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Defining the role of overactive bladder treatments in men with lower urinary tract symptoms

Nature Clinical Practice Urology volume 4, pages 174–175 (2007)Cite this article

While it is clear that men with lower urinary tract symptoms (LUTS) can be effectively treated with medical therapies aimed at benign prostatic enlargement, it is equally clear that the degree of improvement is often modest, and that a subset of men show minimal improvement. One explanation for this is our inability to differentiate between symptoms attributable to detrusor overactivity (DO) and those caused by bladder-outlet obstruction (BOO) secondary to benign prostatic enlargement. Several studies have highlighted the difficulties with linking specific LUTS with urodynamic findings, which implies that the choice of medical therapy (i.e. whether it is directed at the bladder or the prostate) is often empirical. A role for antimuscarinic agents has been suggested in men with LUTS, although the selection of men who will benefit most from monotherapy versus combined therapy, and the clarification of long-term safety concerns, remain important and somewhat contentious issues.

There is certainly a rationale for the use of antimuscarinic agents in men with LUTS. The positive correlation between prevalence of overactive bladder (OAB)-type symptoms (i.e. urgency, frequency, and nocturia) and age in both men and women suggests that BOO is unlikely to be the culprit in all cases of male LUTS and that, perhaps, ischemia that causes detrusor dysfunction might be partially responsible for LUTS in both sexes. Furthermore, urodynamic studies have demonstrated that approximately 50% of symptomatic men with BOO also have DO; it is not always clear, however, whether BOO is responsible for the development of DO. In approximately 30–40% of men with BOO and DO, LUTS will persist after surgical therapy and relief of obstruction—particularly in older men and those with equivocal BOO or predominantly OAB symptoms.1,2 Improvements in LUTS following transurethral resection of the prostate are not dependent on the relief of obstruction. Overall, reluctance to prescribe OAB-specific agents for LUTS in men is likely to stem from concerns about urinary retention and the belief that either modifying a disease process (e.g. benign prostatic hyperplasia) with 5-alpha-reductase inhibitors or decreasing the obstructive effect of that process with the use of alpha blockers is preferable to treatment of a constellation of symptoms (e.g. OAB).

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  1. University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA gary.lemack@utsouthwestern.edu

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  1. GE Lemack is an Associate Professor of Urology at the University of Texas Southwestern Medical Center in Dallas, TX, USA.,

    Gary E Lemack

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The author is a consultant for Allergan, Novartis, and Pfizer.

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Lemack, G. Defining the role of overactive bladder treatments in men with lower urinary tract symptoms. Nat Rev Urol 4, 174–175 (2007). https://doi.org/10.1038/ncpuro0754

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