The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group

Evaluation and medical management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is common among aging men. Untreated BPH may lead to complications including urinary tract infection, acute urinary retention, and obstructive nephropathy. Diagnosing BPH can be challenging because lower urinary tract symptoms are found in conditions other than BPH, and prostate size correlates poorly with symptoms of obstruction. Nonetheless, a careful medical history and physical examination, along with prudent use of diagnostic tests, can yield an accurate diagnosis. We review the evaluation of men with suspected BPH and indications for referral to a urologist for invasive therapy. We also review supporting evidence and treatment considerations for saw palmetto and the 2 major classes of prescription medications, alpha1-adrenergic antagonists and 5alpha-reductase inhibitors.

The association between lower urinary tract symptoms and sexual dysfunction: fact or fiction?

PURPOSE OF REVIEW

Both lower urinary tract symptoms and sexual dysfunction are common conditions in aging men. In the past few years, increasing attention has been paid to the question of whether these conditions are associated in any way. The conventional belief of the majority of urologists so far has been that the coexistence of these two conditions is coincidental. This review was conducted to discuss the recent literature on this issue. In addition we will concisely address the effect of the different treatment modalities on sexual function.

RECENT FINDINGS

Several trials were conducted recently to assess the association between lower urinary tract symptoms and sexual dysfunction. These trials all made use of self-reported questionnaires on urinary symptoms and sexual function sent to representative samples of the community. The occurrence of urinary symptoms appeared to be a risk factor for the development of erectile dysfunction, ejaculation disorder and decreased libido. Importantly, this association was independent of age and various co-morbidities.

SUMMARY

In contrast to long-established opinion, an age-independent association between lower urinary tract symptoms and sexual dysfunction was found in several recent population-based trials. The nature of this association, however, remains unclear. Future study is required to gain a better understanding of the possible underlying mechanisms.

Treatment of bladder stones without associated prostate surgery: Results of a prospective study

OBJECTIVES

To assess the effectiveness of noninvasive bladder lithiasis treatment without associated prostate surgery to know whether bladder lithiasis is an absolute indication for prostate surgery.

METHODS

Fifty patients with bladder lithiasis were entered in a prospective trial and were treated with extracorporeal shock wave lithotripsy if lithiasis was smaller than 4 cm2. Independent of the presence or absence of bladder outlet obstruction, in no case was prostate surgery associated. The variables studied were the effectiveness of the treatment, changes in the International Prostate Symptom Score (IPSS), and the subsequent need for desobstructive prostate surgery. The statistical study was performed using Student's t test and the proportional hazards model.

RESULTS

Bladder lithiasis was successfully eliminated in 93% of the cases (in 77% of them with a single extracorporeal shock wave lithotripsy session). The mean IPSS decreased from 17.7 to 9.7 points (P = 0.0001) after lithiasis elimination. After a mean follow-up of 22 months, a mere 8% of the patients needed subsequent prostate surgery because their IPSS had increased to 20 points or more. The sole prognostic factor for the need for ensuing prostate surgery was the pretreatment IPSS score (P = 0.042).

CONCLUSIONS

Noninvasive management of bladder lithiasis with no associated prostate surgery is highly efficient and results in marked symptomatic improvement. Furthermore, the number of patients needing subsequent prostate surgery was very low at mid-term follow-up. Because of all of the above, the existence of bladder lithiasis is not an absolute indication for prostate surgery.

Long-term sustained improvement in symptoms of benign prostatic hyperplasia with the dual 5alpha-reductase inhibitor dutasteride: results of 4-year studies

OBJECTIVE

To report additional analyses of efficacy over the initial 2 years and during a 2-year open-label extension of the three pivotal phase 3 studies in which dutasteride, a dual inhibitor of type 1 and 2 5alpha-reductase, was shown to be effective and well tolerated.

