Should an antimuscarinic agent be used for persistent LUTS after treatment with an alpha(1)-blocker?

This Practice Point discusses the study by MacDiarmid and colleagues, which is the latest to support a beneficial effect of adding antimuscarinic agents to alpha(1)-blockers in men with persistent lower urinary tract symptoms. Such studies have also alleviated concerns about the adverse effects of antimuscarinic agents, particularly the risk of developing urinary retention. In practice, however, some issues regarding the use of antimuscarinic agents in this patient population remain. First, persistent storage symptoms are suggestive of other pathologies, and this possibility must be carefully evaluated before combined treatment is initiated. Second, postvoid residual urine volume should be repeatedly monitored during antimuscarinic therapy to avoid sequelae of residual urine or urinary retention. Third, the effect of adding an antimuscarinic agent is statistically significant, but might not be clinically significant for the majority of men. Better evaluation of storage symptoms might facilitate the more-appropriate use of combined treatment in this setting.