Urology · EAU

Benign prostatic hyperplasia

EAU

Source:EAU Guidelines on Management of Non-Neurogenic Male LUTS — Update April 2024

Verified Apr 2026

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Red Flags

Acute urinary retention with renal impairment, infection, or significant distress — same-day catheterisation; trial without catheter on alpha-blocker^[1]
Macroscopic haematuria, suspected prostate cancer (raised PSA, abnormal DRE) — separate diagnostic pathway^[1]
Recurrent UTI, bladder stones, refractory retention, hydronephrosis, or persistent residual >300 mL — surgical indication^[1]
Severe LUTS with renal impairment or acute on chronic retention — admit; avoid rapid decompression (post-obstructive diuresis)^[1]

First-line treatment

Interventions

Watchful waiting + lifestyle for mild symptoms^[1]
Reduce evening fluids, avoid caffeine and alcohol after evening, double voiding, bladder retraining, manage constipation; effective for IPSS ≤7
Combination medical therapy for moderate-severe symptoms^[1]
Alpha-blocker for symptom relief; add 5-alpha-reductase inhibitor for prostates >40 mL; combine with antimuscarinic or beta-3 agonist for OAB component; tadalafil 5 mg daily for combined LUTS+ED
Minimally invasive surgical therapy^[1]
Prostatic urethral lift, water vapour thermal therapy (Rezum), aquablation, prostate artery embolisation; outpatient or short-stay options for selected men
Standard surgical procedures^[1]
TURP — gold standard for prostates 30–80 mL. Holmium laser enucleation (HoLEP) — size-independent, lower bleeding. Photoselective vaporisation (GreenLight) — useful in anticoagulated. Simple prostatectomy — large prostates >80–100 mL

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tamsulosin or silodosin (alpha-blocker)^[1]	Selective alpha-1A adrenergic blocker	Tamsulosin 0.4 mg PO daily; silodosin 8 mg PO daily; alfuzosin XL 10 mg PO daily	—	First-line symptomatic; rapid onset; orthostatic hypotension; intraoperative floppy iris syndrome — inform ophthalmologist before cataract surgery
Finasteride or dutasteride (5-ARI)^[1]	5-alpha-reductase inhibitor	Finasteride 5 mg PO daily; dutasteride 0.5 mg PO daily	—	Add to alpha-blocker for prostate >40 mL; takes 6–12 months for full effect; reduces PSA by ~50% (interpret cancer screening); sexual side effects; teratogen
Tadalafil 5 mg (LUTS + ED)^[1]	PDE5 inhibitor	5 mg PO once daily	—	Daily-dose tadalafil approved for combined LUTS and ED; do not combine with nitrates
Antimuscarinic (solifenacin, tolterodine) for OAB component^[1]	Muscarinic antagonist	Solifenacin 5–10 mg PO daily; tolterodine ER 4 mg PO daily	—	Add for OAB symptoms when residual urine acceptable; check PVR before adding (caution if >150 mL); dry mouth, constipation
Mirabegron (beta-3 agonist) for OAB component^[1]	Beta-3 agonist	25–50 mg PO daily	—	Alternative to antimuscarinic; lower dry mouth burden; BP elevation; less anticholinergic side effects
Desmopressin (nocturnal polyuria)^[1]	Vasopressin analogue	60 µg sublingual nightly (women); 25 µg sublingual nightly (men); titrate	—	Selected nocturnal polyuria refractory to lifestyle; check sodium 1, 7, and 30 days, then 3-monthly; risk of hyponatraemia particularly elderly; avoid in HF, hypoalbuminaemia, anti-diuretic medications

Tamsulosin or silodosin (alpha-blocker)^[1]

Selective alpha-1A adrenergic blocker

Adult: Tamsulosin 0.4 mg PO daily; silodosin 8 mg PO daily; alfuzosin XL 10 mg PO daily
Paediatric: —

First-line symptomatic; rapid onset; orthostatic hypotension; intraoperative floppy iris syndrome — inform ophthalmologist before cataract surgery

Finasteride or dutasteride (5-ARI)^[1]

5-alpha-reductase inhibitor

Adult: Finasteride 5 mg PO daily; dutasteride 0.5 mg PO daily
Paediatric: —

Add to alpha-blocker for prostate >40 mL; takes 6–12 months for full effect; reduces PSA by ~50% (interpret cancer screening); sexual side effects; teratogen

Tadalafil 5 mg (LUTS + ED)^[1]

PDE5 inhibitor

Adult: 5 mg PO once daily
Paediatric: —

Daily-dose tadalafil approved for combined LUTS and ED; do not combine with nitrates

Antimuscarinic (solifenacin, tolterodine) for OAB component^[1]

Muscarinic antagonist

Adult: Solifenacin 5–10 mg PO daily; tolterodine ER 4 mg PO daily
Paediatric: —

Add for OAB symptoms when residual urine acceptable; check PVR before adding (caution if >150 mL); dry mouth, constipation

Mirabegron (beta-3 agonist) for OAB component^[1]

Beta-3 agonist

Adult: 25–50 mg PO daily
Paediatric: —

Alternative to antimuscarinic; lower dry mouth burden; BP elevation; less anticholinergic side effects

Desmopressin (nocturnal polyuria)^[1]

Vasopressin analogue

Adult: 60 µg sublingual nightly (women); 25 µg sublingual nightly (men); titrate
Paediatric: —

Selected nocturnal polyuria refractory to lifestyle; check sodium 1, 7, and 30 days, then 3-monthly; risk of hyponatraemia particularly elderly; avoid in HF, hypoalbuminaemia, anti-diuretic medications

Safety-net

Avoid sudden stopping of alpha-blocker before cataract surgery — tell your ophthalmologist about the medication^[1]
Inability to pass urine, severe lower abdominal pain or distension — same-day medical review for catheterisation^[1]
On 5-ARI: PSA halves over 6–12 months; if any rise from new nadir, investigate for prostate cancer^[1]

Referral criteria

Acute or chronic retention not relieved by trial without catheterUrology^[1]
Recurrent UTI, bladder stones, hydronephrosis, or persistent residual >300 mLUrology for surgical evaluation^[1]
Suspected prostate cancerUrology with multiparametric MRI prostate^[1]
Failure of medical therapy after 3–6 months at adequate doseUrology for surgical / MIST evaluation^[1]

Clinical summary

Diagnosis and stepwise medical and surgical management of male non-neurogenic lower urinary tract symptoms attributed to BPH per EAU guidance.

References

1.EAU Guidelines on Management of Non-Neurogenic Male LUTS — Update April 2024 (2024)

Drug

Class

Adult

Paediatric

Notes