[Lower urinary tract symptoms in men]

Lower urinary tract symptoms (LUTS) are frequently encountered in clinical practice, especially in older men. The main focus in the primary treatment of men with complaints of violation of urination should be paid to assessing their severity on the basis of IPSS questionnaire. It is important to identify the predominant symptoms that determine treatment. In the absence of absolute indications for surgical treatment of clinical forms of benign prostatic hyperplasia (BPH), the drug treatment should be used. In cases of the prevalence of obstructive LUTS, first-line treatment is the use of alpha-adrenoblockers. In case of progression of BPH (prostate volume > or = 40 cm3, PSA > 1,5 ng/ml), it is useful to combine the alpha-adrenoblockers with 5alpha-reductase inhibitors. Combined medication in the form of alpha-adrenoblockers and M- cholinergic antagonists is justified in irritative LUTS in men with BPH.

A prospective study of statin drug use and lower urinary tract symptoms in older men

Dyslipidemia and chronic inflammation may play a role in the cause of lower urinary tract symptoms (LUTS) in older men. Use of statin drugs, which are prescribed to lower cholesterol and appear to reduce inflammation, may decrease the incidence or progression of LUTS. The associations of statin drug use with LUTS incidence and progression were prospectively evaluated in the Health Professionals Follow-up Study from 1992 to 2008. Hazard ratios and 95% confidence intervals of incident LUTS (from no or a low International Prostate Symptom Score (IPSS) of 0-7 to a moderate or worse IPSS of ≥15; n = 5,790 cases in 24,715 men) and of LUTS progression (from modest IPSS of 8-14 to severe IPSS of ≥20; n = 2,238 cases in 8,709 men) were calculated comparing current statin use with nonuse. The hazard ratios of LUTS incidence and progression comparing current use to nonuse were greater than 1. However, when comparisons were restricted to participants who used drugs to treat hypertension (a surrogate for uptake of medical care), statin use was not associated with LUTS incidence (hazard ratio = 1.02, 95% confidence interval: 0.94, 1.12) or progression (hazard ratio = 0.98, 95% confidence interval: 0.85, 1.13). Thus, statin use is unlikely to beneficially influence the development or course of LUTS. The present study highlights a methodological issue (confounding) that must be addressed in observational studies on the use of common drugs for indications other than the primary use.

[The antiradical activity of plant extracts and healthful preventive combinations of these exrtacts with the phospholipid complex]

Using the chemiluminescence method, the effective concentration of antioxidants (AO) and its reactivity toward peroxyl radicals (ARA, the k7 constant) have been measured for 13 plant extracts. In fact all extracts demonstrated ARA higher than ionol. Larix dahurica, Hypericum perforatum, Potentilla fruticosa, Aronia melanocarpa and Rhaponticum carthamoides extracts showed the highest values of ARA. The combinations Aronia + Raponticum extracts; Larix + Hibiscus extracts; Schizandra +Aronia extracts were synergistic (the synergism effect beta of 38%, 33% and 22%). Apparently this phenomenon is the result of the synergistic interaction between compounds present in plant extracts. The Phospholipid complex--Lipoid S40, lacting any antioxidant effect alone, showed a potent synergistic effect with Aronia extract (beta3 = 60%), Silybum extract (beta3 = 41%). Clinical trials demonstrated, that combinations "Lipoid + Aronia extract", "Lipoid + Larix extract + Hibiscus extract", "Lipoid + Silybum extract", "Lipoid + Q10 + Rosa majalis extract" may be used as an additional component in the medicinal treatment, or as an individual prophylactic agent.

Emerging therapies: what's new is old and what's old is new

Researchers are constantly seeking ways to improve existing drugs, drug mechanisms of activity, find new indications for old drugs or to develop new drugs to treat urological diseases and conditions. In Canada, tadalafil in a 5 mg daily dosage (old drug), and a new drug, silodosin, have recently become available to treat patients who have benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). In clinical studies, silodosin has shown promise as a treatment for ureteral stones, whereas it has shown conflicting results as a potential treatment for prostatitis. Two new therapies have emerged for treating overactive bladder (OAB): Mirabegron (not yet available in Canada) and fesoterodine (newly introduced in the marketplace). New therapies--denosumab (to prevent skeletal events) and abiraterone acetate and enzalutamide--were recently approved to treat certain patients with advanced prostate cancer. With the advent of new therapies to treat urological diseases, in many cases, primary management of the patient is often shifted from the urologist to the family physician, and sometimes moved from the oncologist to the urologist.

