What are the recommended pharmacological treatments for managing LUTS

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

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 .
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 .
Mirabegron is considered if antimuscarinics are contraindicated, not tolerated, or ineffective. Review occurs at 4–6 weeks for tolerability and efficacy .
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 .

How treatments vary according to severity:

Men with moderate to severe LUTS (IPSS ≥8) are offered alpha-blockers as first-line therapy .
For residual storage symptoms after alpha-blocker therapy, an antimuscarinic or mirabegron may be added or substituted based on tolerability and response .
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 .

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