Uropharmacology for the primary care physician

Advances in the understanding of the pathophysiology of a variety of urological disorders have resulted in the development of novel medications to manage these diseases. While many disorders such as erectile dysfunction, overactive bladder, hypogonadism and benign prostatic hypertrophy have traditionally been managed primarily by urologists, the use of these newer medications has become commonplace in the primary care setting. For example, symptomatic benign prostatic hyperplasia therapy, while historically treated with primary surgical intervention, is now commonly initially managed with medical therapy. Prostate cancer patients are being treated with newer formulations of long term hormone therapy that range from monthly to yearly administration. Additionally, the open dialogue about erectile dysfunction can be directly traced to the development of oral therapy for this condition. Testosterone replacement therapy can be administered using a variety of oral, transdermal and intramuscular therapies in order to minimize side effects and provide a more consistent dosing pattern. Finally, overactive bladder, which is a significant problem socially, has many new medications available for its treatment. This article will review some of the newer classes of urological medications, provide an understanding of basic uropharmacology that may guide treatment recommendations, and provide insight into the potential adverse side effects and interactions of these useful medications.

Traditional medicinal plants of cold desert Ladakh-used against kidney and urinary disorders

AIM OF THE STUDY

Traditional medicine of clod desert Ladakh has large potential to treat various ailments among tribal communities inhabited in the remotest region of Indian subcontinent. This study was conducted to document the new ethno-medico-botanical information and traditional use of medicinal plants against kidney and urinary disorders, and thus to conserve the rapidly disappearing traditional knowledge system of Amchis of Ladakh.

MATERIALS AND METHODS

The information was collected from 105 villages of Leh and Kargil districts of Ladakh region by involving 47 Amchis (the herbalists), village heads and old aged persons including women population through on spot interview and repeated queries among other interviewees over a period of 3 years from 2004-2006.

RESULTS

The use of 68 medicinal plants belonging to 29 families and 58 genera of clod desert was documented against the treatment of kidney and urinary disorders in the tribal communities of Ladakh region in India. These species were used in combination of some exotic species such as Bergenia ligulata, Cinnamomum zeylanicum, Crocus sativus, Elettaria cardamomum, Emblica officinalis, Ficus religiosa, Mangifera indica, Punica granatum, Santalum album, Spondiax axillaris, Terminalia belerica, Terminalia chebula, Zingiber officinale and some medicinal stones, minerals and salts etc. Problem in urine discharge, burning sensation and painful urination, inflammation and bleeding in the kidney, irritable condition of bladder, haemorrhage of kidney and removal of blocked urine and kidney stone were the frequently reported disorders in the study area.

CONCLUSION

The effectiveness of traditional system of medicine, role of Amchis in preparation of remedies according to age, sex and severity of ailment, method of preparation, doses and its administrations among tribal communities of Ladakh provides certain new information. Though the system is extensively used among the tribal communities in the remotest regions but still it has a great scope of proper phytochemical and pharmacological validation of the medicinal plants used in different remedies for conservation and development of traditional system of medicine according to modernization.

Can pre-assessment of patients with LUTS result in early discharge from urology clinic?

Waiting times for appointments for urological out-patients in Ireland and the U.K. can be excessively long. Nurse-led Lower Urinary Tract symptom (LUTs) pre-assessment clinics have been introduced to streamline patient care pathways. We examined whether a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit. A pilot study was undertaken whereby patients referred with LUTS were sent for pre-assessment prior to their out-patients appointment. 214 consecutive patients underwent pre-assessment. Of these, 39 (18%) patients were discharged following their first out-patient visit and 27 (13%) patients were discharged after a second attendance. A further 35 (16%) patients continued to attend but underwent no further investigations or treatment, and possibly should have been discharged earlier. Overall 46% of pre-assessed patients could have been discharged early from the urology clinic. In conclusion a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit.

Hyperuricosuria, an often overlooked cause of recurrent oliguria in children

The association of oliguria with hyperuricosuria is often overlooked. Herein, we report an infant who since the age of five months had recurrent oliguria secondary to hyperuricosuria documented several times in the hospital. The decreased urine output coincided with the presence of increased excretion of uric acid, which fluctuated within 24 hours as well as every few weeks. The child responded to treatment with increase in the fluid fluid intake along with the xanthine oxidase inhibitor, allopurinol. Being alert for hyperuricosuria in cases of oliguria, especially if there is history of gout or stones, may avoid performing many unnecessary investigations.

