REVIEW

American Urological Association and European

Association of Urology guidelines in the
management of benign prostatic
hypertrophy: revisited
Armando A. Juliao a, Mauricio Plata b, Amir Kazzazi c, Yakup Bostanci c, and
Bob Djavan c

Purpose of review
The purpose of this review is to provide a complete revision of two of the most widely used clinical
guidelines in the management of lower urinary tract symptoms induced by benign prostatic hyperplasia
and their importance and compliance among urologists.
Recent findings
Updates of the American Association of Urology and European Association of Urology clinical practice
guidelines (CPGs) were reviewed and analyzed. Literature concerning compliance and application of these
two CPGs in the different working scenarios of practicing has been evaluated.
Summary
Urology has moved to an era in which costs and quality of care are being scrutinized, and compliance to
CPGs will be assessed. Practicing urologists do not have the time to keep up to date with the continuous
incoming literature and CPGs are a great tool to give the highest quality of care to our patients.
Keywords
benign prostatic hyperplasia, clinical practice guidelines, evidence-based medicine, lower urinary tract symp-
toms

INTRODUCTION become available for the treatment of LUTS induced

Benign prostatic hyperplasia (BPH) is a histological
diagnosis that includes stromal and smooth muscle
cell proliferation in the prostatic transitional zone
[1,2]. Lower urinary tract symptoms (LUTSs) is a
medical syndrome that can be caused by multiple
conditions that include BPH as the most important
and frequent cause. The incidence of bothersome
LUTS, based on the world widely used and accepted
International Prostate Symptom Score (IPSS) may
vary from 30 to 40% in patients older than 50 years
[3]. Given these huge numbers of patients, LUTS/
BPH has become a major health issue for many
countries with aging populations.
During the past decade, many changes in the
diagnosis, medical and surgical management of
LUTS have evolved and come to our treatment
armamentarium.
There is a wide range of options that include
pharmacological therapies, mechanical devices and
new surgical interventions have emerged and have
by BPH. However, these new and interesting thera-
peutic modalities have been accompanied by con-
troversy about the correct way for the treatment of
LUTS, leading to a wide range of personal opinions
when choosing the best treatment in patients with
this condition.
There is no universal consensus on how to pro-
perly and cost-effectively diagnose and treat these
patients. During the past two decades, the European
a
UROCENTRO Medical Center, Barranquilla, Colombia, South America,
b
University Hospital – Fundación Santa Fé de Bogotá, Department of
Urology, Universidad de los Andes, Bogota, Colombia, South America
and cDepartment of Urology, New York University School of Medicine,
NYU, New York, USA
Correspondence to Armando A. Juliao, MD, Scientific Director
UROCENTRO Medical Center, Carrera 49 C #80-39, Barranquilla,
Colombia. E-mail: armando.juliao@me.com
Curr Opin Urol 2012, 22:34–39
DOI:10.1097/MOU.0b013e32834d8e87

www.co-urology.com Volume 22  Number 1  January 2012

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 Guidelines: management of benign prostatic hypertrophy Juliao et al.
KEY POINTS
 Urology has moved to an era in which costs and
quality of care are being scrutinized, and compliance
to CPGs will be assessed.
 Practicing urologists do not have the time to keep up to
date with the continuous incoming literature and CPGs
are a great tool to give the highest quality of care to
our patients.
Association of Urology (EAU) and the American
Association of Urology (AUA) have developed and
updated clinical practice guidelines (CPGs), with the
purpose to optimize cost-effectively the manage-
ment of LUTS.
Providing healthcare with the highest standards
implies a medical practice that is consistent with the
best available evidence. Obtaining and appraising
the current medical evidence on any specific uro-
logical topic is beyond the time, qualities and
resources of most urologists. CPGs provide an
updated evidence-based medicine (EBM) platform
on which urologists and clinicians base their prac-
tice. There are multiple variations among CPGs, and
their quality varies among different countries. Many
past articles have addressed this in the past, and by
using different scoring mechanisms have given
qualifications to the different CPGs [4].
