Overview of Evidence for Contemporary Management of Lower Urinary Tract Symptoms Presumed Due to Benign Prostatic Hyperplasia in Males

In the management of patients suffering from lower urinary tract symptoms (LUTS), current therapeutic strategies are watchful waiting, conservative therapy, pharmacologic therapy, and surgery.Pharmacologic therapy should be offered only if conservative management has failed or is inappropriate. It includes 5α-reductase inhibitors (5-ARIs), which are effective in controlling symptoms, shrink prostate volume, and decrease the risk of acute urinary retention and surgery after 12 mo of therapy; α-blockers, which are more effective in controlling LUTS than placebo and the 5-ARIs and are effective also in aborting acute retention; and anticholinergic drugs, which act on storage LUTS. The combination of 5-ARIs and α-blockers is more effective than monotherapy in the long term but also is more expensive and causes more side effects. Anticholinergics should be offered only in combination with an α-blocker to patients with storage LUTS suggestive of overactive bladder who do not have a significantly elevated postvoiding residual urine volume.Surgical interventions should be offered only to men with bothersome or severe symptoms.Standard surgery for voiding symptoms presumed due to secondary bladder outflow obstruction secondary to benign prostatic enlargement includes transurethral resection of the prostate, transurethral vapourisation of the prostate, or holmium laser excision of the prostate. Transurethral incision of the prostate is an alternative for men with a small prostate, and open prostatectomy is an alternative for men with larger prostates. Minimally invasive treatments have been shown to have equivalent efficacy based on the existing evidence.Surgical interventions for recalcitrant storage symptoms include the standard surgical therapies of botulinum toxin, implanted sacral nerve root stimulation, cystoplasty, and, rarely, urinary diversion and implantation of an artificial sphincter to manage stress urinary incontinence.