[Use of botulinum toxin in urology]

Botulinum toxin has been used in urology for more than 20 years. Its application, however, has been restricted to merely a few indications because of the lackof approval. Most studies available have focused on disturbed detrusor-sphincter synergy and overactive bladder. Results of a placebo-controlled study on overactive bladder have now been published. Further studies relevant to the approval of botulinum toxin are being conducted. This substance has also been successful in several other urologic indications.

[The evaluation of urinary tract dysfunction in children with monosymptomatic primary nocturnal enuresis]

The reason for our search was various investigations about urinary tract dysfunctions in enuretic children.

AIM

The aim of our study was estimation of lover urinary tract function in children with monosymptomatic primary nocturnal enuresis without positive reaction for a long non pharmacological therapy.

MATERIAL AND METHODS

54 children after 9-12 months behavioral therapy and short pharmacological treatment (desmopresin) was undergoing urodynamic investigation (uroflowmetry and cystometry).

RESULTS

Urodynamic disorders was found in 44/54 of estimated children. In 34 of children it was overactive bladder, in 6 patients we found detrusor-sphincter discoordination. Five children had decreased bladder capacity. Next to non pharmacological treatment we used anticholinergic or Baclofen depending on the results of urodynamic tests. The response to the treatment (non bedwetting at all) we observed in 34 children (in 9 of them after 3 months of therapy, in 16 after 6 months of therapy and in 12 after 12 months of therapy). The rest of children had decreased number of wet night per month.

CONCLUSION

The pharmacological treatment of urodynamic disorders helps to children with monosymptomatic primary nocturnal enuresis to lost this symptom.

High-dose terazosin therapy (5mg) in Korean patients with lower urinary tract symptoms with or without concomitant hypertension: a prospective, open-label study

PURPOSE

We determined the efficacy and safety of a relatively high dose of terazosin (5mg) in Korean patients with lower urinary tract symptoms (LUTS), with or without concomitant hypertension.

MATERIALS AND METHODS

From July to December 2006, 200 men who consecutively presented with LUTS were prospectively studied. Eight weeks after treatment, blood pressure (BP), uroflowmetry, and International Prostate Symptom Score (I-PSS) were assessed. For analysis purposes, patients were stratified according to concomitant hypertension. Of the 200 patients, 173 completed the scheduled eight-week treatment period.

RESULTS

At baseline, no differences were evident in the two groups in terms of I-PSS, Qmax, PVR and BP. After eight weeks of treatment-although I-PSS and uroflowmetry parameters were not significantly different in the two groups-systolic and diastolic BP in the non-hypertensive control group were higher than in the hypertensive group (p= 0.001 and p=0.0100, respectively). Changes in I-PSS, uroflowmetry parameters, and BPs measured at week eight post- treatment commencement did not significantly differ between the two groups. Moreover, the addition of 5mg of terazosin to antihypertensives did not cause a significant reduction in either systolic or diastolic BP in either group.

CONCLUSION

Adding terazosin to existing antihypertensive regimens did not seem to increase the incidence of adverse events. Our findings suggest that 5mg terazosin is effective and that it has an acceptable safety profile as an add-on therapy for patients with LUTS and concomitant hypertension.

[Progress and prospect of integrative Chinese and Western urinary surgery]

Integrative traditional Chinese and Western urinary surgery is a subject with good prospect and special superiority of combined TCM with Western medicine. In the past decade, great achievements have been obtained by virtue of endeavor from the integrative urinary surgical workers, they set up a good foundation for the development and academic improvement of the cause in our nation.

Daily Administration of Phosphodiesterase Type 5 Inhibitors for Urological and Nonurological Indications

OBJECTIVES

Although the discovery of phosphodiesterases (PDEs) was made soon after the identification of cyclic adenosine monophosphate nearly half a century ago, their true importance in medicine has taken many decades to be realised. The recognition of the important role PDE enzymes play and the impact of altering intracellular cyclic nucleotide levels became significant for most urologists and clinicians in the early 1990s with the discovery of sildenafil, a PDE5 inhibitor (PDE5-I). Once approved around the world, on-demand use of PDE5-Is became the gold standard. Recently, the potential beneficial effects of PDE5-Is on the pulmonary, vascular, and other systems has led to examination of alternative dosing regimens. In this review, we have synthesised the available published peer-reviewed literature to provide a critical contemporary view of evolving indications for PDE5-Is and how alternative dosing regimens may impact on sexual and other functions.

