<p><strong>Among patients with LUTS/BPH who have undergone treatment and do not have symptom improvement, clinicians should pursue an alternative diagnosis and/or recommend an alternative treatment pathway. (<em>Clinical Principle)</em></strong></p>
Discussion
Discussion
<p>As mentioned above, the majority of initial BPH treatments will be empiric due to the inability to easily diagnose LUTS/BPH or to distinguish BPH from LUTS due to non-obstructive causes. Therefore, an initial BPH treatment failure should trigger a re-evaluation of the LUTS etiology rather than automatic escalation of more invasive de-obstruction interventions. Signs that a patient who did not respond to the initial therapy requires reconsideration of the diagnosis which include:</p>
<ol>
<li>increasing or persistently high Q<sub>max</sub> (≥12 mL/s) and low PVR without corresponding improvement in symptoms</li>
<li>a small prostate volume (<30 cc) or low PSA</li>
<li>the presence of a medication or poorly controlled comorbidity that is known to cause LUTS</li>
<li>the presence of significant multimorbidity, frailty, or polypharmacy </li>
<li>predominant nocturia or storage LUTS</li>
</ol>
<p>In this case, alternative diagnoses such as primary bladder dysfunction (including idiopathic OAB or DU), neurogenic LUTS, and other systemic conditions should be strongly considered and treated, if present, prior to escalating BPH treatments.</p>
<p>Signs that a patient who did not respond to initial therapy, particularly with persistent or worsening voiding LUTS, may require escalation to treat ongoing BOO which include:</p>
<ol>
<li>persistently low Q<sub>max </sub></li>
<li>increasing or persistently elevated PVR</li>
<li>a personal history or the development of an absolute indication for BPH treatment (see <strong>Statement 1</strong>)</li>
</ol>