What is the cause of recurrent Lower Urinary Tract Symptoms (LUTS) in a patient with Benign Prostatic Hyperplasia (BPH) taking Cialis (Tadalafil) and Tamsulosin, after initial improvement?

From the Guidelines

For a patient experiencing recurrence of lower urinary tract symptoms (LUTS) after initial improvement on Cialis (tadalafil) and tamsulosin for benign prostatic hyperplasia (BPH), I recommend a thorough reassessment of the patient's condition, focusing on medication adherence, potential disease progression, and the possibility of urinary tract infection, bladder stones, or bladder dysfunction, as suggested by the 2023 European Association of Urology guidelines 1.

Initial Steps

• Evaluate medication adherence as non-compliance is a common cause of symptom recurrence.
• Consider increasing the tamsulosin dose from 0.4mg to 0.8mg daily if the patient is on the lower dose.
• Adding a 5-alpha reductase inhibitor such as finasteride 5mg daily or dutasteride 0.5mg daily to the current regimen may be beneficial, as these medications reduce prostate size over 3-6 months and complement the relaxation of smooth muscle provided by tamsulosin and Cialis 1.

Diagnostic Considerations

• Urinalysis, post-void residual measurement, and possibly uroflowmetry should be performed to rule out urinary tract infection, bladder stones, or bladder dysfunction.
• The role of diagnostic tests such as pressure-flow urodynamic studies, urethrocystoscopy, and ultrasound (transrectal or transabdominal) should be considered, especially if invasive therapies are being contemplated, as per the AUA guideline on management of BPH 1.

Treatment Optimization

• If symptoms persist despite optimization of medical therapy, urological referral for consideration of minimally invasive procedures may be necessary.
• Lifestyle modifications should also be reinforced, including fluid restriction in the evening, limiting caffeine and alcohol, and double voiding techniques.
• The use of combination therapy, such as an alpha-blocker with an anticholinergic, may be considered for patients with both voiding and storage lower urinary tract symptoms, as supported by recent studies 1.

Conclusion is not allowed, so the response ends here.

From the FDA Drug Label

The symptoms associated with benign prostatic hyperplasia (BPH) are related to bladder outlet obstruction, which is comprised of two underlying components: static and dynamic. The static component is related to an increase in prostate size caused, in part, by a proliferation of smooth muscle cells in the prostatic stroma However, the severity of BPH symptoms and the degree of urethral obstruction do not correlate well with the size of the prostate. The dynamic component is a function of an increase in smooth muscle tone in the prostate and bladder neck leading to constriction of the bladder outlet Smooth muscle tone is mediated by the sympathetic nervous stimulation of alpha 1 adrenoceptors, which are abundant in the prostate, prostatic capsule, prostatic urethra, and bladder neck. Blockade of these adrenoceptors can cause smooth muscles in the bladder neck and prostate to relax, resulting in an improvement in urine flow rate and a reduction in symptoms of BPH

The cause of recurrent Lower Urinary Tract Symptoms (LUTS) in a patient with Benign Prostatic Hyperplasia (BPH) taking Cialis (Tadalafil) and Tamsulosin, after initial improvement, cannot be directly determined from the provided drug labels.

• The provided information discusses the mechanism of action of Tamsulosin and Tadalafil, but does not specifically address the cause of recurrent LUTS in patients with BPH taking these medications.
• No conclusion can be drawn regarding the cause of recurrent LUTS in this patient population based on the provided drug labels 2 3.

From the Research

Possible Causes of Recurrent LUTS

• The exact cause of recurrent Lower Urinary Tract Symptoms (LUTS) in a patient with Benign Prostatic Hyperplasia (BPH) taking Cialis (Tadalafil) and Tamsulosin after initial improvement is not explicitly stated in the provided studies 4, 5, 6, 7, 8.
• However, it can be inferred that the combination of Tadalafil and Tamsulosin may not be effective for all patients, and the recurrence of LUTS may be due to various factors such as the progression of BPH, changes in the patient's condition, or the development of tolerance to the medications 6, 8.

Factors Affecting Treatment Efficacy

• The efficacy of the combination therapy may be influenced by the dose and type of phosphodiesterase-5 inhibitors (PDE-5) used, as well as the presence of erectile dysfunction (ED) 6.
• The study by 6 suggests that sildenafil combined with Tamsulosin may be the most effective and tolerated treatment option for BPH-LUTS with or without ED.
• However, the study by 8 found that the combination of Tamsulosin and PDE-5 inhibitors had superior outcomes in terms of IPSS and Qmax compared to monotherapy, but also had higher adverse events.

Treatment Outcomes

• The combination of Tadalafil and Tamsulosin may improve LUTS and ED in patients with BPH, but the treatment outcomes may vary depending on the individual patient's condition and response to the medications 5, 8.
• The study by 7 found that the combination of dutasteride and Tamsulosin improved LUTS to a significantly greater extent than dutasteride or Tamsulosin alone in men with BPH and moderate to severe LUTS.