METHODS

MEDLINE search of all peer-reviewed English literature for the period 1990-2007.

RESULTS

The plethora of articles detailing potential uses of PDE5-I in multiple fields of medicine was uncovered. Use of alternative dosing regimens shows great promise across a number of clinical indications, including post-radical retropubic prostatectomy, pulmonary hypertension, endothelial dysfunction, and salvage of on-demand PDE5-I nonresponders.

CONCLUSIONS

Use of PDE5-I on a daily basis may evolve into a major form of drug administration both for men with erectile dysfunction and for those with a myriad of other conditions shown to benefit from this approach.

[Lavomax in outpatient treatment of urogenital chlamidiasis in males]

Sixty four males (age 21-45 years) with urogenital chlamidiasis were divided into two groups. 34 patients of the study group received interferon inductor and lavomax. 30 patients of the control group--interferon inductor and cycloferon. Treatment efficacy in the study group was higher.

PDE5 inhibitors beyond erectile dysfunction

The phosphodiesterase type-5 (PDE5) inhibitors sildenafil, vardenafil and tadalafil are widely used first-line therapy for erectile dysfunction (ED). Since the advent of sildenafil in 1998, more than 40 million men worldwide have been successfully treated with these compounds. The safety and high tolerability of PDE5 inhibitors make them an attractive tool to investigate further physiological functions of PDE5, for example the modulation of intracellular cyclic GMP (cGMP) pools. As cGMP is a key component of intracellular signaling this may provide novel therapeutic opportunities beyond ED even for indications in which chronic administration is necessary. The approval of sildenafil for the treatment of pulmonary hypertension in 2005 was a notable success in this area of research. A number of other potential new indications are currently in various phases of preclinical research and development. In recent years, extensive but very heterogeneous information has been published in this field. The aim of this review is to summarize existing preclinical and clinical knowledge and critically discuss the evidence to support potential future indications for PDE5 inhibitors.

The role of alpha-adrenoreceptors in the treatment of urological diseases

One of the most important clinical pharmacological invention in the last decades the role of adrenoreceptors in urological disease. The disorders of emptying the bladder are associated to the urology. Plant extracts efficacy is low, indicated only in mild symptoms, surgery has to be performed in advanced cases. Recognise, discovering the role of adrenoreceptors in the prostate, bladder neck has changed the treatment of benign prostatic hyperplasia. Relieving the muscle tension leads to a better urinary flow, decreased residual urine and less complaints. Combination with 5alpha-reductase inhibitor a better results can be achieved. The inflammation in prostate is a frequent disease of all age of males. Spasm of the bladder neck maintains the complaints additional alpha-blocker treatment combined with antibiotics, anti-inflammatory drugs are the best choice to cure the patients. Alpha-adrenergic receptor can be found in the lower part of ureter as well. To promote the spontaneous expulsion of lower ureter stones, or fragments after ESWL (extracorporal shock wave lithotripsy) the alpha-blockers are highly recommended.

(Arylpiperazinyl)cyclohexylsufonamides: Discovery of α1a/1d-selective adrenergic receptor antagonists for the treatment of Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms (BPH/LUTS)

Benign Prostatic Hyperplasia/Lower Urinary Tract Symptoms (BPH/LUTS) can be effectively treated by alpha(1)-adrenergic receptor antagonists. Unfortunately, all currently marketed alpha(1) blockers produced CV related side effects that are caused by the subtype non-selective nature of the drugs. To overcome this problem, it was postulated that a alpha(1a/1d) subtype selective antagonist would bring more benefit for the treatment of BPH/LUTS. In developing selective alpha(1a/1d) ligands, (arylpiperazinyl)cyclohexylsulfonamides were synthesized and their binding profiles against three cloned human alpha(1)-adrenergic receptor subtypes were evaluated. Many compounds show equal affinity for both alpha(1a) and alpha(1d) subtypes with good selectivity against the alpha(1b) subtype. They also overcome the problem of dopamine receptor affinity that previous analogues had exhibited.