[Afala in the treatment of patients with BPH: efficacy and safety]

The double-blind, placebo-controlled, randomized clinical trial involving 94 patients has evaluated the efficacy and safety of domestic preparation afala in patients with symptoms of I-II stages benign prostatic hyperplasia (BPH). It was shown that a 6-month course of treatment with afala at a dose of 2 tablets 4 times a day resulted in a significant reduction in the severity of urinary disorders, estimated by total IPSS score, relative to baseline values and compared to placebo therapy. The most pronounced therapeutic effects of the drug were registered in respect of irritative symptoms of BPH. According uroflowmetry, peak flow rate after 6 months of treatment was increased by more than 50%. Significant clinical benefit persisted not only within the 6-month course of therapy, but 3 months after. Long-term therapy had no effect on the concentration of total, free and complex PSA, testosterone (total and free), dihydrotestosterone, and prolactin in the blood. Absence of adverse effects, biochemical abnormalities, changes in clinical blood and urine confirmed the safety of 6-month therapy.

[Combined action of levofloxacin and DNAase on biofilms of urogenital infection pathogens]

The effect of antibiotics and DNAase on biofilms of unrelated gram-positive and gram-negative bacteria was studied on strains isolated from patients with infectious and inflammatory urinary diseases. It was found that destruction of extracellular DNA biofilms by DNAase increases sensitivity of the bacteria to environmental factors including antibacterial drugs. DNAase addition to forming and formed biofilms created by unrelated bacteria leads to similar dose-dependent changes This evidences for universal action of the enzyme. A synergetic effect occurs in combined action of antibiotic biofilm and DNAase on bacteria.

Phosphodiesterase type 5 inhibitors in the management of non-neurogenic male lower urinary tract symptoms: critical analysis of current evidence

CONTEXT

A large body of epidemiologic data suggests a causal relationship between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). Recently reported studies on phosphodiesterase type 5 inhibitors (PDE5-Is) and LUTS have further contributed to the understanding of mechanisms involved in this relationship and of potential treatment options.

OBJECTIVE

A nonsystematic descriptive review was performed to summarize the literature concerning the role of PDE5-Is in men with LUTS, particularly looking at data derived from clinical trials in relation to the different PDE5-Is or their association with α-blockers.

EVIDENCE ACQUISITION

A comprehensive electronic search was conducted in October 2010 using the Medline database to identify all publications relating to ED and BPH and treatment with sildenafil, vardenafil, tadalafil, udenafil, UK-369003, and combination therapy with alfuzosin and tamsulosin.

EVIDENCE SYNTHESIS

In studies in which either ED or LUTS was the entry criterion, sildenafil appears to improve both erectile function and LUTS in subjects with ED. Placebo-controlled trials of tadalafil and vardenafil showed improvement of LUTS secondary to benign prostatic hyperplasia (BPH), but none of the studies showed a significant effect on urodynamic measures. Exploratory studies with UK-369003 showed improvements in LUTS and ED. Sildenafil or tadalafil associated with alfuzosin or tamsulosin showed greater benefits for the combination therapy for both LUTS and ED. The coadministration of udenafil and an α-blocker in patients with BPH and ED also appeared to improve both LUTS and ED severity.

CONCLUSIONS

Consistent evidence of improvements in LUTS has been shown with PDE5-Is, either alone or in combination with α-blockers. However, effects on urodynamics or objective measures of urinary flow are lacking. Further areas of research include investigation of mechanism of PDE5-Is, urodynamic studies, identification of new efficacy end points, head-to-head comparison with standard of care, potential benefit of add-on treatment, and long-term outcomes.

Pharmacology for common urologic diseases: 2011 review for the primary care physician

Coordination of care between the urologist and primary care physician is critical to effective treatment of a variety of urologic conditions. Medical therapies for benign prostatic hyperplasia, erectile dysfunction, hypogonadism, overactive bladder, and prostate cancer are widely available and a basic understanding of the pathophysiology of these disease states as well as the pharmacology of existing treatment options are necessary to avoid complications and maximize efficacy associated with patient outcomes. Important regulatory decisions have been made concerning the approval and lack of approval of several important urologic medications. Major advances have been made in the therapy of castrate resistant prostate cancer as well as hormonal related skeletal events secondary to advanced carcinoma of the prostate. We provide a 2011 update of the available medications for treatment of several common urologic diseases.

