EAU Guidelines for the Diagnosis and Treatment of Lower Urinary Tract Symptoms in Non-Neurogenic Women (Part 2)

The European Association of Urology (EAU) guidelines for lower urinary tract symptoms (FLUTS) in non-neurogenic women evolved from the previous guidelines for urinary incontinence (UI)
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Part 2 of the new guidelines focuses on hypoactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia
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The UAB recommendation encourages double voiding in women who cannot fully empty the bladder (strength of recommendation: weak)
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Warn women with UAB that there is a risk of pelvic organ prolapse when using abdominal force to improve emptying (strength of recommendation: weak)
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The use of self-intermittent cleaning catheterization (CISC) can be used as a standard of care in patients unable to empty the bladder (strength of recommendation: strong)
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Patients should be fully informed about the technical and risk aspects of CISC (Strength of Recommendation: Strong)
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Indwelling transurethral catheterization and suprapubic cystostomy were only given when other catheterization modalities failed or were inappropriate (strength of recommendation: weak)
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Intravesical electrical stimulation is not routinely recommended for UAB patients (recommended strength: weak)
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Parasympathetic drugs are not routinely recommended for women with UAB (strength of recommendation: strong)
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Alpha-blockers should be given before more invasive techniques (strength of recommendation: weak)
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Intravesical prostaglandins have been given to women with postoperative urinary retention only in well-regulated clinical trials (strength of recommendation: weak)
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When administering botulinum toxin type A external urethral sphincter injections before more invasive procedures, inform patients that the evidence supporting this approach is low (strength of recommendation: weak)
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Sacral nerve stimulation can be given to patients with UAB refractory to conservative therapy (recommendation strength: weak)
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Detrusor myoplasty is not routinely recommended as a treatment for detrusor hypoactivity (strength of recommendation: weak)
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Diagnosis of BOO Recommendations For women with suspected BOO, a complete clinical history should be collected and a comprehensive clinical examination should be performed (strength of recommendation: strong)
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Do not rely solely on measurements from a urine flow study to diagnose BOO in women (strength of recommendation: strong)
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Cystourethroscopy should be performed in women with BOO with suspected anatomical obstruction (strength of recommendation: strong)
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Urodynamic evaluation should be performed in women with suspected BOO (strength of recommendation: strong)
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Conservative treatment should be given to women with functionally obstructed BOO with pelvic floor muscle training (PFMT) aimed at relaxing the pelvic floor muscles (PFM) (recommended intensity: strong)
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Priority is given to research that investigates and promotes understanding of the mechanisms by which PFMT affects pelvic floor coordination relaxation during voiding (strength of recommendation: strong)
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Vaginal pessary is recommended for patients with grade 3 or 4 cystocele BOO (inappropriate or refractory to other treatments) (strength of recommendation: weak)
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 Urinary containment devices should be given to patients with BOO to address the problem of urine leakage due to BOO, not as a disease-modifying treatment (strength of recommendation: weak)
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Self-intermittent clean catheterization (CISC) should be given to women with BOO after urethral stricture or incontinence surgery (strength of recommendation: weak)
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Intraurethral devices are not recommended for women with BOO (strength of recommendation: strong)
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Pharmacotherapy After discussion of potential benefits and adverse factors, urethral-selective alpha-blockers can be given as an off-label option to women with functionally obstructed BOO (Strength of Recommendation: Weak)
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Oral baclofen may be prescribed for women with BOO, especially those with increased electromyographic (EMG) activity and persistent detrusor contractions during urination (strength of recommendation: weak)
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In regulated clinical trials, sildenafil should be given only to women with BOO (strength of recommendation: strong)
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Thyrotropin-releasing hormone is not recommended for women with BOO (strength of recommendation: strong)
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Surgical treatment should be given to women with functional obstruction of BOO with intrasphincteric injection of botulinum toxin (strength of recommendation: weak)
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Sacral neuromodulation should be given to women with functionally obstructed BOO (strength of recommendation: weak)
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Women with pelvic organ prolapse (POP)-related voiding symptoms may experience improvement after surgery (strength of recommendation: weak)
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Urethral dilation can be given to women with urethral stricture leading to BOO, but repeated interventions may be required (strength of recommendation: weak)
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Women with urethral strictures leading to BOO urethrotomy and postoperative urethral dilatation are given, but should be informed of the limited long-term improvement of symptoms and the risk of postoperative urinary incontinence (UI) with this therapy (strength of recommendation: weak)
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Urethral dilatation or urethrotomy is not recommended for women with BOO who have previously undergone midurethral mesh placement, theoretically at risk of urethral extrusion (strength of recommendation: weak)
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Women should be informed of the limited long-term benefit (in terms of PVR volume and QoL only) after endourethrotomy (strength of recommendation: weak)
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Bladder neck incision should be given to women with BOO secondary to primary bladder neck obstruction (strength of recommendation: weak)
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Women undergoing bladder neck incision should be informed of the low risk of postoperative SUI, vesicovaginal fistula (VVF), or urethral stricture
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(Recommended Strength: Strong)
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Urethroplasty can be given to women with BOO due to recurrent urethral stricture after failure of initial therapy (strength of recommendation: weak)
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Patients should be informed that long-term follow-up after urethroplasty should be aware of possible recurrence of urethral strictures (strength of recommendation: weak)
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Women with dysuria after UI surgery should be offered urethral dissection (strength of recommendation: weak)
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Sling surgery (release, incision, partial excision, or excision) should be administered to women with urinary retention or severe dysuria after UI (strength of recommendation: strong)
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Women should be advised of the risk of SUI recurrence and to discuss the need for repeat/concurrent UI surgery after sling repair (Strength of recommendation: strong)
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Nocturia Recommendation Points Collect a complete medical history of nocturia patients (strength of recommendation: strong)
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A validated questionnaire should be used in the assessment of nocturia, reassessment, and/or after treatment (strength of recommendation: weak)
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Nocturia in women was assessed using a 3-day voiding diary (strength of recommendation: strong)
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The use of nocturnal voiding diaries alone to assess nocturia in women is not recommended (strength of recommendation: weak)
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LUTS life>
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Administer PFMT (individually or collectively) to women with nocturia in UI or storage LUTS (strength of recommendation: strong)
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Referral to a sleep clinic is recommended for patients with nocturia and underlying obstructive sleep apnea to assess the utility of CPAP therapy (strength of recommendation: strong)
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After discussion of potential benefits and risks, anticholinergic therapy should be administered to patients with UUI or other storage-phase LUTS uremia (strength of recommendation: strong)
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Women with nocturia should be advised that the combination of behavioral therapy and anticholinergic drugs is unlikely to be more effective than either approach (strength of recommendation: weak)
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Anticholinergics in combination with desmopressin should be given to patients with OAB secondary to nocturnal polyuria and nocturia after consultation of potential benefits and risks (strength of recommendation: weak)
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Vaginal estrogen therapy for women with nocturia Vaginal estrogen therapy should be given to women with nocturia after counseling about potential benefits and risks (strength of recommendation: weak)
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Patients with nocturia secondary to polyuria should be given on-time diuretic therapy after counseling about potential benefits and risks (strength of recommendation: weak)
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References: S.
Arlandis, K.
Bø, H.
Cobussen-Boekhorst et al.
, European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms.
Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia , Eur Urol (2022), https://doi.
org/10.
1016/j.
eururo.
2022.
01.
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