The vanilloid receptor TRPV1: 10 years from channel cloning to antagonist proof-of-concept

The clinical use of TRPV1 (transient receptor potential vanilloid subfamily, member 1; also known as VR1) antagonists is based on the concept that endogenous agonists acting on TRPV1 might provide a major contribution to certain pain conditions. Indeed, a number of small-molecule TRPV1 antagonists are already undergoing Phase I/II clinical trials for the indications of chronic inflammatory pain and migraine. Moreover, animal models suggest a therapeutic value for TRPV1 antagonists in the treatment of other types of pain, including pain from cancer. We argue that TRPV1 antagonists alone or in conjunction with other analgesics will improve the quality of life of people with migraine, chronic intractable pain secondary to cancer, AIDS or diabetes. Moreover, emerging data indicate that TRPV1 antagonists could also be useful in treating disorders other than pain, such as urinary urge incontinence, chronic cough and irritable bowel syndrome. The lack of effective drugs for treating many of these conditions highlights the need for further investigation into the therapeutic potential of TRPV1 antagonists.

A critical review of the pharmacology of the plant extract ofPygeum africanumin the treatment of LUTS

Despite an unremitting increase in the number of patients presenting symptoms of benign prostate hyperplasia (BPH), the viable treatment options remain relatively limited when compared to other disorders of aging. This has spurred an interest in so-called alternative medicines, many of which continue to be used in spite of the more recent emergence of rationally targeted therapies. Nonetheless, in the case of plant extracts, the vast majority of these have not been subjected to the same rigorous pre-clinical pharmacological testing and large-scale clinical trials now required by health authorities. Furthermore, demonstration of their clinical efficacy in BPH has been hindered by trials of limited duration with a high placebo response. Beginning with a preliminary demonstration of in vitro inhibition of growth factor-mediated fibroblast proliferation with Pygeum africanum extract, a detailed series of in vitro and in vivo studies on prostate growth and bladder function were undertaken. These studies, reviewed herein, have permitted the identification of putative molecular targets of Pygeum africanum extract affecting both growth factor-mediated prostate growth as well as specific parameters of bladder function. These results, corroborated in part by short-term clinical efficacy, set the stage for a large-scale clinical trial to investigate the efficacy of Pygeum africanum extract in the treatment of lower urinary tract symptoms.

Finasteride to evaluate the efficacy of dutasteride in the management of patients with lower urinary tract symptoms and enlarged prostate

Patients with lower urinary tract symptoms and enlarged prostate were randomized to receive, in a double blind fashion, either Finasteride 5 mg/day or Dutasteride 0.5 mg/day for a period of 12 weeks. IPSS score, Qmax, and Quality of Life were assessed at the end of 0 and 12 week periods. Dutasteride significantly improved Qmax, reduced IPSS score, and improved Quality of Life as compared to Finasteride at the end of the 12-week period. Dutasteride with its inhibitory effects on type 1 and 2 5alpha-reductase, produces significantly better results than Finasteride.

Short-term efficacy and long-term compliance/treatment failure of the alpha1 blocker naftopidil for patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

OBJECTIVE

To evaluate treatment failure during a 4-year follow-up period after administration of naftopidil for patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) in real-life clinical practice.

MATERIAL AND METHODS

A total of 247 patients with LUTS/BPH who had an International Prostate Symptom Score (IPSS) of > or =8 were enrolled in the study. Naftopidil, 50 mg/day, was given to the patients. They were followed for 4 years with periodic evaluation. Treatment failure was defined as conversion to other medical treatment or to surgery.

RESULTS

Of the 247 patients, treatment failure occurred in 42 (17.0%) during the 4-year follow-up period. The 4-year treatment failure rate was on the Kaplan-Meier curve 35.0%. Among parameters assessed at baseline, prostate volume (PV) was the only significant determinant of treatment failure: patients with a PV of > or =35 ml had a 2.1 times higher hazard of treatment failure than those with a PV of <35 ml (95% CI 1.06-4.33; p=0.03). Patients with a severe IPSS at 12 weeks after administration of naftopidil had a 3.5 times higher hazard than those having a mild/moderate IPSS (95% CI 1.34-9.26; p=0.01). After 4 years, 200 patients (81%) had stopped taking naftopidil because of adverse events, treatment failure, loss to follow-up, etc.