Androgen replacement therapy contributes to improving lower urinary tract symptoms in patients with hypogonadism and benign prostate hypertrophy: a randomised controlled study

PURPOSE

We performed a randomised controlled study regarding the effects of androgen replacement therapy (ART) on lower urinary tract symptoms (LUTS) in hypogonadal men with benign prostate hypertrophy (BPH).

METHODS

Fifty-two patients with hypogonadism and BPH were randomly assigned to receive testosterone (ART group) as 250 mg of testosterone enanthate every 4 weeks or to the untreated control group. We compared International Prostate Symptom Score (IPSS), uroflowmetry data, post-voiding residual volume (PVR) and systemic muscle volume at baseline and 12 months after treatment.

RESULTS

Forty-six patients (ART group, n=23; control, n=23) were included in the analysis. At the 12-month visit, IPSS showed a significant decrease compared with baseline in the ART group (15.7 +/- 8.7 vs. 12.5 +/- 9.5; p<0.05). No significant changes were observed in the control group. The ART group also showed improvement in maximum flow rate and voided volume (p<0.05), whereas no significant improvements were observed in the controls. PVR showed no significant changes in either group. In addition, the ART group showed significant enhancement of mean muscle volume (p<0.05), whereas no significant changes were seen in the controls.

CONCLUSION

ART improved LUTS in hypogonadal men with mild BPH.

ATP and P2X purinoceptors in urinary tract disorders

The pharmacological concept of specifically targeting purinoceptors (receptors for ATP and related nucleotides) has emerged over the last two decades in the quest for novel, differentiated therapeutics. Investigations from many laboratories have established a prominent role for ATP in the functional regulation of most tissue and organ systems, including the urinary tract, under normal and pathophysiological conditions. In the particular case of the urinary tract, ATP signaling via P2X1 receptors participates in the efferent control of detrusor smooth muscle excitability, and this function may be heightened in disease and aging. Perhaps of greater interest, ATP also appears to be involved in bladder sensation, operating via activation of P2X3-containing receptors on sensory afferent neurones, both on peripheral terminals within the urinary tract tissues (e.g., ureters, bladder) and on central synapses in the dorsal horn of the spinal cord. Such findings are based on results from classical pharmacological and localization studies in nonhuman and human tissues, gene knockout mice, and studies using recently identified pharmacological antagonists - some of which have progressed as candidate drug molecules. Based on recent advances in this field, it is apparent that the development of selective antagonists for these receptors will occur that could lead to therapies offering better relief of storage, voiding, and sensory symptoms for patients, while minimizing the systemic side effects that curb the clinical effectiveness of current urologic medicines.

Cyclic nucleotide metabolism including nitric oxide and phosphodiesterase-related targets in the lower urinary tract

The clinical data on the use of the orally active phosphodiesterase (PDE) type 5 inhibitors sildenafil (VIAGRA™), vardenafil (LEVITRA™), and tadalafil (CIALIS™) for the treatment of male erectile dysfunction have boosted research activities on the physiology and pharmacology of the organs of the lower urinary tract (LUT). This includes both intracellular signal transduction in the prostate, urinary bladder (detrusor), and urethra, as well as central brain and spinal cord pathways controlling the function of the LUT. Such efforts provided the basis for the development of new therapeutic modalities into the management of dysfunctions/ syndromes of the LUT, some of which are already offered to the patients. The pharmacological treatment of the overactive bladder and the so-called benign prostatic syndrome, including LUT symptomatology and bladder outlet obstruction secondary to benign prostatic enlargement, has primarily focused on selective, orally available drugs acting by influencing intracellular regulatory mechanisms. These agents are regarded efficacious, have a fast onset of drug action in the target tissue and an improved effect-to-side-effect ratio. Better understanding of the functional significance of proteins related to cyclic nucleotide-dependent pathways, such as nitric oxide synthase, cytosolic and membrane-bound guanylyl cyclases, PDE isoenzymes and cyclic AMP- and cyclic GMP-binding protein kinases, the relative distribution in tissues of the LUT, and the consequences for urogenital function, seems to be of particular interest in order to identify new or more selective pharmacological approaches to manage disorders of the LUT. The present review focuses on cyclic nucleotide-related targets involved in the control of the function of the bladder, prostate, and urethra and the significance of those proteins in the process of evolving new pharmacological options for the treatment of LUT symptoms secondary to benign prostatic hyperplasia as well as dysfunctions of the storage and voiding capability of the urinary bladder.

