength of recommendation: strong)
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When performing the cloth pad test, a standardized duration and detection procedure should be used (recommended strength: strong)
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Response to therapy is especially assessed when cloth pad testing is required to quantify UI (strength of recommendation: weak)
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Upper urinary tract (UTT) or lower urinary tract (LUT) imaging is not routinely performed as part of LUTS evaluation (strength of recommendation: strong)
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Management of OAB Document the current medication history of all OAB patients (strength of recommendation: strong)
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Check for any new medications associated with development or worsening of OAB symptoms (strength of recommendation: weak)
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Ensure women with OAB and/or caregivers are aware of available treatment options before deciding on continence (recommended strength: strong) Incontinence pads and/or control devices are not feasible when managing wet OAB with temporary symptom control and other treatments (recommended strength: strong) strong)
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Prophylactic antibiotics may be offered to patients with recurrent UTI undergoing self-intermittent cleaning catheterization (CISC) or indwelling catheters (strength of recommendation: strong) after discussions regarding the increased risk of antibiotic resistance
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Encourage overweight or obese adult patients with OAB/UI to lose weight and maintain weight loss (strength of recommendation: strong)
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Advising adults with OAB to reduce caffeine intake may improve symptoms of urgency and frequency, but not incontinence (strength of recommendation: strong)
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The type and amount of fluid intake in patients with OAB should be checked (strength of recommendation: weak)
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Provide smoking cessation methods for smoking OAB patients (strength of recommendation: strong)
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Need to prompt urination in adults with cognitive impairment OAB (strength of recommendation: strong)
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Bladder training can be used as first-line treatment for adult patients with OAB/urge urinary incontinence (UUI) (strength of recommendation: strong)
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Make sure the pelvic floor muscle training (PFMT) program is as intensive as possible (recommended intensity: strong)
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Consider transcutaneous tibial nerve stimulation (PTNS) as an option to improve symptoms in women with OAB/UUI who do not benefit from anticholinergic drugs (strength of recommendation: strong)
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For adults with OAB who fail conservative treatment, anticholinergic drugs or mirabegron can be given (strength of recommendation: strong)
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When possible, consider extended-release formulations of anticholinergics (strength of recommendation: strong)
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If anticholinergic therapy is ineffective, consider increasing the dose or administering alternative anticholinergic agents, or mirabegron, or combination therapy (strength of recommendation: strong)
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Early evaluation of OAB patients using anticholinergic drugs is encouraged, including efficacy and adverse effects (strength of recommendation: strong)
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Elderly women should be cautious with long-term anticholinergic therapy, especially in women at risk for or with existing cognitive impairment (strength of recommendation: strong)
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Anticholinergic burden and associated complications should be assessed in patients who are considering anticholinergic therapy to improve OAB symptoms (strength of recommendation: weak)
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Vaginal estrogen therapy may be given to patients with symptoms associated with LUTS and genitourinary syndrome (GSM) of menopause (strength of recommendation: weak)
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Intravesical injection of botulinum toxin type A (100U) can be given to OAB/UUI patients who have failed conservative or medical therapy (recommended strength: strong)
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Before botulinum toxin therapy, patients should be warned about the limited duration of treatment response, the risk of UTIs, and the possible long-term need for CISC (strength of recommendation: strong)
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Female patients who are responsive to botulinum toxin may receive repeat injections of botulinum toxin as needed (see manufacturer's guidelines or instructions for minimum time frame for repeat injections) (recommended strength: strong)
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For OAB/UUI patients who have failed anticholinergic therapy, sacral nerve stimulation (SNS) can be given (recommended strength: strong)
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Patients with implanted SNS should be provided with lifelong monitoring for lead displacement, failure, and battery wear (recommended strength: strong)
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Enhanced cystoplasty can be given to OAB/UUI patients who have failed all other treatment options and who have been suggested to be at (small) risk of malignancy (strength of recommendation: weak)
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Patients undergoing enhanced cystoplasty should be advised that they may be at high risk for CISC (ensure that the patient is willing and able to accept it) and that lifelong monitoring is required (strength of recommendation: strong)
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Detrusectomy should not be used as a treatment for UUI (strength of recommendation: weak)
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Only for this subset of patients - OAB/UUI patients who have failed ostomy and minimally invasive therapy and who have been advised of possible malignancy risk (small) - urinary diversion (strength of recommendation: weak)
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Diagnosis of SUI For the treatment of uncomplicated SUI, routine urodynamic testing is not required (strength of recommendation: strong)
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Preoperative urodynamic testing can be performed in patients with SUI with associated storage symptoms, as well as in patients with unclear type of incontinence, suspected voiding dysfunction, associated with pelvic organ prolapse (POP), or who have undergone prior SUI surgery (strength of recommendation: weak)
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A cloth pad test with standardized duration and detection procedure should be used (recommended strength: strong)
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Standardized cloth pad tests can be used to quantify SUI, especially when assessing response to treatment (strength of recommendation: weak)
