Introduction: The EAU guideline Management of Non-Neurogenic Male LUTS gives the advice for lifestyle changes and to promote self-management in male patients with uncomplicated LUTS. This is based on a British study were a group intervention aimed at promoting self-management was compared to watchful waiting (1). That study showed that in the self-management group, men had less treatment failure defined as an increase in IPSS of 3 points, use of medication or surgery related to LUTS or an acute urine retention. 
The content of the intervention was solely based on consensus of urologists and therefore not evidence-based. Also, the practical application in daily practice may be hampered by the group approach, including nurse guidance. This may also lead to patients getting advices or information that do not apply to them, even though we know that patients are best served by improving their main complaint (2).
Aim: To develop an online intervention that gives personalized lifestyle and self-management advice, based on scientific literature and the opinion of urologists and general practitioners (GPs).

Study design: Scoping review, and survey among urologists and GPs.
Materials and method: For the scoping review we searched Embase and Pubmed databases for literature about self-management in LUTS patients till March 2017. Two independent researchers screened each publication, and also checked the reference list of included articles for relevant publications. After identifying possible components for a self-management program, literature was searched for evidence for that specific component. 
The different components usable in a self-management program found in the scoping review (see results) were used in a questionnaire, distributed among urologists (in training) and GPs (in training). The questionnaire was constructed as follows: a summary of the available literature with level of evidence and level of recommendation; the question if this component should be incorporated in an online intervention; and if yes, the question if the advice should be given to each male patient with uncomplicated LUTS or to a specific subgroup. At the end we asked if participants missed a component. Participants were also able to inspect the full evidence table for a component if they wished. 
The Dutch society for urologists distributed the questionnaire through e-mail, among all urologists (in training), requesting them to fill in the questionnaire. For GPs (in training) distribution was done using the contacts of our department of general practice. Additionally, we personally approached GPs and urologists. For analysis, IBM SPSS version 25 was used.

Results: The primary search of scoping review yielded 828 publications. Final selection included 25 publications covering nine components that could be used in a self-management program: 1) giving information and education about symptoms, 2) pelvic floor muscle training (PFMT), 3) bladder training, 4) urethral milking, 5) double voiding, 6) caffeine management, 7) alcohol management, 8) fluid management, and 9) exercise advice. Only for four of the nine components there was scientific evidence from one or more intervention studies: giving information and education about symptoms, PFMT, urethral milking, and caffeine management. The level of evidence for each of these components was level 2. The other five components were based on observational studies or indirect comparisons only (Table 1). 
The survey was fully completed by 136 of 175 participating physicians (completion rate 78%); 63 GPs (in training) and 73 urologist (in training). The responses to the question if each component should be included in a self-management program are presented in Table 1. The participants positively judged on seven of the nine components (more than 50% positive). The component “double voiding” was collectively rejected (80% negative, neutral or no opinion). Fluid management was rejected by the GPs, but accepted by the urologists (24% vs 62% positive).
On the question if every patient with LUTS should receive the component, a positive response was registered by 85% for information and education, 71% for caffeine management, 79% for alcohol management and 64% for fluid management. For the other components it was around 50% for every patient and 50% for a specific group of patients. If we look at the answers for which specific group, most common answer is: “PFMT” for patients with post void dribbling and incontinence; “bladder training” for patients with storage problems and frequent micturition; “urethral milking” for patients with post void dribbling; and “exercise advice” for patients with overweight (BMI above 30).
In the final question, 37% of the participants suggested that a component should be added to the intervention. Most mentioned component was voiding position (standing versus sitting). We sought for additional evidence for this component and found a recent systematic review (3). From this review it appeared that no evidence is available to support this advice.

Interpretation of results: In this study we found nine possible components for a new online intervention on self-management for men with uncomplicated LUTS. It appeared that the level of evidence for these components was low. Despite this, eight components were considered as relevant by urologist, urology trainees, GPs and GP trainees. For another self-management advice, suggested by many of the participants in this survey, we found no evidence to support the advice.
The discrepancy between (lack of) evidence and positive recommendations given by physician may reflect strong opinions about the separate parts of self-management advices, which may be part of routine daily care. Notably, the absence of evidence for these advises doesn’t equal the presence of evidence against these advices.
Participants were consentient that information and education, caffeine, alcohol and fluid management should be given to each patient with LUTS. For the other components around 50% of the participants found that it should only be given to a specific subgroup. This supports the provision of personalized care.

Concluding message: In the absence of evidence for self-management advices, the majority of physicians (both urologists and GPs) advocated the implementation of these advices in a new online self-management program. Parts of this program will be available for all patients, whereas other parts may be suited for individual patients. For this, the program will focus on individual complaints, based on symptom type and severity, bladder diaries, and other patient characteristics.
We are now studying the impact of this intervention in men referred to secondary care, by ways of comparing it to routine outpatient care.

Brown CT, Yap T, Cromwell DA, et al. Self management for men with lower urinary tract symptoms: Randomised controlled trial. BMJ. 2007;334(7583):25.
Lee SW, Doo SW, Yang WJ, Song YS. Importance of relieving the most bothersome symptom for improving quality of life in male patients with lower urinary tract symptoms. Urology. 2012;80(3):684-687.
de Jong Y, Pinckaers JH, ten Brinck RM, Lycklama a Nijeholt AA, Dekkers OM. Urinating standing versus sitting: Position is of influence in men with prostate enlargement. A systematic review and meta-analysis. PLoS One. 2014;9(7):e101320.