The quest to find the perfect treatment for male LUTS has consumed urologists for decades. On the medical front, the battle ground has been α‐blockers with varying receptor selectivity and tolerability, 5‐α‐reductase inhibitors which inhibit different isoforms, anticholinergics (which transitioned from contraindication to cutting edge) and, more recently, β3 agonists and phosphodiesterase‐5 (PDE5) inhibitors. Similarly, the surgical management of BPH (which may or may not be the cause of male LUTS) has seen numerous procedures and operations investigated and marketed with promises to cut, burn, cook, freeze, enucleate or ablate with a laser, pressure wash, steam, cut off the blood flow, staple open, stent open or surgically remove adenoma, all with the goal of reducing urinary symptoms.

Nagasubramanian et al. [1] investigated whether the addition of tadalafil 5 mg to tamsulosin 0.4 mg offers a benefit over tamsulosin 0.4 mg alone. This randomized double‐blind placebo‐controlled study was carried out in men who were aged 60 years, on average, with moderate symptom scores (IPSS 15–16/35), and who were mostly dissatisfied with urinary quality of life; flow rates were low but reasonably maintained (~ 10 mL/s), and most of the men had post‐void residual urine volumes < 100 mL. The addition of daily tadalafil resulted in a 1.7‐point improvement in the IPSS, a 0.7‐point improvement in urinary quality of life, and an almost 2‐mL/s improvement in peak flow (and not surprisingly an improvement in erectile function). The improvement in flow rate is notable as an objective measure of effect, and not something that has been shown consistently with PDE5 inhibitors. A recent systematic review found only three out of nine randomized trials showed a significant improvement in flow rate when PDE5 inhibitors plus α‐blockers were compared with α‐blockers alone [2].

There are now numerous combinations of medical therapy that can be offered to men with LUTS, and it is useful to look to some of the recent meta‐analyses to understand the magnitude of effect these medications may offer, and then consider whether the additional medication is worth the added expense, possible medication interactions and potential side effects. Figure 1 summarizes the changes in the IPSSs from various meta‐analyses which studied different combinations of α‐blockers and PDE5 inhibitors [2-5], with fairly consistent results: either an α‐blocker or a PDE5 inhibitor helps improve LUTS to a similar degree, and the addition of one to the other improves LUTS a little bit more. The challenge is that these improvements are modest, and a smaller proportion of patients are actually ‘responders’ (those with an improvement above the minimally clinically important threshold of the IPSS and perceptible to the patient). With all the combinations of medical therapy, it is becoming increasingly difficult to keep track of the various possibilities. A nice network meta‐analysis [6] (although now 6 years old) addressed the question about the various permutations of medical therapy, and their conclusion was that an α‐blocker plus a PDE5 inhibitor was best for improving LUTS, which mirrors the conclusion of the present study [1]. A better understanding of male LUTS clusters [7] now needs to be integrated with study of the various medical and surgical treatment options to more accurately tailor specific treatment to the right patient.

寻找男性LUTS完美治疗方法的探索已经耗费了泌尿科医师数十年的时间。在医学方面，战场一直是具有不同受体选择性和耐受性的α受体阻滞剂，抑制不同亚型的5αα还原酶抑制剂，抗胆碱能药（从禁忌症过渡到最前沿），以及最近的β3激动剂和磷酸二酯酶。 ‐5（PDE5）抑制剂。同样，BPH的外科手术治疗（可能是也可能不是雄性LUTS的原因）已经进行了许多调查和销售的程序和操作，并有望通过激光，高压清洗来切割，燃烧，烹饪，冷冻，去核或消融，蒸汽，切断血流，打开吻合钉，打开支架或通过外科手术切除腺瘤，所有这些都是为了减轻泌尿系统症状。

Nagasubramanian等。[ 1]研究了将他达拉非5 mg添加到坦索罗辛0.4 mg中是否比单独的坦索罗辛0.4 mg有益处。这项随机双盲安慰剂对照研究是针对平均年龄60岁，症状评分中等（IPSS 15–16 / 35）并且对泌尿生活质量不满意的男性进行的；流速低，但合理维持（〜10 mL / s），并且大多数男性的术后尿液残留尿量<100 mL。每天添加他达拉非可导致IPSS改善1.7点，尿液生活质量改善0.7点，峰值流量改善近2 mL / s（不足为奇的是勃起功能得到改善）。流量的改善作为效果的客观衡量指标是值得注意的，而不是与PDE5抑制剂一致显示的东西。2 ]。

现在，可以为患有LUTS的男性提供多种药物治疗组合，仔细查看一些近期的荟萃分析，以了解这些药物可能提供的作用强度，然后考虑是否需要额外的药物治疗，这很有用。值得增加的费用，可能的药物相互作用和潜在的副作用。图1总结了各种荟萃分析中IPSS的变化，这些荟萃分析研究了α受体阻滞剂和PDE5抑制剂的不同组合[ 2-5]，结果相当一致：无论是α受体阻滞剂还是PDE5抑制剂，都可以将LUTS改善到相似的程度，而另一种添加可以使LUTS改善更多。挑战在于这些改进是适度的，并且实际上有较小比例的患者是“响应者”（这些改进超过了IPSS的最低临床重要阈值并且可以被患者感知）。通过药物治疗的所有组合，跟踪各种可能性变得越来越困难。不错的网络荟萃分析[ 6]（尽管现在已经6岁了）解决了关于药物治疗的各种排列问题，他们的结论是α受体阻滞剂加PDE5抑制剂最能改善LUTS，这反映了本研究的结论[ 1 ]。现在需要对男性LUTS簇更好的理解[ 7 ]与各种医学和外科治疗方案的研究相结合，以更准确地为合适的患者量身定制具体的治疗方法。