Medical management of lower urinary tract symptoms in men with benign prostatic enlargement

With the high prevalence of bothersome lower urinary tract symptoms (LUTS) in older men, clinical management has to be fairly simple and straightforward. In the absence of severe problems requiring immediate action, and after excluding possible other etiological factors by a simple diagnostic algorithm, the key parameter for therapeutic decisions is the severity of LUTS, in particular the degree of annoyance and irritation, and prostatic enlargement. Patients with bothersome LUTS request rapid improvement but also worry about possible deterioration, complications, and the need for surgery. With a prostate volume above 30-40 mL and/or prostate-specific antigen (PSA) serum >1.5 ng/mL, the combination of an alpha-1 blocker with a 5-alpha-reductase inhibitor (5-ARI) should be first-line treatment. With prostates <30 mL at baseline the issue whether the prostate really is the culprit becomes central. Given the rapid onset of action of alpha-1 blockers, a 4-6-week trial appears to be a logical approach. If the International Prostate Symptom Score does not improve and storage symptoms prevail, an overactive bladder appears more likely as causative factor and antimuscarinics are the next step. Based on available data this is recommended as add-on medication to the alpha-1 blocker. With no improvement, or increasing postvoid residual the diagnostic algorithm needs to be revisited and more extensive urodynamic evaluation may be needed.