Over the past three decades, there has been a concerted effort by many medical organizations to create clinical practice guidelines (CPGs) across a wide spectrum of conditions and diseases. Ultimately, CPGs are designed to maximize patient quality of life and outcomes and to minimize adverse events and patient burden. Guidelines are not mandates or commandments nor should they be interpreted as absolutes. Nevertheless, they can augment clinical expertise in delivery of more optimal results.

The authors herein review the journey undertaken by the European Association of Urology (EAU) in the initial creation of, modification and adoption of CPG’s for men with voiding symptoms. Most significantly, terms evolved from benign prostatic hyperplasia (BPH) to male lower urinary tract symptoms (LUTS) and finally adding the modifier ‘non-neurogenic”. These iterations were designed in part to provide a more robust data repository which accurately reflects the multifactorial nature of LUTS as men age. This is contrast to the American Urological Association (AUA) guidelines (full disclosure: I have been a member of the AUA BPH Guidelines Committee for over 15 years) which have maintained the term BPH since 1994. While arguments can be made on either side of the Atlantic on terminology, for the most part there is significant overlap in analysis and recommendations.

Moreover, despite advances in science and technology, the health care delivery system fails to consistently provide QUALITY medical care to patients. How do we assess quality? What outcomes are important when defining quality? And ultimately, do CPGs help or matter? Finally, there are numerous internal barriers including awareness, familiarity and agreement.

The challenge in creating CPGs is the quality of evidence that is analyzed. Ultimately, it’s what you put into the data blender that determines the quality of the guideline recommendations. In a recent study, it appears that the strength of evidence correlated with recommendation levels [1]. Of 939 statements across 29 AUA guidelines in 2021, the levels of evidence were: Grade A: 39 (4.2%), Grade B: 188 (20%), Grade C: 297 (31.6%), Clinical Principle: 185 (19.7%) and Expert Opinion: 230 (24.5%). Oncology has more Grade A and less Grade C; diagnosis and evaluation more likely based on Clinical Principle, strong recommendations more likely supported by high – grade evidence and most of the evidence for AUA Guidelines in NOT high grade.

In summary, the EAU should be commended for their focus and long-standing commitment to the creation of meaningful CPG’s. As in the AUA CPG process, lots of time, effort and focus is spent in the creation and modification of CPG’s with the hope of continued improvement in urologic care. Looking into the future, use of technology and remote care / diagnosis will help in improving access and hopefully improve long term care in the management of men with LUTS and BPH.