Despite these two huge efforts and the efforts of
other multiple working groups around the world in
trying to unify the treatment of LUTS, there is wide
variation in the application of these clinical practice
&&
guidelines [5 ,6]. These variations depend on
multiple factors that include geographic differences,
practice setting and experience and account largely
by the differences in the use of optional and non-
routinely recommended tests and treatments [7].
DIFFERENCES IN MANAGEMENT OF
LOWER URINARY TRACT SYMPTOMS
AND BENIGN PROSTATIC HYPERPLASIA
The evaluation and treatment of BPH has changed
markedly, and these changes include the develop-
ment of CPGs for investigation of BPH, the use of
standard symptom scores and quality of life assess-
ment, and the introduction of new medical thera-
pies and technology. Despite the enormous
quantities of literature on BPH, many uncertainties
still exist regarding the appropriate evaluation and
management of these patients. Although multiple
CPGs have addressed the optimal treatment of men
with LUTS, there remain wide variations in the
patterns of clinical practice.
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When urologists and primary care physicians
(PCPs) were asked to rate criteria that determined
the diagnostic tests and prescription of four treat-
&
ment modalities, there was little agreement [8 ].
Another big difference in the management of
patients with BPH is marked by the type or urologist
that first sees the patient. Academic, urban and
southern urologists in the US tend to practice with
more compliance to CPGs, which makes the man-
agement of BPH more uniformal and optimal [9].
REVIEW OF AMERICAN ASSOCIATION OF
UROLOGY AND EUROPEAN ASSOCIATION
OF UROLOGY CLINICAL GUIDELINES
The AUA guidelines defines an index patient as a
male aged 45 or older who is consulting a qualified
healthcare provider for their LUTS with no history of
non-BPH causes of LUTS and the symptoms can be
associated with an enlarged prostate gland or not or
bladder outlet obstruction or histological BPH. The
guideline does not apply when other conditions are
the cause of the symptoms.
An expert panel examined the evidence and
drafted statements which were tempered by the
Panel’s expert opinion. These statements were
graded into three levels depending on the flexibility
in their application being a standard if the health
outcomes of the alternative interventions are suffi-
ciently well known to permit meaningful decisions
and there is virtual unanimity about which inter-
vention is preferred. The second level is a recom-
mendation in which the health outcomes of the
alternative intervention are sufficiently well known
to permit meaningful decisions and an appreciable
but not unanimous majority agrees on which inter-
vention is preferred. The third level is an option in
which the health outcomes of the interventions are
not sufficiently well known to permit meaningful
decisions, or preferences are unknown or equivocal.
The EAU guidelines are intended to give advice
on the pathophysiology and definitions, assess-
ment, treatment, and follow-up of men older than
40 years with no neurogenic LUTS. The guideline is
primarily intended to be used by urologist but can be
used by general practitioners and will be updated
every 2 years.
The EAU guidelines on BPH published in 2006
classified the evidence in three categories. Recom-
mended when there is evidence to support the use of
a test or treatment, optional when the test is done at
the discretion of the physician and not recom-
mended when there is no evidence to support the
use of this test.
The guideline on non-neurogenic male LUTS
published in 2010 by the EAU classified the level
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 Benign prostatic hyperplasia
of evidence according to a classification system from
the Oxford Centre for Evidence-based Medicine
Levels of Evidence. Ranging from level 1 [best evi-
dence, i.e. meta-analysis to level 4 (expert opinion)].
A grade of recommendation ranging from a strong
(grade A) to a weak (grade C) recommendation is
&&
made [5 ,6].
