What are the recommended pharmacological treatments for managing LUTS in men, and how do they differ based on symptom severity?

Pharmacological treatments for lower urinary tract symptoms (LUTS) in men include:

• Alpha-blockers (alfuzosin, doxazosin, tamsulosin, or terazosin) are recommended for men with moderate to severe LUTS (an IPSS of 8 or more) and can reduce both storage and voiding symptoms. They are usually considered first-line treatment due to their rapid onset, efficacy, and low adverse effects. Men should be reviewed at 4 to 6 weeks and then every 6 to 12 months to assess symptoms and adverse effects ¹.
• Antimuscarinics (e.g., oxybutynin, tolterodine, darifenacin) are offered to manage symptoms of overactive bladder, especially if residual storage symptoms persist after alpha-blocker treatment. Review occurs every 4 to 6 weeks until stable, then every 6 to 12 months ¹.
• Mirabegron is considered if antimuscarinics are contraindicated, not tolerated, or ineffective. Review occurs at 4–6 weeks for tolerability and efficacy ¹.
• 5-alpha reductase inhibitors (dutasteride or finasteride) are recommended for men with larger prostates (>30 g) or PSA >1.4 ng/ml at high risk of progression, often in combination with alpha-blockers ¹.

How treatments vary according to severity:

• Men with moderate to severe LUTS (IPSS ≥8) are offered alpha-blockers as first-line therapy ¹.
• For residual storage symptoms after alpha-blocker therapy, an antimuscarinic or mirabegron may be added or substituted based on tolerability and response ¹.
• Men with larger prostates or high risk of progression may be considered for combination therapy with a 5-alpha reductase inhibitor and an alpha-blocker ¹.