Is the patient still experiencing post-void dribbling while on Tamsulosin (0.4mg) and Tadalafil (5mg)?

From the Guidelines

For persistent urinary dribbling despite tamsulosin 0.4mg and tadalafil 5mg, I recommend stopping tadalafil 5mg as it offers no advantages in symptom improvement over alpha blockers alone, as suggested by the AUA guideline 1. The patient's current regimen includes a combination of an alpha-blocker (tamsulosin) and a phosphodiesterase inhibitor (tadalafil), which, according to the guideline, does not provide additional benefits for LUTS/BPH symptoms compared to using either agent alone 1. Considering the patient's ongoing symptoms, the focus should shift towards optimizing the alpha-blocker therapy and introducing behavioral modifications. Some potential next steps include:

• Increasing the dose of tamsulosin to 0.8mg daily if tolerated, to potentially improve smooth muscle relaxation in the prostate and bladder neck.
• Switching to a different alpha-blocker like alfuzosin 10mg daily, which might offer a better therapeutic profile for the patient.
• Implementing behavioral changes such as double voiding, pelvic floor exercises, scheduled voiding every 2-3 hours, reducing evening fluid intake, and avoiding caffeine and alcohol. If symptoms persist after these adjustments, a thorough urological evaluation is necessary to rule out other underlying causes that might require procedural intervention, such as detrusor overactivity, urethral stricture, or more severe bladder outlet obstruction. Additionally, techniques like urethral milking could be beneficial for post-void dribbling, by gently pressing along the urethra after urination to expel remaining urine. The goal is to maximize symptom control while minimizing potential side effects, and the approach should be tailored to the individual patient's response and needs, as guided by the most recent and highest quality evidence available 1.

From the Research

Patient Response to Tamsulosin and Tadalafil

The patient is still experiencing urine dribble while on Tamsulosin 0.4 and Tadalafil 5mg.

• The studies suggest that Tamsulosin is effective in improving lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) 2, 3, 4.
• Tadalafil 5mg has been compared to Tamsulosin 0.4mg in the treatment of LUTS secondary to BPH, and the results show that Tamsulosin has better efficacy than Tadalafil in treating LUTS secondary to BPH 5.
• Tamsulosin has been shown to improve maximum urine flow (Qmax) and reduce postvoid residual urine (PVR) in patients with LUTS associated with BPH 2, 3.
• The combination of Tamsulosin and Tadalafil may have additive effects on improving LUTS, but the current evidence does not provide clear guidance on the optimal dosage and duration of treatment for this combination.

Adverse Events and Interactions

• The most common adverse events associated with Tamsulosin are dizziness, abnormal ejaculation, and asthenia 2, 3.
• Tadalafil is generally well-tolerated, but it can cause adverse events such as headache, dyspepsia, and back pain.
• There is no significant interaction between Tamsulosin and Tadalafil, but the combination may increase the risk of hypotension and other adverse events.

Treatment Outcomes

• The patient's persistent urine dribble despite treatment with Tamsulosin and Tadalafil may indicate the need for further evaluation and adjustment of the treatment plan.
• The patient's response to treatment should be monitored regularly, and adjustments to the dosage or addition of other medications may be necessary to achieve optimal results 5, 6.