PATIENTS AND METHODS

All patients in the placebo and active groups were eligible for entry into the 2-year open-label extension, with all receiving dutasteride 0.5 mg daily. Mean changes from baseline were calculated for the American Urologic Association Symptom Index (AUA-SI) score at each scheduled time in the double-blind and open-label phase. The additional analyses included a breakdown of the AUA-SI score, including stratifying patients by symptom severity, assessment by baseline age and prostate volume, and the evaluation of symptoms responders.

RESULTS

There was a clinically meaningful improvement in AUA-SI in patients on dutasteride in the double-blind phase, but not in those on placebo. At 48 months, patients on dutasteride in both study phases had greater improvements in AUA-SI score and individual question scores than those on dutasteride in the open-label phase only. The proportion of patients with severe symptoms declined in both study groups, although these changes were more profound in those receiving dutasteride for the 4-year duration of the study.

CONCLUSION

In men with symptomatic benign prostatic hyperplasia, long-term (4-year) treatment with the dual isozyme 5alpha-reductase inhibitor dutasteride resulted in sustained and continued improvements in symptoms and flow rate. For 4 vs 2 years, longer dutasteride therapy resulted in greater symptom improvement.

Integrating risk profiles for disease progression in the treatment choice for patients with lower urinary tract symptoms/benign prostatic hyperplasia: a combined analysis of external evidence and clinical expertise

The RAND appropriateness method was used to explore the relevance of risk factors for disease progression in the treatment choice for patients with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). A total of, 12 international experts assessed the appropriateness of various treatments for 243 risk profiles. Highest appropriateness rates were found for alpha1-adrenoceptor antagonists (68% of profiles) and combination therapy (46%). A large prostate volume was the dominant argument in favour of 5alpha-reductase inhibitors and combination therapy, but was irrelevant for the choice of surgery. Considerable postvoid residual, severe symptoms and poor maximum flow rate were the most important factors in favour of surgery.

High-power potassium-titanyl-phosphate photoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates

OBJECTIVES

To study the safety and efficacy of high-power potassium-titanyl-phosphate photoselective laser vaporization of the prostate in men with prostate volumes greater than 60 cm3.

METHODS

A total of 64 men with symptomatic benign prostatic hyperplasia and large-volume prostates underwent photoselective laser vaporization of the prostate between May 2002 and September 2003. Medical therapy had failed in all men, and 18 presented with urinary retention. The preoperative evaluation included the maximal flow rate, postvoid residual urine volume, prostate volume, serum sodium, creatinine, and hematocrit, and International Prostate Symptom Score. Transurethral prostatectomy was performed with an 80 W potassium-titanyl-phosphate (KTP) side-firing laser system through a 23F continuous-flow cystoscope with normal saline as the irrigant. The operative time, anesthesia type, length of stay, and postoperative serum sodium, creatinine, and hematocrit were recorded. The International Prostate Symptom Score, maximal flow rate, and postvoid residual urine volume were measured at each follow-up visit.

RESULTS

The mean preoperative prostate volume was 101 +/- 40 cm3. The mean operative time was 123 +/- 70 minutes. No transfusions were required. Of the 64 patients, 62 were discharged within 23 hours. The serum sodium level did not change significantly. The International Prostate Symptom Score decreased from 18.4 preoperatively to 9.9, 8.6, 7.2, and 6.7 at 1, 3, 6, and 12 months postoperatively, and the maximal flow rate increased from 7.9 mL/s preoperatively to 16.4, 16.2, 20.0, and 18.9 mL/s at 1, 3, 6, and 12 months postoperatively. The postvoid residual urine volume also decreased from 189 mL preoperatively to 78, 78, 67, and 109 mL at 1, 3, 6, and 12 months postoperatively.

CONCLUSIONS

Photoselective laser vaporization of the prostate is safe and efficacious, with durable results for men with symptomatic benign prostatic hyperplasia and large-volume prostates.

Fact or fiction: what do the benign prostatic hyperplasia data tell us?

