EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction

Lower urinary tract symptoms (LUTS), which are quite common especially in elderly men, may be caused by a number of diseases. A sharp decline in the quality of life forces patients to see an urologist who has to apply a differentiated approach in order to identify the cause of LUTS and choose the correct method of treatment.

Urinary infection is one of the most common community- and hospital-acquired bacterial infections. In the United States about 11% of all women aged over 18 note episodes of urinary tract infection every year. 40-50% of the total population of adult women have had at least one episode of acute urinary tract infection during their lives. The incidence of the disease is highest in the age group 18-24 years: the frequency is from 1 to 5 times per year [1]. In 18-39 years age group the risk for recurrent urinary infection episode up to six months after the end of the initial one is 24% [2]. About 5% of patients note repeated exacerbations during the year following the initial acute episode of urinary tract infection.

Today it is difficult to think of a clinician who does not utilize a multitude of pharmacotherapeutic options. The modern clinical pharmacology has significantly expanded the opportunities for conservative, medicinal treatment of diseases for which surgery was the only method of cure in the past. The growth in the arsenal of drugs, however, often results in prescription of a multitude of drugs at the same time. It becomes increasingly important therefore to assess drug interactions to enhance efficacy of treatment and prevention of adverse reactions.

The article presents an overview of current literature on the etiology and pathogenesis, key aspects of diagnosis and treatment of recurrent urinary tract infections. Clinical recommendations should contribute to more adequate prescription of antibiotics to patients with urinary tract infections. The preference should be given to antibiotics with lower risks associated with resistance increase. Fluoroquinolones and other broad-spectrum antibiotics should be kept in mind as second-line therapy. It is also recommended to minimize prophylactic use of antibiotics in patients with recurrent urinary tract infections, possibly eliminate the existing risk factors for relapse and continue the search for alternative methods of treatment and prevention of urinary tract infections.

Today various types of robotic reconstructive plastic surgery on the ureter and bladder have become a reality. Surgical treatments vary from simple removal of a misplaced suture to uretherocystoanastomosis. Robot-assisted technology is not less effective than open surgery while being less invasive and allowing to reduce the risk of many complications, the length of hospital stay, and providing a much better cosmetic result. Robotic system outperforms the traditional laparoscopic and open techniques due to its 3D visualization of anatomical structures, thorough and delicate dissection, elimination of natural tremor, precise and focused suturing, minimum traction and displacement of surrounding organs and structures, and ergonomic features.

Incontinence is one of the most common diseases in women, especially in the elderly population. Certain gynecological disorders are characterized by dysfunctional voiding, such as stress urinary incontinence and overactive bladder. Therapeutic recommendations are based on the causes of dysfunctional voiding and the course of the disease.

For many years, prolapse of internal reproductive organs in women has been quite a common gynecological disease [1, 2, 4, 11-13] often requiring surgical correction. The incidence of genital prolapse (56.3%) is highest at the age of 50 and above, however recently the disease has tended to become younger. Women under 45 years constitute 30-37.5% of genital prolapse patients, women under 30 years old - 10.1-12.3%. Severe forms of the disease have prevailed over the recent years, involving adjacent organs and deterioration of their function [4].

Incontinence is one of the most common diseases in women, especially in the elderly population. Certain gynecological disorders are characterized by dysfunctional voiding, such as stress urinary incontinence and overactive bladder. Therapeutic recommendations are based on the causes of dysfunctional voiding and the course of the disease.

The first mentioning of plant extracts for the treatment of urination disorders in men with prostate disease dates back to the ancient Egypt, namely XV century BC. Currently we know of about 30 kinds of plant extracts which are used in the treatment of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH) or chronic prostate inflammation. More than 40 clinical studies have been published which demonstrate the efficacy of herbal medicines for male LUTS.

Erectile dysfunction (ED) and premature ejaculation (PE) are the two main complaints in male sexual medicine [1, 2, 14]. Erectile dysfunction is a very delicate problem: not every man will have courage to share it with his doctor. The trouble can occur at any age; bad erection is often a real tragedy for the stronger sex. Family life imbalance can seriously deteriorate the quality of life, cause problems at work or even lead to severe depression.

Benign prostatic hyperplasia (BPH), for a long time known as benign prostatic hypertrophy, is so widespread that many researchers say, it inevitably occurs in men who have lived long enough for BPH to develop. BPH is one of the most common diseases in males from the age of 40-50 years. Histological study reveals hyperplasia in more than 60% of 60-year-old patients, and it is clinically manifested in more than 40% of men of this age group [1]. About 20% of men after the age of 60 note a significant deterioration in the quality of life due to urination disorder. Benign prostatic hyperplasia is characterized by a broad variety of symptoms.

Phosphodiesterase type 5 (PDE5) inhibitors modulate afferent nerve activity, increase nitric oxide activity resulting in the corpus cavernosal smooth muscle relaxation in the penis, prostate, urethra and bladder neck. According the European Urological Association guidelines, PDE5 inhibitors reduce the severity of moderate to severe symptoms of impaired urination in men with and without erectile dysfunction (ED). An overview of recent literature on the use of PDE5 inhibitors showed that they can be used clinically in the treatment of erectile dysfunction as well as in the therapy of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia and in patients with LUTS after radical prostatectomy. The aim of our study was to evaluate the role of tadalafil in restoring continence in patients after bilateral nerve-sparing robotic radical prostatectomy (bilateral NSRRPE).

Antagonists of α1-adrenergic receptors (α-blockers) are among the most effective drugs for the treatment of patients with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH; LUTS/BPH). Based on the results of treatment outcome analysis, the American Urological Association acknowledged these drugs as drugs of choice for the treatment of BPH [1].