Urinary Symptoms and Prostate Enlargement in Men: The 2026 Guideline Update

Frequent urination, getting up at night to urinate, a weak or interrupted flow, dribbling after urination and a sense of urgency are common symptoms, especially in men over 50. These symptoms are often linked only to prostate enlargement. However, the European Association of Urology (EAU) guideline on lower urinary tract symptoms in men approaches the problem not only through the prostate but through the symptoms and all their possible causes. In this article we summarise the main points of the update published in March 2026.

Is the prostate the only cause of urinary symptoms in men?

No. The guideline stresses that, as well as prostate enlargement and the obstruction it causes, lower urinary tract symptoms can be linked to many causes, such as an overactive bladder, weak contraction of the bladder muscle, a narrowing of the urethra, producing too much urine at night, stones and certain medicines. In the guideline’s words, it is common for more than one of these causes to be present at the same time in a man with urinary symptoms.

For this reason, the assessment is made through questions about the symptoms, validated questionnaires such as the IPSS prostate score, an examination, a urine test, urine flow measurement and measurement of the amount of urine left in the bladder after passing urine. In the 2026 edition, a new subsection on prostate cancer was also added to the diagnosis chapter: it is pointed out that prostate cancer can be found incidentally in more than 5% of patients who have surgery for prostate enlargement.

Do men with mild symptoms need treatment?

According to the guideline, monitoring is a suitable option for many men whose symptoms are not bothersome. In one study cited, about 85% of men with mild symptoms were reported to have remained stable under monitoring at the end of one year. The advice given during monitoring includes:

• Adjusting fluid intake in the evening or before going out
• Cutting down on caffeine and alcohol
• Relaxed and double voiding (trying again shortly after passing urine)
• Stroking the urethra from the base of the penis towards the tip to prevent dribbling after urination
• Distraction techniques during urgency, and bladder training

For getting up at night to urinate, see our article on nocturia (waking at night to urinate).

What has changed for beta-3 agonist medicines?

Beta-3 agonists are a group of medicines that help the bladder muscle to relax and aim to reduce storage symptoms such as frequent urination, a sense of urgency and urge incontinence. In the 2026 update, the strength of recommendation for these medicines was updated, and the guideline gives the use of beta-3 agonists in men with moderate to severe storage symptoms a strong recommendation.

Things to know:

• These medicines can raise blood pressure; it is recommended that blood pressure is measured before and during treatment, and they are not used in severe, uncontrolled high blood pressure.
• In studies, the change in the amount of urine left in the bladder was found to be small.
• The guideline states that long-term efficacy and safety studies in men are not yet available, and that further evidence in men is awaited for the newer medicines in the group.

The doctor decides which medicine is suitable, according to the type of symptoms, prostate volume, other conditions and the other medicines being taken.

What is a weak bladder (detrusor underactivity), and how is it managed?

Detrusor underactivity means that the bladder empties slowly or incompletely because the bladder muscle cannot contract with enough strength or for long enough. Because its symptoms (a slow flow, passing urine taking a long time, a feeling of incomplete emptying) are very similar to prostate obstruction, it can only be told apart with urodynamics (a pressure-flow study). The guideline reports that it is found in about 10% of men referred for urodynamics, and in up to 48% of those over 70.

According to the new management pathway added to the 2026 edition:

• If there is also prostate obstruction, the prostate treatment algorithm is followed; patients are informed about the possible benefits of surgery.
• If there is no obstruction and the urine left in the bladder is between 150 and 300 mL, monitoring with yearly ultrasound and blood tests can be carried out; for patients who want treatment, intermittent catheterisation is discussed and a 4–12-week trial of an alpha-blocker can be recommended.
• If the urine left in the bladder is above 300 mL, the patient is taught intermittent self-catheterisation; for those who cannot do this, a long-term catheter (preferably through the lower abdomen) is considered. Behavioural advice such as double voiding and relaxing the pelvic floor muscles, and a trial of an alpha-blocker, are also among the options.
• If these steps do not bring results, a trial of sacral neuromodulation is listed as an option.

The guideline recommends explaining clearly to patients that the evidence on the effectiveness of these treatments is limited.

What was presented at the congress for people who use intermittent catheters?

At the EAU26 congress in London, two randomised trials were presented showing that in patients who use intermittent self-catheterisation, catheters that can be washed and reused were not worse than single-use catheters in terms of urinary tract infection. In the COMPaRE trial from the Netherlands, mild irritation of the urethra was more common with reused catheters; in the MultICath trial from the UK, problems with the catheters sticking were reported more often. These results do not mean that this is suitable for every patient; the type of catheter should be chosen together with the doctor and nurse.

Why do young men get urinary symptoms?

A new section dedicated to young men was added to the 2026 edition. According to the guideline, up to 20% of men younger than 50 report moderate or more severe symptoms. In this age group, two functional causes stand out: the bladder neck not opening enough during urination, and the external muscles being unable to relax while passing urine. The symptoms often last for years and may come with chronic pelvic pain and recurrent urinary tract infections.

The guideline recommends video-urodynamics for diagnosis in these cases; for treatment, it states that alpha-blockers for the bladder neck problem, and behavioural therapy and biofeedback for the problem of the muscles not relaxing, should be considered as the first choice (weak recommendation).

What are the new recommendations on urinary incontinence in men?

Recommendations on the diagnosis and conservative treatment of urinary incontinence in men were added to the guideline. For the assessment, a detailed history, examination, a validated questionnaire, a bladder diary, a pad weight test and measurement of the urine left in the bladder after passing urine are given strong recommendations. Lifestyle changes, bladder training and a review of medicines are also among the recommendations. For details, see the urinary incontinence page.

At the American Urological Association (AUA) meeting in May 2026, it was also emphasised that shared decision-making in the treatment of prostate enlargement matters, with symptom relief, preservation of sexual function and the durability of the result considered together.

When should you see a urologist?

An assessment is advisable if your urinary symptoms are affecting your daily life or your sleep, if your urine flow has become markedly weaker, if you are leaking urine, or if you have blood in your urine, recurrent infections or a history of stones. If you are unable to pass urine at all, go to the emergency department without waiting. For treatment options, see the enlarged prostate treatment page. Keeping a bladder diary for 2–3 days before your appointment and bringing a list of the medicines you take makes the assessment easier.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions and reports by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.

Sources

• EAU Guidelines on Management of Non-neurogenic Male LUTS 2026 – Full text (PDF)
• EAU Guidelines on Management of Non-neurogenic Male LUTS 2026 – Summary of changes
• EAU26 Highlights: Day 1 – Uroweb (COMPaRE trial)
• Single-Use vs Reusable Catheters for Intermittent Catheterization in Patients With Urinary Retention: The COMPaRE Randomized Clinical Trial (JAMA Netw Open 2026) – UroToday
• Review of the European Association of Urology (EAU) Congress 2026 – European Medical Journal (MultICath trial)
• A field on the move – AUA Daily News (AUA2026)