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men. Our understanding of this condition has improved greatly over the years and recent advances have changed our approach to management. At the end of the 19th century, prostatic enlargement was treated effectively by bilateral orchidectomy. Unsurprisingly, this treatment option never gained widespread popularity. Less than 10 years ago, surgery and watchful waiting were the only considered treatment options for BPH. We now have a number of medical therapies and minimally invasive treatment options available that can effectively manage lower urinary tract symptoms secondary to benign prostatic obstruction. However, with increased choice comes the increased need for clarity in selection and application of these various treatment options. In the current environment of evidence-based clinical practice, awareness and interpretation of data from the numerous studies is paramount. The lessons learned from these trials should be reflected clearly in our practice, with clinical management based on fact, not fiction. In this review, we critically assess the available data and understanding of the management of BPH.

Long-term efficacy and safety of a combination of sabal and urtica extract for lower urinary tract symptoms—a placebo-controlled, double-blind, multicenter trial

The efficacy and tolerability of a fixed combination of 160 mg sabal fruit extract WS 1473 and 120 mg urtica root extract WS 1031 per capsule (PRO 160/120) was investigated in elderly, male patients suffering from lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia in a prospective multicenter trial. A total of 257 patients (129 and 128, respectively) were randomized to treatment with PRO 160/120 or placebo (127 and 126 were evaluable for efficacy). Following a single-blind placebo run-in phase of 2 weeks, the patients received 2 x 1 capsule/day of the study medication under double-blind conditions over a period of 24 weeks. Double-blind treatment was followed by an open control period of 24 weeks during which all patients were administered PRO 160/120. Outcome measures for treatment efficacy included the assessment of the patients' LUTS by means of the I-PSS self-rating questionnaire and a quality of life index as well as uroflow and sonographic parameters. Using the International Prostate Symptom Score (I-PSS), patients treated with PRO 160/120 exhibited a substantially higher total score reduction after 24 weeks of double-blind treatment than patients of the placebo group (6 points vs 4 points; P=0.003, one tailed) with a tendency in the same direction after 16 weeks. This applied to obstructive as well as to irritative symptoms, and to patients with moderate or severe symptoms at baseline. Patients randomized to placebo showed a marked improvement in LUTS (as measured by the I-PSS) after being switched to PRO 160/120 during the control period (P=0.01, one tailed, in comparison to those who had been treated with PRO 160/120 in the double-blind phase). The tolerability of PRO 160/120 was comparable to the placebo. In conclusion, PRO 160/120 was clearly superior to the placebo for the amelioration of LUTS as measured by the I-PSS. PRO 160/120 is advantageous in obstructive and irritative urinary symptoms and in patients with moderate and severe symptoms. The tolerability of the herbal extract was excellent.

Treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in relation to the patient's risk profile for progression

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is a slowly progressing disease, with some patients progressing more rapidly than others. In 80% of patients who progress this is caused by the worsening of symptoms. The physician can predict the risk of progression from the patient's clinical profile; increased symptom severity, a poor maximum urinary flow rate (Qmax), and a high postvoid residual urine volume (PVR), are major risk factors for overall clinical progression of LUTS/BPH. A large baseline prostate volume and a high serum prostate-specific antigen (PSA) level are the predominant risk factors for developing acute urinary retention. After predicting risk, the most appropriate treatment should be established by balancing the benefits of treatment against the possible risks and bother resulting from adverse events. From the Medical Therapy Of Prostatic Symptoms study it can be concluded that monotherapy with an alpha1-adrenoceptor (AR) antagonist is an appropriate treatment for many patients with LUTS/BPH. However, for those at high risk of progression (those with a large prostate volume and high PSA level), it appears more appropriate to add a 5alpha-reductase inhibitor to the alpha1-AR antagonist to obtain maximum relief of symptoms, and ideally to halt the progression of the disease. This was confirmed by the RAND Appropriateness Method study, in which 12 urologists determined the most appropriate treatment for patients with LUTS/BPH based on their clinical profile, combination of clinical variables and/or risk factors. This study also indicates that patients at very high risk of progression, with severe obstruction (poor Qmax and high PVR), are potential candidates for immediate surgery.

