Current medical treatment of lower urinary tract symptoms/BPH: do we have a standard?
OBJECTIVE
The pharmacological treatment of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) is based on alpha-blockers and 5α-reductase inhibitors isolated or in combination. Silodosin, an alpha-1A specific alpha-blocker is the only innovation in these groups of agents. This classical paradigm is being challenged by antimuscarinics, 5-phosphodiesterase inhibitors (PDE5i) and β3-adrenoreceptor agonists.


RESULTS
Silodosin is effective in reducing BPH/LUTS, including nocturia and shows little cardiovascular adverse events. Antimuscarinic drugs isolated or in combination with alpha-blockers improve storage symptoms without any harmful effect to the voiding function. PDE5i alone improve BPH/LUTS. Combination of PDE5i with alpha-blockers provides better symptomatic control than alpha-blockers alone. A recent head-to-head comparison of tadalafil 5 mg/day with tamsulosin 0.4 mg/day showed that these agents provided the same improvement in BPH/LUTS and, surprisingly, the same improvement in the urinary flow. In fact, previous studies with tadalafil had not shown any effect of tadalafil on flow. In addition, tadalafil but not tamsulosin improved sexual function. Mirabegron, the first β3-adrenoreceptor agonist, while improving BPH/LUTS in men with bladder outlet obstruction, do not decrease urinary flow or detrusor pressure.


CONCLUSIONS
The standard medical treatment for BPH/LUTS is still based on alpha-blockers, 5ARIs or its combination. In the future, it is expected that BPH/LUTS treatment will become individualized, according to the type of symptoms, presence of sexual dysfunction and risk of BPH progression. This will challenge our concept of standard treatment for BPH/LUTS.
aDepartement of Urology, Hospital S. João bFaculty of Medicine cIBMC, Institute for Molecular and Cell Biology, Porto, Portugal.
João
J
Silva
Carlos Martins
CM
Silva
Francisco
F
Cruz
D058891:5-alpha Reductase Inhibitors / Q000627:therapeutic use; D058668:Adrenergic alpha-1 Receptor Antagonists / Q000627:therapeutic use; D058667:Adrenergic beta-3 Receptor Agonists / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D059411:Lower Urinary Tract Symptoms / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D018727:Muscarinic Antagonists / Q000627:therapeutic use; D058986:Phosphodiesterase 5 Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D011467:Prostate / Q000187:drug effects / Q000503:physiopathology; D011470:Prostatic Hyperplasia / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000187:drug effects / Q000503:physiopathology; D064804:Urological Agents / Q000009:adverse effects / Q000627:therapeutic use*
D058891:5-alpha Reductase Inhibitors; D058668:Adrenergic alpha-1 Receptor Antagonists; D058667:Adrenergic beta-3 Receptor Agonists; D018727:Muscarinic Antagonists; D058986:Phosphodiesterase 5 Inhibitors; D064804:Urological Agents