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Treatment of SUI encourages overweight and obese women with LUTS/SUI to lose weight and maintain weight loss (strength of recommendation: strong)
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Temporary symptom control and other treatments should not be administered while incontinence pads and/or control devices are used to treat OAB (strength of recommendation: strong)
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Monitorable intensive PFMT should be given to all women with SUI or MUI (including older women, antenatal and postpartum women) as first-line therapy for at least 3 months (strength of recommendation: strong)
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Make sure that the PFMT program is carried out as closely as possible (recommended intensity: strong)
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The efficacy and adverse events of PFMT should be balanced against the expected effects and complications of invasive procedures for SUI (strength of recommendation: strong)
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When treating SUI, do not use skin electrodes (skin, vagina, anus) for electrical stimulation alone (recommended strength: strong)
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Vaginal estrogen therapy should be given to postmenopausal women with SUI and symptoms of vaginal atrophy (strength of recommendation: strong)
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Duloxetine (where available) can be administered to patients with SUI who are refractory to other conservative treatments and who wish to avoid invasive treatments, and should be carefully consulted on the risk of adverse events (Strength of recommendation: strong)
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Due to the higher risk of adverse events, duloxetine therapy should be accepted and discontinued using dose titration (strength of recommendation: strong)
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When appropriate, patients who have attempted or failed conservative treatment should be offered different surgical options, and the advantages and disadvantages of each approach should be discussed (Strength of recommendation: strong)
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The use of the new device in the treatment of SUI is intended only as part of a research program
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Results must be monitored by a registry or as part of a regulated research trial (strength of recommendation: strong)
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Vaginal suspension (laparoscopic or laparoscopic) may be offered to women seeking SUI after a thorough discussion of the risks and benefits of other surgical modalities (strength of recommendation: strong)
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After a thorough discussion of the risks and benefits of other surgical modalities, autologous sling placement may be offered to women seeking SUI (strength of recommendation: strong)
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After a thorough discussion of the risks and benefits of other surgical modalities, urethral filler injections may be given to women seeking SUI (strength of recommendation: strong)
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For patients with SUI requiring low-risk urethral filler surgery, it should be understood that its efficacy is lower than other surgical modalities, repeated injections may be required, and long-term persistence and safety have not been established (strength of recommendation: strong)
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Do not use autologous fat and hyaluronic acid as urethral fillers due to higher risk of adverse events (strength of recommendation: strong)
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After a thorough discussion of the risks and benefits of other surgical modalities, midurethral sling (MUS) may be given to women seeking SUI (strength of recommendation: strong)
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Female patients should be advised that the retropubic route of MUS has superior long-term outcomes compared to the transobturator route (strength of recommendation: strong)
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Women should be informed of MUS-related complications, and all alternative treatments should be discussed in light of the most recent surgical approaches (Strength of Recommendation: Strong)
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Women undergoing single-incision sling should be advised that the long-term outcome remains uncertain (strength of recommendation: strong)
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Obese patients with SUI should be advised that surgery is associated with higher risks and potentially lower benefits (strength of recommendation: weak)
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Elderly patients with SUI should be advised of the higher risks associated with surgery and the potentially lower benefits (strength of recommendation: weak)
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Women receiving an artificial urinary sphincter or an adjustable pressure device should be advised that, although curative is possible, there is a high risk of complications, mechanical failure, or the need for implantation (strength of recommendation: strong)
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Diagnosis and Treatment of MUI Classify MUI as stress or urge incontinence whenever possible (strength of recommendation: weak)
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Bladder diaries and urodynamics should be used as part of a multimodal assessment of MUI to help identify the most appropriate treatment strategy (strength of recommendation: strong)
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For people with MUI, the most bothersome symptoms should be treated first (Strength of recommendation: weak)
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For adults with MUI, bladder training should be used as first-line therapy (intensity of recommendation: strong)
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Monitorable intensive PFMT can be used as first-line therapy for all women with MUI, including older and postpartum women, and should be continued for at least 3 months (strength of recommendation: strong)
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Anticholinergic drugs or β3 agonists should be given for patients with MUI predominant with urgency (strength of recommendation: strong)
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Duloxetine may be given to selected patients who do not respond to other conservative treatments and wish to avoid invasive therapy in patients with predominantly stressful MUI who should be carefully counseled about the risk of adverse events (strength of recommendation: weak)
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Female patients should be advised that surgery for MUI is less likely to be successful than surgery for SUI alone (Strength of recommendation: strong)
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Women with MUI should be informed that UI may not be cured by monotherapy; other problems and most bothersome symptoms of incontinence may need to be treated (Strength of Recommendation: Weak)
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References AK Nambiar, S.
Arlandis, K.
Bø et al.
, European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms.
Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed UrinaryIncontinence , Eur Urol (2022), https://doi.
org/10.
1016/j.
eururo.
2022.
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