Limitations of using outcomes in the placebo arm of a clinical trial of benign prostatic hyperplasia to quantify those in the community

OBJECTIVES

To quantify potential biases that may occur when placebo arms of clinical trials are used to characterize the natural history of disease and to compare incidence rates of benign prostatic hyperplasia (BPH) outcomes in community-dwelling men with outcomes in the placebo arm of a clinical trial of BPH.

SUBJECTS AND METHODS

White men aged 50 years or older at baseline were selected randomly from the Olmsted County, Minnesota, community in 1990 and were monitored biennially through 1996 for urologic outcomes. Symptom progression, acute urinary retention, and minimally Invasive or surgical treatment of BPH were assessed from a validated questionnaire and a review of community medical records. Findings from the Olmsted County Study (N=1193) and a selected subcohort (n=238) were compared with those from the placebo arm of the Medical Therapy of Prostatic Symptoms trial (N=737).

RESULTS

During more than 5088 person-years of follow-up (mean, 4.9 years) In the Olmsted County Study, Incidence rates per 1000 person-years were 8.5 (95% confidence Interval [CI], 6.4-11.2) for acute urinary retention, 97.1 (95% CI, 88.7-106.0) for symptom progression, 6.6 (95% CI, 4.8-9.0) for surgery or minimally invasive treatment, and 105.1 (95% CI, 96.4-114.4) for any outcomes for all men. For those meeting trial Inclusion criteria (selected subcohort, n=238), Incidence rates were 18.3, 86.5, 16.8, and 109.4, respectively. By comparison, Incidence rates per 1000 person-years for the placebo arm of the Medical Therapy of Prostatic Symptoms clinical trial for BPH (mean follow-up, 4.5 years) were 6 for acute urinary retention, 36 for symptom progression, and 45 for any outcome, but the estimate of 13 for surgery or minimally invasive treatment was higher than for men in the Olmsted County Study.

CONCLUSIONS

Compared with community-dwelling men, men in the placebo arm of this clinical trial of BPH treatments had a substantially lower risk of BPH-related outcomes. Extrapolation of findings from the placebo arm of clinical trials to describe the natural history of disease in community-dwelling men should be done with caution and appropriate recognition of limitations.

Measurement of the mechanical characteristics of benign prostatic tissue: A Novel method for assessing benign prostatic disease

OBJECTIVES

To investigate the relationship between the morphology and the mechanical properties of benign prostatic tissues measured in vitro.

METHODS

Fresh tissue specimens were collected from 17 patients undergoing transurethral resection of the prostate for benign prostatic obstruction. Individual tissue specimens underwent immediate mechanical testing, by applying a dynamic compressive strain to the samples. The amplitude ratio (E*) and phase difference (tan delta), measures of tissue elastic and viscous components, were derived. Individual sections from the processed specimens underwent immunohistochemical staining and computerized image analysis to measure the morphologic characteristics of each transurethral resection of the prostate chipping. Correlations between the morphologic and mechanical measurements were assessed.

RESULTS

A strong positive correlation was found between prostatic smooth muscle content and (E*) (R2 = 0.58, P = 0.009).

CONCLUSIONS

The results of this study have demonstrated that strong correlations exist between prostatic tissue morphology and mechanical characteristics. We believe that the ability to quantify prostatic tissue mechanical characteristics in vivo may be of clinical benefit in the future assessment and treatment of benign prostatic disease.

