A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: Focus on the bladder

Lower urinary tract symptoms (LUTS) are highly prevalent among older men and have a negative impact on health-related quality of life. Frequent comorbidity with potential prostatic disease adds complexity to the management of male LUTS. In this review, we discuss the pathophysiological conditions that underlie male LUTS, and examine the relationship between symptoms and urodynamic findings. The contribution of bladder dysfunction to male LUTS, with a particular emphasis on overactive bladder (OAB) symptoms, is explored. We also consider pharmacotherapeutic options for male LUTS. Pharmacotherapies that target the prostate (α₁-receptor antagonists and 5α-reductase inhibitors) often fail to alleviate OAB symptoms, and may not be the most appropriate therapy for men with storage LUTS. Multiple studies have suggested that antimuscarinic therapy alone or in combination with α₁-receptor antagonists improve OAB symptoms in men with and without bladder outlet obstruction. Although these agents may represent appropriate first-line therapies for men with OAB symptoms, the therapeutic potential of antimuscarinics alone or in combination with α₁- receptor antagonists in this population should be evaluated in large-scale, well-designed clinical trials.