<p><strong>For patients with LUTS/BPH and persistent storage LUTS despite pharmacologic treatment, clinicians should add behavioral/lifestyle interventions. (<em>Expert Opinion</em>)</strong></p>
Discussion
Discussion
<p>Persistent storage LUTS despite effective medical or surgical treatment of BOO is common. Although comparative effectiveness trials of behavioral and/or lifestyle interventions versus an active drug comparator group were not included in the literature search criteria for this Guideline, multiple high-quality clinical trials have demonstrated that behavioral and/or lifestyle interventions are superior to antimuscarinic drug monotherapy for persistent storage LUTS after AB monotherapy for BPH. For example, the MOTIVE trial demonstrated that the effect of 8-week behavioral intervention on mean voids per day was non-inferior to oxybutynin extended release among 143 men with persistent storage LUTS after 4 weeks of AB monotherapy.<sup>209</sup> In a planned subgroup analysis of MOTIVE participants with nocturia, the behavioral intervention was superior to oxybutynin.<sup>210</sup> A subsequent trial (COBALT) further demonstrated superiority of 6-weeks of behavioral therapy compared to oxybutynin plus tamsulosin as first-line treatment for men with storage LUTS with or without BPH, although they excluded men with significant obstruction based on Q<sub>max</sub> <8.0 mL/s.<sup>211</sup> After men in both intervention groups were escalated to combination therapy with behavioral therapy plus oxybutynin and tamsulosin, combination therapy was superior to drug therapy alone but was not superior to behavioral therapy alone. No adverse events were reported by 86% of participants in the behavioral therapy alone group versus 32% in the drug therapy alone group and 34% in the combination therapy group. Overall, there is a clear net benefit for behavioral therapy alone versus pharmacologic treatment for storage LUTS in patients with BPH.</p>