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Management of Non-Neurogenic Female Lower Urinary Tract Symptoms (LUTS)

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Management of Non-Neurogenic Female Lower Urinary Tract Symptoms (LUTS) EAU Guidelines on Management of Non-Neurogenic Female Lower Urinary Tract Symptoms (LUTS) C.K. Harding (Chair), M.C. Lapitan (Vice-chair), S. Arlandis, K. Bø, E. Costantini, J. Groen, A.K. Nambiar, M.I. Omar, V. Phé, C.H. van der Vaart Guidelines Associates: F. Farag, M. Karavitakis, M. Manso, S. Monagas, A. Nic an Riogh, E. O’Connor, B. Peyronnet, V. Sakalis, N. Sihra, L. Tzelves © European Association of Urology 2021 TABLE OF CONTENTS PAGE 1. INTRODUCTION 10 1.1 Aim and objectives 10 1.2 Panel composition 10 1.3 Available publications 10 1.4 Publication history 11 2. METHODS 11 2.1 Introduction 11 2.2 Review 11 2.3 Future goals 11 3. DIAGNOSTIS 12 3.1 History and physical examination 12 3.1.1 Summary of evidence and recommendation for history taking and physical examination 12 3.2 Patient questionnaires 12 3.2.1 Summary of evidence and recommendations for patient questionnaires 13 3.3 Bladder diaries 13 3.3.1 Summary of evidence and recommendations for bladder diaries 13 3.4 Urinalysis and urinary tract infection 14 3.4.1 Summary of evidence and recommendations for urinalysis 14 3.5 Post-void residual volume 14 3.5.1 Summary of evidence and recommendations for post-void residual 14 3.6 Urodynamics 15 3.6.1 Variability 15 3.6.2 Diagnostic accuracy 15 3.6.3 Predictive value 16 3.6.4 Summary of evidence and recommendations for urodynamics 17 3.7 Pad testing 17 3.7.1 Summary of evidence and recommendations for pad testing 17 3.8 Imaging 18 3.8.1 Ultrasound 18 3.8.2 Detrusor wall thickness 18 3.8.3 MRI 18 3.8.4 Summary of evidence and recommendations for imaging 19 4. DISEASE MANAGEMENT 19 4.1 Overactive bladder 19 4.1.1 Epidemiology, aetiology, pathophysiology 19 4.1.2 Classification 19 4.1.3 Diagnostic evaluation 19 4.1.3.1 Bladder diaries 19 4.1.3.2 Urodynamics 19 4.1.3.3 Summary of evidence and recommendations regarding associated conditions 20 4.1.4 Disease management 20 4.1.4.1 Conservative management 20 4.1.4.1.1 Addressing underlying disease/cognitive impairment 20 4.1.4.1.1.1 Summary of evidence and recommendation regarding associated conditions 20 4.1.4.1.2 Adjustment of other medication 20 4.1.4.1.2.1 Summary of evidence and recommendations for adjustment of non-LUTS medication 21 4.1.4.1.3 Urinary containment 21 4.1.4.1.3.1 Summary of evidence and recommendations for urinary containment 22 4.1.4.1.4 Lifestyle interventions 22 2 MANAGEMENT OF NON-NEUROGENIC FEMALE LOWER URINARY TRACT SYMPTOMS (LUTS) - 2021 4.1.4.1.4.1 Caffeine intake 22 4.1.4.1.4.2 Fluid intake 22 4.1.4.1.4.3 Obesity and weight loss 22 4.1.4.1.4.4 Smoking 22 4.1.4.1.4.5 Summary of evidence and recommendations for lifestyle interventions 23 4.1.4.1.5 Behavioural and physical therapies 23 4.1.4.1.5.1 Prompted voiding and timed voiding 23 4.1.4.1.5.2 Bladder Training 23 4.1.4.1.5.3 Pelvic floor muscle training 23 4.1.4.1.5.4 Electrical stimulation 24 4.1.4.1.5.5 Acupuncture 24 4.1.4.1.5.6 Posterior tibial nerve stimulation 24 4.1.4.1.5.6.1 Percutaneous posterior tibial nerve stimulation 24 4.1.4.1.5.6.2 Transcutaneous posterior