What's the next step for a 58-year-old man with moderate to severe Lower Urinary Tract Symptoms (LUTS) and microscopic hematuria, who wants to preserve ejaculation?

From the Guidelines

For a 58-year-old man with moderate to severe LUTS and microscopic hematuria who wants to preserve ejaculation, the recommended next step is to start an alpha-blocker medication such as tamsulosin (Flomax) at 0.4 mg daily or silodosin (Rapaflo) at 8 mg daily, as suggested by the 2021 AUA guideline on management of benign prostatic hyperplasia 1.

Before initiating medication, he should undergo evaluation for the microscopic hematuria, including:

• Urine cytology
• Upper tract imaging (CT urogram or renal ultrasound)
• Cystoscopy to rule out bladder cancer or other urological conditions A PSA test should be performed if not done within the past year.

For ejaculation preservation, alfuzosin (Uroxatral) 10 mg daily may be preferred as it has a lower rate of ejaculatory dysfunction (10-28%) compared to tamsulosin (10-30%) or silodosin (28-75%) 1.

Alternatively, a 5-alpha reductase inhibitor like finasteride 5 mg daily could be considered, though it takes longer to work (3-6 months) and may cause erectile dysfunction or decreased libido 1.

Alpha-blockers work by relaxing smooth muscle in the prostate and bladder neck, improving urine flow within days to weeks.

Lifestyle modifications should accompany medication, including:

• Limiting evening fluids
• Avoiding caffeine and alcohol
• Practicing timed voiding

It's also important to note that the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms recommend offering prostatic urethral lift (Urolift) to men with LUTS interested in preserving ejaculatory function, with prostate volume <70 ml and no middle lobe 1.

However, based on the most recent and highest quality study, the initial treatment should focus on alpha-blocker medication and lifestyle modifications, with further evaluation and treatment options considered based on patient response and preferences.

From the FDA Drug Label

Patients in A Long-Term Efficacy and Safety Study had moderate to severe symptoms at baseline (mean of approximately 15 points on a 0 to 34 point scale). The improvement in BPH symptoms was seen during the first year and maintained throughout an additional 5 years of open extension studies. Finasteride tablets decreased prostate volume by 17.9% (from 55.9 cc at baseline to 45.8 cc at 4 years) compared with an increase of 14.1% (from 51.3 cc to 58.5 cc) in the placebo group (p<0.001).

The patient has moderate to severe Lower Urinary Tract Symptoms (LUTS) with an IPSS of 18 and a prostate size of 40 grams. Given the patient's desire to preserve ejaculation and the presence of microscopic hematuria, finasteride may be considered as a treatment option. However, the patient's hematuria should be further evaluated before initiating treatment.

• Finasteride can reduce the size of the prostate and improve symptoms of BPH.
• The patient's prostate size is within the range where finasteride has been shown to be effective.
• However, the presence of microscopic hematuria requires further evaluation to rule out other causes before starting finasteride therapy. Considering the information provided and the potential benefits of finasteride in reducing prostate size and improving BPH symptoms, the next step could be to evaluate the cause of the patient's hematuria and then consider finasteride (B) as a treatment option, while also considering other diagnostic steps such as cystoscopy (C) to evaluate the hematuria. 2 2

From the Research

Patient Profile

• Age: 58 years
• IPSS: 18 (moderate to severe Lower Urinary Tract Symptoms)
• Sexually active and wants to preserve ejaculation
• Prostate exam: 40 gram smooth prostate
• PVR: 20 mL
• PSA: 1.4 ng/mL
• Urinalysis: 4 RBC/HPF (microscopic hematuria)

Treatment Options

• The patient's symptoms and profile suggest the need for a treatment that balances the relief of LUTS with the preservation of sexual function, particularly ejaculation.
• Options include:
  • Alpha-blockers like tamsulosin, which can relieve LUTS but may have a risk of ejaculatory dysfunction 3.
  • 5-alpha reductase inhibitors like finasteride, which can reduce prostate volume and improve LUTS but are associated with a risk of erectile dysfunction, ejaculatory disorders, and decreased libido 4, 5, 6.
  • Other treatments like Prostatic Urethral Lift (UroLift) or water vapor thermal therapy, which may have different side effect profiles.

Considerations for Preserving Ejaculation

• Given the patient's desire to preserve ejaculation, treatments that have a lower risk of ejaculatory dysfunction may be preferred.
• Alpha-blockers other than tamsulosin might be considered, as they may have a lower risk of affecting ejaculation 3.
• The use of 5-alpha reductase inhibitors should be carefully considered due to their potential impact on sexual function, including ejaculation 4, 5, 6.

Next Steps

• Considering the patient's moderate to severe LUTS, microscopic hematuria, and desire to preserve ejaculation, a thorough evaluation of the risks and benefits of each treatment option is necessary.
• Further discussion with the patient about the potential side effects of each treatment and their impact on sexual function is crucial.
• Based on the provided evidence, options like tamsulosin (A) or finasteride (B) could be considered, but their potential effects on ejaculation must be weighed against their benefits for LUTS relief 3, 4, 5, 6.
• Other options like cystoscopy (C) might be necessary to investigate the cause of microscopic hematuria.
• Prostatic Urethral Lift (UroLift) (D) or water vapor thermal therapy (E) could be alternative treatments, but their suitability depends on various factors including prostate size and the patient's overall health status.