DIAGNOSTIC EVALUATION
The AUA panel considered that the recommen-
dations for diagnosis published by the 2005 Inter-
national Consultation of Urologic Diseases and the
publication by Abrams et al. [10] in 2009 were valid
and do not deserve further study because they
reflected a best practice in this area. A basic evalu-
ation should be performed on every patient with
LUTS. This includes medical history, assessment of
symptoms and bother, physical exam including
digital rectal examination (DRE), urinalysis, serum
prostate specific antigen (PSA) levels, but the
benefits and risks of using serum PSA testing to
diagnose prostate cancer should be discussed with
the patient [10]. The routine measurement of crea-
tinine levels is no longer recommended in the initial
evaluation of LUTS (not recommended). Frequency
volume charts should be used when nocturia is the
dominant symptom but may also be used in other
settings. The detailed evaluation in the AUA guide-
line involves the use of standardized questionnaires
(recommended); flow recording and residual urine
are optional tests. Pressure flow studies are not
indicated in the routine evaluation of men with
LUTS or to predict the response to the medical
therapy but may be beneficial in cases in which
Qmax is greater than 10 ml/s to determine the need
for invasive therapy to relieve bladder outlet
obstruction (BOO). Imaging of the upper urinary
tract is not recommended as a routine but can be
indicated in patients with infection, hematuria,
urolithiasis, and renal insufficiency. Endoscopy is
not recommended unless the patient has the same
conditions mentioned for imaging.
The EAU recommended as investigations,
clinical history, symptom assessment, physical
examination and a validated symptom score, that
is IPSS. The recommendation of PSA measurement is
done when a diagnosis of prostatic carcinoma will
change the management. Regarding creatinine, the
EAU guideline considered cost-effective its measure-
ment in all patients based on the recommendations
by the Agency for Health Care Policy Research and
the fourth international consultation on BPH
(recommended). Urinalysis is recommended in
the primary evaluation but there is little evidence
in the medical literature to support it
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(recommended). Digital rectal exam DRE is also
recommended; however, DRE impact in the early
diagnosis of PCa has been questioned. DRE is useful
in evaluating the size of the prostate gland (recom-
mended). The EAU guideline recommends evalu-
ation of the upper urinary tract with creatinine
and/or ultrasonography. Regarding micturition dia-
ries, the recording of a 24-h frequency volume chart
in the course of an initial consultation is considered
to be a standard investigation. Uroflowmetry is
recommended in the work-up of patients with LUTS
and is considered mandatory before surgery (recom-
mended). Postvoid residual is recommended during
initial assessment. Urodynamic studies (pressure-
flow studies) are considered optional and they can
be used in counseling patients regarding the out-
come of surgical therapies for BPH (option). How-
ever, should be considered for patients prior to
surgical treatment if they are young or elderly, high
postvoid residual (PVR), Qmax more than 15 ml/seg,
neurogenic disorders, radical pelvic surgery or
previous invasive treatment. Cystoscopy is also con-
sidered an optional test and recommended as a
guideline at the time of surgical treatment to rule
out other pathology and to assess the shape and size
of the prostate [11].
BASIC MANAGEMENT
If the patient has LUTS only and the symptoms are
not bothersome or the patient does not want treat-
ment, no further evaluation is recommended.
In patients with bothersome symptoms the
physician can discuss with the patient treatment
alternatives based on the results of the initial evalu-
ation with no further tests. The guidelines highlight
the importance of the discussion of the benefits and
risks involved with each of the treatment altern-
atives and the choice of treatment should be reached
in a shared decision-making process between the
physician and patient [12].
TREATMENT ALTERNATIVES
It is considered a standard that the Information on
the benefits and harms of treatment alternatives for
LUTS secondary to BPH should be explained and
shared with the patient with moderate to severe
symptoms (AUA-SI score 8) who is bothered enough
to consider therapy.
The patient must be informed of all available
options of treatment, the benefits, risk and costs of
each of them so he can participate in the choice
of therapy.
Patients with mild symptoms or patients with
moderate or severe symptoms not bothered by their
Volume 22  Number 1  January 2012
 Guidelines: management of benign prostatic hypertrophy Juliao et al.
LUTS should be managed with watchful waiting
(standard). This is a practice in which the patient
is monitored but does not receive any intervention.
It is an appropriate option for men with symptoms
not bothersome and who do not have any compli-
cation of LUTS and BOO such as renal insufficiency,
urinary retention or recurrent infection [13].
Regarding medical management, the AUA
guidelines state that the use of alfuzosin, doxazosin,
tamsulosin, and terazosin is appropriate and they
provide effective treatment alternatives for patients
with bothersome, moderate to severe LUTS secon-
dary to BPH (AUA-SI score 8). With minimal differ-
ences in the adverse events profiles of these agents
and the same efficacy (option). The generic alpha-
blockers, which are less costly, can be reasonable
choices. Nevertheless require dose titration and
blood pressure monitoring (option).
