<p><strong>In addition to optimizing modifiable risk factors, clinicians should prescribe a uroselective AB to be taken for at least three days prior to a voiding trial to treat patients with AUR related to LUTS/BPH. (<em>Clinical Principle</em>)</strong></p>
Discussion
Discussion
<p>Patients suffering from AUR often have an identifiable triggering event such as excessive fluid intake, bladder overdistention, alcohol consumption, anticholinergic or sympathomimetic medication, general or regional anesthesia, UTI, and constipation.<sup>418</sup> Whilst there are no clinical trials demonstrating that optimizing these factors improve the likelihood of a successful TWOC, it is considered standard practice to identify and correct these factors that can be modified.</p>
<p>At least 13 RCTs have demonstrated the benefit of ABs in improving the success rates of TWOC.<sup>419</sup> One meta-analysis of RCTs comparing ABs to placebo found a rate of successful TWOC of 60.2% versus 38.1%, respectively, with minimal adverse events in the AB groups.<sup>420</sup> The optimal timing of TWOC and duration of AB therapy has yet to be established, although some evidence exists to suggest that delayed TWOC is superior to immediate removal,<sup>421</sup> hence the pragmatic recommendation of three days of an AB prior to TWOC. Comparative trials between different uroselective ABs show similar efficacy.<sup>422-424</sup></p>
<p>There have been two small, single center RCTs comparing tamsulosin to a combination of tamsulosin and a PDE-5I (one with sildenafil<sup>425</sup> and another with tadalafil<sup>426</sup>). Neither was able to demonstrate that combination therapy had a significant benefit.</p>
<p>One small, single center RCT compared tamsulosin to a combination of tamsulosin and alfuzosin, and found the combination therapy to be superior at reducing the need for re-catheterization (77% versus 54%).<sup>151</sup> While this small study is insufficient evidence to recommend the general use of this combination, it may be a viable strategy for patients who fail to void with a single agent and are not eligible for surgical treatment.</p>