tibial nerve stimulation 24 4.1.4.1.5.7 Summary of evidence and recommendations for behavioural and physical therapies 24 4.1.4.2 Pharmacological management 25 4.1.4.2.1 Anticholinergic drugs 25 4.1.4.2.1.1 Comparison of different anticholinergic agents 26 4.1.4.2.1.2 Anticholinergic drugs vs. conservative treatment 27 4.1.4.2.1.3 Anticholinergic drugs: adherence and persistence 27 4.1.4.2.1.4 Summary of evidence and recommendations for anticholinergic drugs 28 4.1.4.2.2 Beta-3 agonists 28 4.1.4.2.2.1 Summary of evidence and recommendation for mirabegron 29 4.1.4.2.3 Anticholinergics and beta-3 agonists: the elderly and cognition 29 4.1.4.2.3.1 Applicability of evidence to the general elderly population 30 4.1.4.2.3.2 Anticholinergic burden 30 4.1.4.2.3.3 Summary of evidence and additional recommendations for use of anticholinergic drugs in the elderly 30 4.1.4.2.4 Oestrogens 31 4.1.4.2.4.1 Summary of evidence and recommendation for oestrogen therapy 31 4.1.4.3 Surgical management 31 4.1.4.3.1 Bladder wall injection of botulinum toxin A 31 4.1.4.3.1.1 Summary of evidence and recommendations for bladder wall injection of botulinum toxin A 32 4.1.4.3.2 Sacral nerve stimulation 32 4.1.4.3.2.1 Summary of evidence and recommendation for sacral nerve stimulation 33 4.1.4.3.3 Cystoplasty/urinary diversion 33 4.1.4.3.3.1 Augmentation cystoplasty 33 4.1.4.3.3.2 Detrusor myectomy (bladder auto-augmentation) 34 4.1.4.3.3.3 Urinary diversion 34 4.1.4.3.3.4 Summary of evidence and recommendations for cystoplasty/urinary diversion 35 4.1.5 Follow-up 35 4.1.5.1 Recommendations for follow-up of patients with overactive bladder 35 4.2 Stress Urinary Incontinence 36 4.2.1 Epidemiology, aetiology, pathophysiology 36 4.2.2 Classification 36 4.2.3 Diagnostic evaluation 36 4.2.3.1 History and physical examination 36 MANAGEMENT OF NON-NEUROGENIC FEMALE LOWER URINARY TRACT SYMPTOMS (LUTS) - 2021 3 4.2.3.1.1 Summary of evidence and recommendation for history and physical examination for SUI 37 4.2.3.2 Patient questionnaires 37 4.2.3.2.1 Summary of evidence and recommendation for patient questionnaires 37 4.2.3.3 Post-void residual volume 37 4.2.3.3.1 Summary of evidence and recommendations for post-void residual volume 37 4.2.3.4 Urodynamics 38 4.2.3.4.1 Summary of evidence and recommendations for urodynamics 38 4.2.3.5 Pad testing 39 4.2.3.5.1 Summary of evidence and recommendations for pad testing 39 4.2.3.6 Imaging 39 4.2.3.6.1 Summary of evidence and recommendation for imaging 40 4.2.4 Disease management 40 4.2.4.1 Conservative management 40 4.2.4.1.1 Obesity and weight loss 40 4.2.4.1.1.1 Summary of evidence and recommendation for obesity and weight loss 40 4.2.4.1.2 Urinary containment 40 4.2.4.1.2.1 Summary of evidence and recommendations for urinary containment 40 4.2.4.1.3 Pelvic floor muscle training 41 4.2.4.1.3.1 Efficacy of pelvic floor muscle training in stress urinary incontinence 41 4.2.4.1.3.2 Efficacy of electrical stimulation 41 4.2.4.1.3.3 Long-term efficacy of pelvic floor muscle training 42 4.2.4.1.3.4 Efficacy of pelvic floor muscle training in childbearing women 42 4.2.4.1.3.5 Pelvic floor muscle training in the elderly 42 4.2.4.1.3.6 Summary of evidence and recommendations for pelvic floor muscle training 43 4.2.4.1.4 Electromagnetic