Prazosin and phenoxybenzamine were not
reviewed but in the 2003 BPH guidelines the data
were insufficient to support a recommendation
and this has been maintained (recommendation).
LUTS patients under treatment with alpha-blockers
should be asked about planned cataract surgery.
Men with planned cataract surgery should avoid
the initiation of alpha-blockers until their cataract
surgery is completed (recommendation).
The combination of an alpha-blocker and
5-alpha reductase inhibitors (5-ARIs) is an effective
treatment for patients with LUTS and prostatic
enlargement based on volume, PSA levels and or
enlargement on DRE (option).
5-ARIs may be used to prevent progression of
LUTS secondary to BPH and to reduce the risk of
urinary retention and future prostate-related surgery
(option). 5-ARIs should not be used in men with
LUTS without prostatic enlargement (recommen-
dation).
Finasteride is considered an effective alternative
in men with refractory hematuria presumably due to
prostatic bleeding. There is no similar evidence for
dutasteride but the expert opinion is that dutaster-
ide likely functions in a similar fashion (option).
There is not enough evidence to recommend
using 5-ARIs preoperatively to reduce intraoperative
bleeding or the need for blood transfusions (option).
Anticholinergic agents are appropriate and
effective treatment alternatives for the management
of LUTS secondary to BPH in men without an elev-
ated residual and when LUTS is predominantly irri-
tative (option). Before the anticholinergic is started,
a baseline PVR should be determined (recommen-
dation).
No dietary supplement, combination phyto-
therapeutic agent is recommended for the manage-
ment of LUTS secondary to BPH (recommendation).
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Saw palmetto has no clinically meaningful effect on
LUTS (recommendation).
Minimally invasive therapies
Transurethral needle ablation (TUNA) of the pros-
tate is an appropriate and effective treatment
alternative for bothersome moderate or severe LUTS
secondary to BPH according to the AUA guidelines
(option). The EAU guidelines state that TUNA is an
alternative to transurethral resection of the prostate
(TURP) in those patients who wish to avoid the
complications of the TURP, but patients should
be aware of significant retreatment rates and less
improvement in symptoms and quality of life (level
of evidence 1a, recommendation A).
Transurethral microwave thermotherapy
(TUMT) is considered by the AUA guidelines as
effective in partially relieving LUTS secondary to
BPH and may be considered in men with moderate
or severe symptoms (option). The EAU guidelines
determine that TUMT is equivalent to TURP in
symptom improvement but has less morbidity. It
has lower flow improvements as well as higher
retreatment rates in TUMT compared to TURP (level
of evidence 1a, recommendation A).
Surgical procedures
The AUA guidelines recommended surgery for
patients who have renal insufficiency secondary
to BPH, who have recurrent urinary tract infections,
bladder stones or gross hematuria due to BPH, and
those who have LUTS refractory to other therapies
(recommendation). The guidelines also consider
that the open prostatectomy is an appropriate and
effective treatment alternative for men with mod-
erate to severe LUTS and/or who are significantly
bothered by these symptoms (option). The EAU
guidelines considered the open prostatectomy as
the first choice in men with LUTS refractory to
drugs, prostate sizes greater than 80–100 ml in the
absence of Holmium lasers (level of evidence 1b,
recommendation A).
Men with moderate to severe LUTS and/or who
are significantly bothered by these symptoms can
consider a laparoscopic or robotic prostatectomy.
There are insufficient published data on which to
base a treatment recommendation (AUA option).
According to the AUA guidelines, transurethral
laser enucleation with Holmium [holmium laser
resection of the prostate (HoLRP), holmium laser
enucleation of the prostate (HoLEP)], transurethral
ablation [holmium laser ablation of the prostate
(HoLAP), and photoselective vaporization (PVP)]
are considered effective treatment alternatives.
www.co-urology.com 37
 Benign prostatic hyperplasia
The choice of approach should be based on the
patient’s presentation, anatomy, the surgeon’s
level of training and experience, and a discussion
of the potential benefit and risks for complications
(option).
