on both LUTS and urinary flow rate than tamsulosin or alfuzosin.

Maybe tamsulosin is more used by most urologists because of aggressive marketing?? I could be mistaken. Article is a bit difficult to read.—-see only coloured parts

LOWER URINARY TRACT SYMPTOMS14www.trendsinmenshealth.comTRENDS IN UROLOGY & MEN’S HEALTH     NOVEMBER/DECEMBER 2016Lower urinary tract symptoms, which most commonly develop as a result of benign prostatic hyperplasia (BPH), are extremely prevalent. Ninety per cent of men reaching the age of 80 can be expected to have histological BPH, and more than half of them will suffer signicant LUTS. As the global population ages, more and more men are destined to experience impairment of their quality of life (QoL) as a consequence of prostatic enlargement and associated bladder outow obstruction. Their partners may also suffer because of the disabling symptoms that trouble their spouse  or partner.It seems clear, however, that men with LUTS are often reluctant to seek medical advice. Perhaps they assume that frequency of micturition and reduction of their ow rate is simply a natural consequence of ageing; alternatively, some may fear that, if they consult a urologist, he or she may advise surgery and this might have negative consequences for their sex life. It has been clearly demonstrated that there is LUTS, alpha-blockers and men’s healthROGER KIRBYWith an increasing number of men presenting with lower urinary tract symptoms (LUTS), erectile dysfunction (ED) and  the metabolic syndrome, Roger Kirby suggests that it is time to review current treatment approaches to avoid making some problems worse, and to try combinations of treatments that may be more benecial for our patients.Roger Kirby, Medical Director, The Prostate Centre, LondonFor a man with lower urinary tract symptoms and the metabolic syndrome, treatments need to help, not hinder, the likelihood of erectile problems (© Gustoimages/Science Photo Library)LOWER URINARY TRACT SYMPTOMS15www.trendsinmenshealth.comTRENDS IN UROLOGY & MEN’S HEALTH     NOVEMBER/DECEMBER 2016a strong correlation between LUTS and ED.1 Indeed, the greater the International Prostate Symptom Score (IPSS), the more likely the sufferer is to experience sexual dysfunction. Moreover, the combination of LUTS and ED often has a very negative impact on QoL. Men suffering both sets of symptoms are often mainly concerned about further deterioration of the latter.Another important social trend of the 21st century is the so-called ‘tsunami’ of weight gain. In men, this is characterised by central obesity and very often accompanied by the other three features that comprise the ‘metabolic syndrome’, namely, diabetes, hypertension and hyperlipidaemia. There is now a well-recognised association between obesity and LUTS. As a consequence, urologists and GPs are likely to be seeing more and more patients with a combination of urological symptoms and clinical features of the metabolic syndrome. Signicantly, men with central obesity are very likely to have early sexual dysfunction, low morning testosterone levels, and signs and symptoms of hypogonadism. The reason for this is thought to be the role of lectins and cytokines secreted by intra-abdominal fat in suppressing pituitary luteinising hormone (LH), with consequent reduction of production of testosterone from the Leydig cells of the testes.CURRENT TREATMENTThere are several alpha-blockers available for the treatment of LUTS secondary  to BPH. In most countries, around 80%  of men treated for these symptoms  receive a slow-release formulation of an alpha-blocker as rst-line therapy. Tamsulosin has selective afnity for the alpha-1A adrenoceptor and alfusosin is also ‘uroselective’; however, doxazosin has more balanced selectivity for all three subtypes of the alpha-1 adrenoceptor: alpha-1A, alpha-1B and alpha-1D.  These differences may have important clinical consequences. Several studies  have suggested that doxazosin has a greater benecial impact on both LUTS and urinary ow rate than tamsulosin or alfuzosin.2 Moreover, the profound selectivity of tamsulosin for the alpha-1A adrenoceptor probably accounts for the development of anejaculation, which is often troublesome to patients, as well as the so-called ‘oppy iris syndrome’, which is bothersome to eye surgeons performing cataract surgery.3Following the publication of the  MTOPS (Medical Therapy of Prostatic Symptoms) study of the combination  of doxazosin and nasteride,4 and  the subsequent randomised trial of tamsulosin and dutasteride,5 many clinicians opted for dual therapy  with an