Contemporary Combination Therapy in the Treatment of LUTS/BPH

The primary treatment of lower urinary tract symptoms thought to be associated with histological benign prostatic hyperplasia causing bladder outflow obstruction (LUTS/BPH) has evolved from an emphasis on surgical through to medical therapies. More recently there has been an increasing trend toward developing combination pharmacotherapy utilizing agents with differing mechanism of action aimed at the various pathophysiolgies potentially underpinning voiding and storage symptoms. The focus has been on clinical benefit such as reducing disease progression, acute urinary retention and need for BPH surgery in the case of alpha-blockers (AB) and 5-alpha-reductase inhibitor combination. This effect appears to be appropriate in the subset of men with larger prostates. Anti-muscarinics with AB is safe and effective treatment in those with bothersome storage symptoms and LUTS/BPH, although only confirmed as not associated with retention based on the existing literature for men with low PVR’s </=200 ml. Further studies with longer follow up are needed to establish long-term efficacy and safety of this combination. Phosphodiesterase inhibitors with AB is an emerging combination that has demonstrated considerable improvement in IPSS and in some cases flow rates in the small number of randomized studies conducted, confirmed by a recent meta-analysis. The major challenge in the future will be determining which specific groups of men are most likely to benefit from which combination therapies whilst considering cost implications and the potential for increased side effects consequent upon using two therapeutic classes in combination.