[Dopaminergic stimulation in the non-motor symptoms of Parkinson's disease]

INTRODUCTION AND DEVELOPMENT

The non-motor symptoms of Parkinson's disease have a great impact in terms of quality of life. They are frequently underdiagnosed and clinical experience suggests that not only is dopamine therapy ineffective but that in many cases it is also responsible for the appearance of some of these symptoms. Different studies have drawn attention to the involvement of the dopaminergic pathways in the pathogenesis of some non-motor symptoms. It has been observed that they can undergo fluctuations in relation to dopaminergic stimulation, generally in wearing off states, while displaying a significant correlation with motor fluctuations and a clinical response with continuous dopaminergic therapy.

CONCLUSIONS

Although recent reviews offer insufficient evidence for treatment of non-motor symptoms with dopaminergic therapy, involvement of the dopaminergic pathways in the aetiopathogenesis of some of these disorders and the clinical observation that such symptoms undergo fluctuations in relation to pulsatile dopaminergic stimulation may lead us to reconsider the possible role of dopaminergic therapy in the treatment of these symptoms.

Uropharmacology in primary care: 2010 update

Many disorders such as erectile dysfunction, overactive bladder, hypogonadism and benign prostatic hypertrophy have traditionally been managed primarily by urologists. The development of newer agents to treat many of these conditions has allowed the primary care provider to manage many of these common conditions. The use of these newer medications has become commonplace in the primary care setting. This article will update some of the most commonly used urologic medications to optimize patient management strategies by the primary care provider or in coordination with the urologist.

[Botulinum toxin useful in urological problems]

Urological and gastroenterological patients may benefit from the therapeutic use of botulinum neurotoxin. Urologic indications include overactive bladder refractory to conventional treatments, painful bladder, chronic pelvic pain syndromes and problems with bladder emptying. Currently, there are no approved therapeutic indications for urologic conditions. In general, botulinum neurotoxin treatment is well tolerated and adverse events are predictable and limited to the urogenital tract, though rare severe and fatal complications have been reported.

Drug treatment of urological symptoms: estimating the magnitude of unmet need in a community-based sample

OBJECTIVE

To examine, in a community-based sample, the use of prescription drugs for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH), overactive bladder, erectile dysfunction, urinary incontinence, and painful bladder syndrome; and to determine whether the use of recommended medications varied by sociodemographics, symptom severity, access to care, and other factors.

SUBJECTS AND METHODS

In a cross-sectional analysis of data obtained from 5503 men and women residents participating in the Boston Area Community Health Survey of Boston, MA, urological symptoms were ascertained by in-person interviews conducted during 2002-2005, using validated symptom scales. Medication use in the past 4 weeks was captured using a combination of drug-inventory methods and self-report.

RESULTS

Compared to the prevalence of symptoms, the prevalence of use of medications for urological conditions was very low among men and women. The highest prevalence of use was among men with moderate-to-severe LUTS/BPH symptoms, where 9.6% used recommended drugs. Use of medications did not vary consistently by race/ethnicity or socioeconomic status, but was often associated with symptom severity. More frequent and more recent use of medical care was also associated with greater use of urological medications.

CONCLUSIONS

Only a small proportion of community-dwelling men and women with urological symptoms are receiving recommended effective drug treatments for urological conditions. While not all persons are candidates for drug treatment, our results suggest that there is a substantial unmet need in the general population.

The use of botulinum toxin type A in urological procedures

Botox is a sterile, vacuum-dried, purified BoNT-A produced from fermentation of Clostridium botulinum. There is an abundance of literature to support the use of Botox in urology, and its off-label use continues to grow. While there are no FDA-approved clinical indications, there are ongoing phase II and III studies to approve Botox for use in some urological conditions. This article will explore the use of Botox in urology and provide a brief review of the literature supporting its use.

Are female lower urinary tract symptoms alleviated by alpha-adrenoreceptor antagonists?

This commentary discusses the article by Low and colleagues, who studied the effect of terazosin in women with lower urinary tract symptoms (LUTS) and an International Prostate Symptom Score (IPSS) > o =8. Terazosin therapy significantly improved IPSS quality-of-life scores and King's Health Questionnaire scores. These findings might seem surprising, because previous studies have shown that alpha-adrenoreceptor antagonists are not effective in women with overactive bladder, which is considered the most common form of LUTS in females. Many women have voiding symptoms, however, and the inclusion criteria in this study resulted in a different population profile compared with those of other studies of female LUTS. The mechanism behind the effect of terazosin is unclear. Without urodynamic characterization, it cannot be established whether patients in the study were obstructed, or whether the effect of terazosin was related to a decrease in bladder outflow resistance.