alpha-blocker and a 5-alpha reductase inhibitor (5-ARI) for their patients with LUTS. However, it is clear from the clinical trial data that many patients on this combination suffered sexual dysfunction as a result of the medication. The 5-ARI appeared to cause loss of libido, reduced ejaculate volume and erectile dysfunction in some patients, while tamsulosin sometimes resulted  in anejaculation. ALTERNATIVE APPROACHAn alternative approach to combination therapy in men with both LUTS and impending or actual ED is to combine an alpha-blocker with a phosphodiesterase 5 inhibitor (PDE5I). Since doxazosin has been shown to be mildly benecial to sexual function, it might be considered the  alpha-blocker of choice in this situation.6 Once the patient is stable on this medication, or alternatively on alfuzosin, a PDE5I such as tadalal (Cialis) 5mg or sildenal 25mg (increasing if necessary to 50mg or 100mg) once a day can be safely added without signicant risk of inducing postural hypotension.From a men’s health standpoint, the use of an alpha-blocker with balanced adrenoceptor selectivity, such as doxazosin, makes good sense. It not only rapidly and effectively improves bothersome LUTS, but also has a positive rather than negative impact on sexual function.7 It is also potentially benecial in many of the comorbidities that many of the more elderly patients with LUTS also suffer from. For example, doxazosin reduces blood pressure in hypertensive patients, but has no clinically signicant effect in normotensive individuals.8 Doxazosin also improves lipid prole,  and reduces insulin resistance and  platelet stickiness. It may be usefully deployed in patients with pre-diabetes  and those who have coronary artery disease. Of course, in overweight individuals, medication should also  be combined with advice about lifestyle and diet. In cases where the comorbidities are more severe, other medications, such as a statin or metformin for diabetes, and a rst-line antihypertensive, such as amlodipine, may be required to reduce cardiovascular risk and promote normoglycaemia and normotension. In men with demonstrable hypogonadism and no clinical features of prostate cancer, testosterone replacement therapy may also be indicated.CONCLUSIONIn conclusion, it seems clear that  many men presenting with LUTS  resulting from BPH suffer signicant comorbidities, the most troublesome  of which is often ED. Rather than treat them with a medication or medications that may further impair sexual function, treatment with an alpha-blocker that  is safe and rapidly effective, as well  as mildly benecial for this important  aspect of life, seems reasonable. If further help is required, a PDE5I can safely be added later and other comorbidities  treated appropriately as required. The  ‘The combination of LUTS and ED can have a very negative impact on quality of life’LOWER URINARY TRACT SYMPTOMS16www.trendsinmenshealth.comTRENDS IN UROLOGY & MEN’S HEALTH     NOVEMBER/DECEMBER 2016net result may be a happier, healthier cohort of men who no longer avoid  seeking help for their urinary symptoms  for fear of receiving a medical treatment  or operation that could impact negatively on their sexual performance.Declaration of interestsRoger Kirby has lectured in the Middle East and Asia on behalf of Pzer.REFERENCES1.   Rosen R, Altwein J, Boyle P, et al. . Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7). Eur Urol 2003;44:637–49.2.   Kirby RS. A randomized, double-blind crossover study of tamsulosin and controlled-release doxazosin in patients with benign prostatic hyperplasia. BJU Int 2003;91:41–4.3.  Kaplan SA. Re: Prospective masked comparison of intraoperative oppy iris syndrome severity with tamsulosin versus alfuzosin. J Urol 2015;193:949.4.   McConnel JD, Roehrborn CG, Bautista OM. The long term effect of doxazosin, nasteride, and combination therapy  on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003;349:2387–98.5.   Roehrborn CG, Siami P, Barkin J, et al. for CombAT Study Group. The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study. Eur Urol 2010;57:123–31.6.  Kaplan SA, DE Rose AF, Kirby RS, et al. Benecial effects of extended-release doxazosin and doxazosin standard on sexual health. BJU Int 2006;97:559–66.7.   Kirby RS, O’Leary M, Carson C. Efcacy of extended-release doxazosin and doxazosin standard in patients with concomitant benign prostatic hyperplasia and sexual dysfunction. BJU Int 2005;95:103–9.8.   Steers W, Kirby RS. Clinical ease of using doxazosin in BPH patients with and without hypertension. Prostate Cancer Prostatic Dis 2005;8:152–7.