What is the best treatment for Lower Urinary Tract Symptoms (LUTS)?

Best Treatment for Lower Urinary Tract Symptoms (LUTS)

Alpha blockers should be offered as first-line treatment for patients with moderate to severe LUTS attributed to benign prostatic hyperplasia (BPH). 1

Initial Evaluation and Assessment

• Before initiating treatment, clinicians should perform a medical history, physical examination, International Prostate Symptom Score (IPSS) assessment, and urinalysis to confirm LUTS is attributed to BPH 1
• LUTS severity should be quantified using the IPSS, which evaluates both obstructive symptoms (impaired stream, incomplete emptying, intermittency) and irritative symptoms (nocturia, frequency, urgency) 1

Medical Therapy Algorithm

First-Line Treatment

• Alpha blockers (alfuzosin, doxazosin, silodosin, tamsulosin, or terazosin) should be offered as first-line treatment for patients with moderate to severe LUTS/BPH 1
  • Alpha blockers provide rapid symptom improvement (4-7 point reduction in IPSS compared to 2-4 points with placebo) 1
  • Clinical trials with tamsulosin showed significant improvements in total AUA Symptom Score and peak urine flow rate compared to placebo 2
  • Choice of alpha blocker should be based on patient age, comorbidities, and side effect profiles (e.g., ejaculatory dysfunction, blood pressure changes) 1

Alternative First-Line Option

• PDE5 inhibitors (tadalafil 5mg daily) should be discussed as a treatment option for patients with LUTS/BPH, particularly those with concurrent erectile dysfunction 1
  • Tadalafil 5mg daily has shown a mean change in IPSS of -5.4 points compared to -3.6 points with placebo 1
  • The percentage of treatment responders (≥3 point improvement) was significantly higher with tadalafil compared to placebo 1

Treatment Based on Prostate Size

• 5-alpha reductase inhibitors (5-ARIs) should be used as monotherapy or in combination with alpha blockers for patients with LUTS/BPH with prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement on DRE) 1
  • 5-ARIs alone or in combination with alpha blockers reduce the risk of disease progression, urinary retention, and need for prostate surgery 1, 3
  • Finasteride has shown a 51% reduction in risk of acute urinary retention or BPH-related surgery compared to placebo 3

For Predominant Storage Symptoms

• Anticholinergic agents, alone or in combination with an alpha blocker, may be offered to patients with moderate to severe predominant storage LUTS 1
• Beta-3-agonists in combination with an alpha blocker may be offered to patients with moderate to severe predominant storage LUTS 1

Combination Therapy

• Alpha blocker + 5-ARI combination should be offered only to patients with LUTS associated with demonstrable prostatic enlargement (>30cc on imaging, PSA >1.5ng/mL, or palpable enlargement) 1, 4

  • Large studies (MTOPS and CombAT) showed significant reductions in clinical progression with combination therapy over monotherapy 1

• Alpha blocker + anticholinergic combination may be offered to patients with moderate to severe predominant storage LUTS 1, 4

• Alpha blocker + beta-3-agonist combination may be offered to patients with moderate to severe predominant storage LUTS 1, 4

• Do not combine tadalafil with alpha blockers as this offers no advantages in symptom improvement over either agent alone 1

Follow-up and Monitoring

• Patients should be evaluated 4-12 weeks after initiating treatment to assess response to therapy 1
• For alpha blockers and other fast-acting medications, follow-up can be as early as 4 weeks; for 5-ARIs, waiting 3-6 months is advised 1
• Follow-up should include IPSS assessment and possibly post-void residual (PVR) measurement 1

Surgical Options When Medical Therapy Fails

• Surgery should be considered for patients with refractory symptoms despite medical therapy, urinary retention, recurrent UTIs, bladder stones, or gross hematuria due to BPH 1
• Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment 1, 5
• Newer minimally invasive options include laser enucleation procedures (HoLEP, ThuLEP) which are suitable regardless of prostate size 1

Common Pitfalls and Caveats

• When prescribing alpha blockers, inquire about plans for future cataract surgery due to risk of intraoperative floppy iris syndrome (IFIS) 1
• Patients should be informed about potential sexual side effects of 5-ARIs before starting therapy 1
• For patients on anticoagulation requiring surgery, consider HoLEP, PVP, or ThuLEP which have lower bleeding risks 1
• When using 5-ARIs, PSA values should be doubled for accurate interpretation to avoid delayed diagnosis of prostate cancer 1