Initial choices and final outcomes in lower urinary tract symptoms

Management of lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) requires careful thought so that the most appropriate treatment can be targeted to each individual patient. Initial choices in the management of LUTS/BPH include watchful waiting, medical therapies and surgical interventions. A decision on treatment choice should be taken together with the patient. It should be based on the best available scientific evidence but also be individualised to patients' circumstances and personal choices. Management of LUTS/BPH should be focused on the burden and impact of urinary symptoms and related quality of life. The rate of treatment failure, which can be assessed through the switch to other medical therapy or surgery and/or the delay or prevention of complications related to LUTS/BPH, is also important. Beneficial effects of treatment should be balanced against the incidence of adverse events associated with therapy. Medical therapy has been shown to be effective in improving short-term outcomes (maximum urinary flow rate and symptom scores). Increasing evidence indicates that in the long-term more selective alpha(1)-adrenoceptor (AR) antagonists such as alfuzosin and tamsulosin may reduce the risk of treatment failure with a comparable rate to finasteride. Although the different alpha(1)-AR antagonists are equivalent in efficacy they differ in tolerability with the subtype selective tamsulosin having the lowest risk for interference with blood pressure regulation. Transurethral resection of the prostate (TURP) improves storage symptoms to a lesser extent and/or more slowly than it improves voiding symptoms. In contrast, alpha(1)-AR antagonists improve both voiding and bothersome storage symptoms to the same extent and quite rapidly which has a considerable impact on quality of life. alpha(1)-AR antagonists also relieve storage symptoms to almost the same extent as TURP. Ultimately the initial choice of treatment will depend upon its efficacy, speed of onset, durability, tolerability and on patients' choice. For the majority of patients with moderate to severe symptoms a subtype selective alpha(1)-AR antagonist such as tamsulosin offers the best current combination of efficacy and tolerability.