CONCLUSIONS

There were significant improvements in IPSS and urinary flow rate with naftopidil although it is unknown whether these improvements were significantly larger than the placebo effect as the study was non-randomized. However, only 19% of patients were known to have continued with the same medication for 4 years in real-life clinical practice. Patients who have a large prostate at baseline and a severe IPSS at 12 weeks after treatment are more likely to have treatment failure, although a prospective study is needed to confirm this.

Pharmaceutical Agents and Pregnancy in Urology Practice

Urologic medical conditions are not frequently encountered during pregnancy. Still, urologists often are asked to treat pregnant patients for conditions that require prescriptions. In the generally healthy population of pregnant women, the use of pharmaceutical agents is usually reserved for women who have either infections or necessary surgical procedures. This article addresses the implications for pregnancy of common urologic conditions in generally healthy pregnant women, namely simple urinary tract infections that demand nitrofurantoin and complex urinary tract infections that necessitate fluoroquinolones treatment. It also examines the implications of nonobstetric surgical intervention.

A decision aid for GPs for the treatment of elderly male patients with lower urinary tract symptoms (LUTS)

BACKGROUND

GPs have four main treatment options for lower urinary tract symptoms (LUTS): watchful waiting, alpha-blockers, 5-alpha-reductase inhibitors or (referral for) surgery. Guidelines do not provide clear cut-off values for (combinations of) symptoms and physical examination results to decide which treatment is best.

OBJECTIVE

(i) To develop a decision aid ('checklist') for GPs for the treatment of patients with LUTS. (ii) To assess its value for use in a primary care population. Materials and methods. Population-based cross-sectional study. Included were subjects with uncomplicated LUTS for whom treatment in primary care may be appropriate. [International Prostate Symptom Score (IPSS) > or = 8, no prior prostate surgery, prostate-specific antigen (PSA) value < 10 ng/ml]. For each subject the appropriateness of surgery and alpha-blocker treatment was determined using a previously validated formalized international expert panel judgement. Regression models using data available in primary care were constructed to predict the panel judgement. Subsequently these models were transformed into simple checklists. Finally, the efficiency of these checklists was calculated.

RESULTS

The best checklists consisted of age, symptoms severity, type of symptoms, a quality of life score and PSA value. Assuming one would like to provide at least 95% of the subjects for whom a certain treatment is appropriate with this treatment (i.e. 'sensitivity' of the checklist > or = 95%), one can reach a positive predictive value of 50-60%.

CONCLUSION

Simple checklists based on the judgement of experts regarding the most appropriate therapy can help GPs to advise their patients of a rational treatment strategy.

Under what conditions is feedback microwave thermotherapy (ProstaLund Feedback Treatment) cost-effective in comparison with alpha-blockade in the treatment of benign prostatic hyperplasia and lower urinary tract symptoms?

OBJECTIVE

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are a common condition in men, and their incidence increases with age. The objective of this study was to evaluate the potential cost-utility of microwave thermotherapy, specifically the ProstaLund Feedback Treatment (PLFT), versus alpha-blockade in Swedish patients with LUTS due to BPH.

MATERIAL AND METHODS

A health-economic simulation model, based on long-term disease progression and costs, was developed to analyse the cost-utility of PLFT in comparison with alpha-blockade over a 3-year period based on data from published literature, treatment programmes and official price lists. Outcome measures used in the analysis were quality of life, survival and reduction in International Prostate Symptom Score. Sensitivity analyses were performed for a number of essential variables. The perspective of the study is the healthcare sector. All costs are expressed as 2003 prices.

RESULTS

Three years after an intervention with PLFT or initiation of drug treatment the cost-utility of PLFT was estimated at approximately euro 6600-9500 per quality-adjusted life-year gained. The cost-utility was further improved over a longer time period, and PLFT appears to be cost-saving after 5 years. One important finding from the model simulation was that PLFT also seems to be favourable in patients with less pronounced symptoms. This result may be further validated when additional results from controlled clinical trials become available.

CONCLUSIONS

The present model simulation indicates that treatment with PLFT seems to be cost-effective compared with drug therapy with alpha-blockade. The result shows that the time-frame of the analysis has a great impact on the cost-effectiveness ratio.