The EAU guidelines considered the HoLEP and
532 nm green light laser vaporization as minimally
invasive alternatives to TURP with improvements
comparable to TURP (level of evidence 1b, recom-
mendation A).
The intraoperative safety seems to be higher
with the 532 nm laser than the TURP and should
be considered in patients receiving anticoagulant
medication or with a high cardiovascular risk (level
of evidence 3, recommendation B).
Both guidelines considered the transurethral
incision of the prostate (TUIP) as an appropriate
and effective treatment alternative in men with
moderate to severe LUTS and/or who are signifi-
cantly bothered by these symptoms when prostate
size is less than 30 ml (AUA option) (EAU level of
evidence 1a, recommendation A).
Transurethral vaporization of the prostate
(TUVP) is an appropriate and effective treatment
alternative in men with moderate to severe LUTS
and/or who are significantly bothered by symptoms
and is considered only by the AUA guideline
(option).
The AUA guideline considered that the TURP is
an appropriate and effective primary alternative for
surgical therapy in men with moderate to severe
LUTS and/or who are significantly bothered by these
symptoms (option). The choice of a monopolar or
bipolar approach should be based on the patient
characteristics, anatomy, the surgeon’s experience
and discussion of the potential risks and likely
benefits [14].
The EAU consider the monopolar TURP as the
surgical standard procedure for men with prostate
sizes of 30–80 ml, benign prostatic obstruction and
moderate-to-severe LUTS (level of evidence 1a,
recommendation A). This procedure is considered
to be superior to medical and minimally invasive
therapies in improving symptoms but the morbidity
is higher. Bipolar TURP achieves short-term results
comparable to monopolar TURP (level of evidence
1a, recommendation A).
Intraurethral stents are considered an alterna-
tive for men with comorbidities as an alternative
to catheterization but the evidence is poor and
they are not recommended by the EAU guidelines
(level of evidence 3, recommendation C). The
AUA does not evaluate the role of the prostatic
stents.
Other treatments such as prostatic ethanol
injection and intraprostatic botulin injection are
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considered experimental and performed only in
clinical trials according to the EAU guidelines (level
of evidence 3, recommendation C).
FOLLOW-UP
The EAU guidelines state that patients under watch-
ful waiting should be viewed every 6 months and
assessed with IPSS and uroflowmetry with a post-
voidal residual volume measurement. Patients
under medical management with alpha-blockers
should be assessed after 1 month of initiating
therapy for evaluation of treatment success and
side-effects. In absence of important side-effects,
treatment should be continued. Patients under
alpha-blockers should be assessed every 6 months
with a IPSS and a uroflowmetry and a postvoid
residual volume. Patients receiving 5-ARIs should
be assessed at 12 weeks after initiating therapy and
then every 6 months with the same protocol as
alpha-blockers [5 ].
&&
Follow-up after surgery should be at 4–6 weeks
after removal of the catheter; at this visit a IPSS and a
uroflowmetry are recommended [5 ].
&&
The AUA CPGs do not state follow-up strategies.
CONCLUSION
Practice and documentation of evidence-based
clinical practice is an area of critical importance
for every urologist around the globe. Given the
enormous amount of literature that needs to be
reviewed by a urologist, and time is lacking, CPGs
are a wonderful resource for maintaining a urologist
practice up to date. Medicine has moved to an era in
which costs and quality of care are being scrutinized,
and compliance to CPGs will be assessed. It is the job
of the different urological associations to promote
the diffusion and use of these CPGs by practicing
urologists so that quality of care to patients with
LUTS and BPH can be achieved with the highest
standards.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 80–81).
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prostatic hyperplasia. Urol Clin North Am 2009; 36:443.
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prostatic hyperplasia. J Urol 2005; 173:1256.
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1803.
The most recent and well known study on AUA guidelines. A good recommenda-
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Guidelines on non-neurogenic treatment of male LUTS, European Association
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& patient preferences and satisfaction. Int J Clin Pract 2010; 64:1425–1435.
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www.co-urology.com 39