Introduction and clinical context
This table provides a structured review of the main pharmacological classes used to treat lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Treatment decisions are guided by the predominant symptom phenotype (voiding, storage or mixed), the risk of progression (urinary retention and surgery) and the impact on sexual function.
Alpha-1 blockers
These include tamsulosin, alfuzosin, silodosin and terazosin. They provide rapid relief of voiding symptoms, such as weak urinary stream, hesitancy, straining and incomplete bladder emptying. They may cause orthostatic hypotension, dizziness and retrograde ejaculation. They are appropriate when the primary aim is symptom control and disease progression is not the main concern.
5-alpha-reductase inhibitors
These include finasteride and dutasteride. They have a slow onset of action and are the only medicines capable of modifying the natural history of the disease when the prostate is enlarged. They reduce prostate volume and the risk of urinary retention or the need for surgery. They are indicated when the prostate volume is ≥40 mL and/or PSA is ≥1.5 ng/mL. Adverse effects include reduced libido, erectile dysfunction and gynaecomastia.
Antimuscarinic agents and β3-adrenergic agonist
Antimuscarinic agents, such as solifenacin, tolterodine and oxybutynin, are useful for storage symptoms, including urgency, urinary frequency and urgency urinary incontinence. They may cause dry mouth, constipation and, rarely, urinary retention; post-void residual urine should therefore be assessed before and during treatment.
The β3-adrenergic agonist mirabegron is an alternative with a lower anticholinergic burden and better tolerability in older adults, although it may increase blood pressure.
PDE5 inhibitor: tadalafil 5 mg
Daily tadalafil is indicated in patients with LUTS and erectile dysfunction, allowing simultaneous improvement of urinary symptoms and sexual function. It may be used alone or in combination with an alpha-1 blocker, with blood pressure monitoring.
Rational combinations
Combination therapy is useful in mixed phenotypes or when different therapeutic goals need to be addressed:
• Alpha-1 blocker + 5-ARI: enlarged prostate and risk of progression
• Alpha-1 blocker + antimuscarinic agent: voiding and storage symptoms
• Alpha-1 blocker + β3-adrenergic agonist: alternative when antimuscarinic agents are not tolerated
• Alpha-1 blocker + tadalafil: LUTS and erectile dysfunction
Follow-up strategy
During follow-up, it is important to reassess symptoms, for example using the IPSS, as well as PSA, prostate volume, post-void residual urine and quality of life. Surgical treatment should be considered in the presence of urinary retention, recurrent urinary tract infections, persistent haematuria, treatment failure or significant functional impairment.
Conclusion
The treatment algorithm should identify the predominant phenotype, estimate the risk of progression and consider the impact on sexual function. The table organises these elements concisely, facilitating an individualised approach during clinical practice.
