Achieving the Total Approach in Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia (LUTS/BPH) Management

Abstract

Patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) seek medical advice because they are bothered by their urinary symptoms. In addition, these patients may in the long-term progress symptomatically (approximately 75% of LUTS/BPH patients) and may develop serious complications such as acute urinary retention (AUR) and/or may ultimately need prostatic surgery. However, not all patients are at the same risk of progression and, therefore, need the same total treatment approach. For patients at low risk, the goal of LUTS/BPH treatment is to provide rapid and sustained improvement of symptoms and quality of life (QoL) with minimal morbidity. For patients at intermediate or high risk, treatment should additionally delay or prevent disease progression. Newer, more selective α 1-adrenoceptor (AR) antagonists, such as tamsulosin, provide rapid (within days) and durable symptom relief in a wide variety of LUTS/BPH patients with a low potential for (cardiovascular) adverse events. In patients at low-intermediate risk of progression (i.e. small-intermediate prostate volume/low-intermediate prostate specific antigen (PSA)), they also reduce the incidence of AUR. Newer, more selective α 1-AR antagonists also seem to have a low switch rate to other medical therapy or prostatic surgery, which may be explained by their favourable efficacy/tolerability ratio. Patients at high risk of progression (e.g. those with a large prostate volume/high PSA) may obtain further benefit from combination therapy with a 5α-reductase inhibitor. It, therefore, seems to be appropriate to use an α 1A/α 1D-AR antagonist such as tamsulosin as first choice treatment for patients at low/intermediate and add a 5α-reductase inhibitor such as finasteride to patients at high risk of progression (e.g. large prostate volume/high PSA).