stimulation 43 4.2.4.2 Pharmacological management 43 4.2.4.2.1 Oestrogen 43 4.2.4.2.1.1 Summary of evidence and recommendations for oestrogens 44 4.2.4.2.2 Duloxetine 44 4.2.4.2.2.1 Summary of evidence and recommendations for duloxetine 44 4.2.4.3 Surgical management 45 4.2.4.3.1 General considerations 45 4.2.4.3.1.1 Recommendations for surgical treatment of SUI 46 4.2.4.3.2 Surgery for women with uncomplicated stress urinary incontinence 46 4.2.4.3.2.1 Open- and laparoscopic colposuspension surgery 46 4.2.4.3.2.1.1 Summary of evidence and recommendation for open- and laparoscopic colposuspension surgery for stress urinary incontinence 47 4.2.4.3.2.2 Autologous sling 47 4.2.4.3.2.2.1 Summary of evidence and recommendation for autologous sling 47 4.2.4.3.2.3 Urethral bulking agents 48 4.2.4.3.2.3.1 Summary of evidence and recommendations for urethral bulking agents 48 4.2.4.3.2.4 Mid-urethral slings 49 4 MANAGEMENT OF NON-NEUROGENIC FEMALE LOWER URINARY TRACT SYMPTOMS (LUTS) - 2021 4.2.4.3.2.4.1 Summary of evidence and recommendations for mid-urethral slings 52 4.2.4.3.2.5 Other treatments for uncomplicated SUI 53 4.2.4.3.2.5.1 Summary of evidence and recommendations for other treatments for uncomplicated SUI 53 4.2.4.3.3 Surgery for women with complicated stress urinary incontinence 53 4.2.4.3.3.1 Colposuspension or sling (synthetic or autologous) following failed primary SUI surgery 54 4.2.4.3.3.1.1 Summary of evidence for surgery in those with recurrent SUI following failed primary SUI surgery 54 4.2.4.3.3.2 Adjustable slings 55 4.2.4.3.3.2.1 Summary of evidence for adjustable slings 55 4.2.4.3.3.3 External compression devices 55 4.2.4.3.3.3.1 Summary of evidence for external compression devices 56 4.2.4.3.3.4 Recommendations for complicated stress urinary incontinence 56 4.2.4.3.4 Surgery for stress urinary incontinence in special patient groups 56 4.2.4.3.4.1 Stress urinary incontinence surgery in obese women 56 4.2.4.3.4.2 Stress urinary incontinence surgery in elderly women 56 4.2.4.3.4.3 Summary of evidence and recommendations for SUI surgery in special patient groups 57 4.2.5 Follow-up 57 4.3 Mixed urinary incontinence 57 4.3.1 Epidemiology, aetiology and pathophysiology 57 4.3.2 Diagnostic evaluation 58 4.3.2.1 Summary of evidence and recommendations for the diagnosis of mixed urinary incontinence 58 4.3.3 Disease Management 58 4.3.3.1 Conservative management 58 4.3.3.1.1 Pelvic floor muscle training in mixed urinary incontinence 58 4.3.3.1.2 Bladder training 59 4.3.3.1.3 Electrical stimulation 59 4.3.3.2 Summary of evidence and recommendations for conservative management in MUI 59 4.3.3.3 Pharmacological management 59 4.3.3.3.1 Tolterodine 59 4.3.3.3.2 Duloxetine 60 4.3.3.3.3 Summary of evidence and recommendations for pharmacological management of MUI 60 4.3.3.4 Surgical management 60 4.3.3.4.1 Summary of evidence and recommendations for surgery in patients with MUI 61 4.4 Underactive bladder 61 4.4.1 Epidemiology, aetiology, pathophysiology 61 4.4.1.1 Epidemiology 61 4.4.1.2 Aetiology 62 4.4.1.3 Pathophysiology 62 4.4.2 Classification 63 4.4.3 Diagnostic evaluation 63 4.4.3.1 Symptoms associated with detrusor underactivity 63 4.4.3.2 Urodynamic studies 63 MANAGEMENT OF NON-NEUROGENIC
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