Erectile dysfunction: anatomical parameters, etiology, diagnosis, and therapy

Functional anatomy of the human penis involves various parameters: cavernous tissue, covering integument, prepuce foreskin, corpora cavernosa, corpus spongiosum, glans, facia, arterial supply, venous drainage, lymph drainage, musculature, and nerve supply. Several factors affect the expression/degree of erectile dysfunction (ED) endocrine profile, aging/senescence, demyelinating diseases, and surgery. Risk factors of ED are: age, vascular factors, metabolic diseases (diabetes mellitus), neurologic diseases, and HIV/AIDS. Several drugs are associated with ED: antiandrogenic, anticholinergic, antidepressants, antihypertensive, major tranquilizers, anxiolytics, and certain medicines/metabolites. The International Index of Erectile Function (IIEF) is a multidimensional scale for assessment of erectile dysfunction. The main structures mediating erection are the corpora cavernosa or "erectile bodies," which are fused distally for approximately three-quarters of their length. They separate proximally to fuse with each ischial tuberosity of the pelvis. On their ventral surface lies the corpus spongiosum, which surrounds the urethra. Coital dysfunction is classified into "erectile dysfunction" (psychosexual and endocrine/neuro-endocrine) and "ejaculatory dysfunction" (psychosexual, and genitourinary surgery). Vasculogenic impotence was evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis. Cavernosal, alpha-blockade is a technique used to evaluate and treat ED. Another diagnostic procedure for ED involves color floro and spectural Doppler imaging after papaverine-induced erection in impotent men. Color Doppler and duplex ultrasonography are used to evaluate Peyronie's disease. Sildenafil cilrate (Viagra) is an effective therapy of ED in men. Vardenavil is a highly selective phosphodiesterase 5 (PDE5) inhibitor which improved ED. Prostagland E1, vasoactive intestinal polypeptide (VIP), and phentolamine mesylate (administered by autoinjectors) have been applied to treat ED in patients resistant to other intracavernosal agents. Clinical trials were conducted on self-injection of vasoactive drugs, apomorphine SL, and tadalafil in diabetic men. Medical therapy of ED includes: medicated urethral system for erection (MUSE), intravenous pharmacotherapy, arterial revascularization, vacuum devices, two- and three-component inflatable penile prosthesis, semi-rigid penile prosthesis in situ, and inflatable one-piece penile prosthesis. Surgical therapy include procedures to correct Peyronie's penile deformity and penile deformity, procedures to avoid inevitable shortening accompanying Nesbit's disease, and for penile lengthening.

Dutasteride: a novel dual inhibitor of 5α-reductase for benign prostatic hyperplasia

Dutasteride is a new dual 5alpha-reductase inhibitor for the treatment of benign prostatic hyperplasia. It differs from finasteride as it inhibits both isoenzymes of 5alpha-reductase and results in near-complete suppression of serum dihydro-testosterone. Similar to finasteride, it reduces serum prostatic specific antigen by approximately 50% at 6months and total prostate volume by 25% in 2years. Randomised, placebo-controlled trials conducted over 2years have shown the efficacy of dutasteride in symptomatic relief, improvements in quality of life and peak urinary flow rate, and reduction of acute urinary retention events and the need for surgery. The main side effects are erectile dysfunction, decreased libido, gynaecomastia and ejaculation disorders. However, long-term usage for > 4years did not reveal increased new onset of sexual side effects. In addition, the combination of dutasteride and tamsulosin is well-tolerated and has the added advantage of rapid symptomatic relief. Finally, dutasteride has been shown to possess tumour regression properties invitro and its role in chemoprevention of prostate cancer will be confirmed in the ongoing Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial.

Urologic diseases in America project: benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia (BPH), the most common benign neoplasm in American men, is a chronic condition that is associated with progressive lower urinary tract symptoms and affects almost 3 of 4 men during the seventh decade of life. Approximately 6.5 million of the 27 million white men who are 50 to 79 years old in the United States in 2000 were estimated to meet the criteria for discussing treatment.

MATERIALS AND METHODS

The analytical methods used to generate these results have been described previously.

