What are the causes of Lower Urinary Tract Symptoms (LUTS)?

From the Guidelines

Lower urinary tract symptoms (LUTS) are best managed with a combination of lifestyle modifications and medications tailored to the specific symptoms, as recommended by the 2023 European Association of Urology guidelines 1. For men with benign prostatic hyperplasia (BPH)-related LUTS, alpha-blockers like tamsulosin (0.4mg daily) are first-line treatments, providing rapid symptom relief within days to weeks. For larger prostates, 5-alpha reductase inhibitors such as finasteride (5mg daily) or dutasteride (0.5mg daily) can be added, though they take 3-6 months for full effect. Some key points to consider in the management of LUTS include:

• The importance of lifestyle modifications, such as limiting fluid intake before bedtime, reducing caffeine and alcohol consumption, practicing timed voiding, and performing pelvic floor exercises.
• The use of medications, such as alpha-blockers and 5-alpha reductase inhibitors, to alleviate symptoms.
• The need for urological referral for possible surgical intervention in men with significant post-void residual urine or urinary retention. These symptoms occur due to either bladder outlet obstruction from prostate enlargement or detrusor muscle overactivity/underactivity, with aging being the primary risk factor for both conditions, as discussed in the 2021 AUA guideline on management of lower urinary tract symptoms attributed to benign prostatic hyperplasia 1. It is also important to note that the management of LUTS should be individualized, taking into account the patient's values and preferences, as well as the presence of any underlying medical conditions, as emphasized in the 2013 evaluation and treatment of lower urinary tract symptoms in older men 1. Overall, the goal of treatment is to improve symptoms, reduce morbidity, and enhance quality of life, as highlighted in the 2023 European Association of Urology guidelines 1.

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). Patients randomized to finasteride tablets who remained on therapy for 4 years had a mean (± 1 SD) decrease in symptom score of 3.3 (± 5. 8) points compared with 1.3 (± 5.6) points in the placebo group. A statistically significant improvement in symptom score was evident at 1 year in patients treated with finasteride tablets vs placebo (-2.3 vs -1.6), and this improvement continued through Year 4. The improvement in BPH symptoms was seen during the first year and maintained throughout an additional 5 years of open extension studies. Symptoms were quantified using a score similar to the American Urological Association Symptom Score, which evaluated both obstructive symptoms (impairment of size and force of stream, sensation of incomplete bladder emptying, delayed or interrupted urination) and irritative symptoms (nocturia, daytime frequency, need to strain or push the flow of urine) by rating on a 0 to 5 scale for six symptoms and a 0 to 4 scale for one symptom, for a total possible score of 34.

LUTS (Lower Urinary Tract Symptoms) can be alleviated with finasteride tablets. The symptoms include:

• Obstructive symptoms:
  • Impairment of size and force of stream
  • Sensation of incomplete bladder emptying
  • Delayed or interrupted urination
• Irritative symptoms:
  • Nocturia
  • Daytime frequency
  • Need to strain or push the flow of urine Finasteride tablets have been shown to decrease the symptom score by a mean of 3.3 points after 4 years of treatment, compared to 1.3 points in the placebo group 2. The improvement in symptoms was evident at 1 year and continued through Year 4.

From the Research

Definition and Prevalence of LUTS

• Lower Urinary Tract Symptoms (LUTS) are a spectrum of symptoms that may or may not be due to benign prostatic obstruction (BPO) 3.
• LUTS are common, causing significant bother and impair quality of life, and are divided into storage, voiding or post micturition symptoms 3.

Treatment Options for LUTS

• alpha(1)-Adrenoceptor antagonists are now well established as the most common treatment for LUTS suggestive of bladder outflow obstruction associated with benign prostatic hyperplasia 4.
• Tamsulosin is a subtype-selective alpha(1A)- and alpha(1D )-adrenoceptor antagonist that is effective in patients with mild to severe LUTS associated with BPH 5.
• Other treatment modalities are available, including 5alpha-reductase inhibitors, watchful waiting, behavioral and dietary modifications, and surgery to relieve BPO 4, 3.

Efficacy and Safety of alpha-Blockers

• alpha-Blockers, such as tamsulosin, alfuzosin, and silodosin, are effective in improving urinary flow and reducing symptoms of LUTS 5, 4, 6.
• The most commonly reported adverse effects of alpha-blockers are dizziness, asthenia, postural hypotension, and syncope 4.
• Silodosin is a highly selective alpha(1A)-receptor antagonist that is well-tolerated and has minimal effects on blood pressure 6.

Combination Therapy for LUTS

• Initial combined treatment of alpha-blocker plus anticholinergic agent may be effective in improving storage symptoms in men with LUTS and overactive bladder 7.
• However, dose modification may be necessary to prevent adverse events, such as dry mouth and acute urinary retention 7.