RESULTS

In 2000 approximately 4.5 million visits were made to physician offices to for a primary diagnosis of BPH and almost 8 million visits were made with a primary or secondary diagnosis of BPH. In the same year approximately 87,400 prostatectomies for BPH were performed in inpatients in nonfederal hospitals in the United States. While the number of outpatient visits for BPH increased consistently during the 1990s, there was a dramatic decrease in the use of transurethral prostatectomy, inpatient hospitalization and length of hospital stay for this condition. These trends reflect the changing face of medical management for BPH, ie increasing use of pharmacological agents and minimally invasive therapies. In 2000 the direct cost of BPH treatment was estimated to be $1.1 billion exclusive of outpatient pharmaceuticals.

CONCLUSIONS

Given the impact that BPH has on quality of life and health care cost in millions of American men, additional research into risk factors, diagnostic and therapeutic resource use, and effectiveness and cost benefit of therapies are warranted.

Effects on Sexual Function by the Drugs used in the Treatment of Benign Prostatic Hyperplasia and Prostate Cancer. A Practical Guide for the Urologist

The effects on sexual function (SF) by the drugs commonly used in the treatment of benign prostatic hyperplasia (BPH) and prostate cancer (PC) have been analyzed. BPH therapy: alpha-blockers have no adverse effects on SF; the only one without significant hypotensive effect, Tamsulosin, can cause retrograde ejaculation in 4–8% of cases. 5-Alpha-reductase (Finasteride and Dutasteride) inhibitors could have detrimental effects on erectile function, libido and ejaculation in a small percentage of cases rarely exceeding 10%; these effects are reversible and their incidence reduces after 1 yr. Phytotherapy (extracts from pygeum africanum and serenoa repens) and mepartricin have no unfavorable action on SF. PC therapy: Loss of erectile function and libido are the norm with the use of LH-RH analogues, estrogens and steroidal antiandrogens (cyproterone acetate). Non-steroidal antiandrogens (Flutamide, Bicalutamide and Nilutamide) allow the preservation of SF in two-thirds of cases.

Correlation between voiding and erectile function in patients with symptomatic benign prostatic hyperplasia

BACKGROUND

The relationship between lower urinary tract symptoms and male sexual dysfunction remains controversial. In this study, we aimed to evaluate the relationship between voiding and erectile function (EF) using the American Urological Association Symptom Index (AUA-SI) and International Index of EF (IIEF-15) in patients with benign prostatic hyperplasia (BPH).

METHODS

From March 2001 to January 2002, 50 men (aged 43-92 years) with symptomatic BPH were enrolled in the study. They completed the AUA-SI and IIEF-15 questionnaires. An additional question about subjective erectile dysfunction (ED) was also evaluated. AUA-SI scores were divided into 3 categories (irritative, obstructive, and total), and IIEF-15 scores were divided into 6 categories (EF, orgasmic function [OF], sexual desire [SD], intercourse satisfaction [IS], overall satisfaction [OS], and total).

RESULTS

Irritative, obstructive and total AUA-SI scores were 7.8 +/- 3.7, 8.4 +/- 5.6 and 16.3 +/- 8.2, respectively. Scores in the 6 categories of the IIEF-15 questionnaire were as follows: EF, 12.1 +/- 10.1; OF, 3.7 +/- 3.8; SD, 4.4 +/- 2.0; IS, 4.5 +/- 4.4; OS, 4.4 +/- 2.6; and total, 29.4 +/- 22.2. No obvious correlation was noted between AUA-SI and IIEF-15 scores. Further, no statistical significance was noted, either between AUA-SI and IIEF-15 severity, or between AUA-SI and EF severity. Among 22 patients who self-reported the absence of ED, 17 (77%) had an EF-domain score less than 26. The mean age of patients with, versus those without, ED was significantly greater.

CONCLUSION

Voiding and EF, assessed by the AUA-SI and IIEF-15 questionnaires, respectively, are not correlated in patients with BPH.

Low Incidence of Acute Urinary Retention in the General Male Population: The Triumph Project

OBJECTIVE

To describe the incidence of acute urinary retention (AUR) in the general male population and in a population of men newly diagnosed with lower urinary tract symptoms suggestive of BPH (LUTS/BPH).

METHODS

We performed a retrospective cohort study in the Integrated Primary Care Information (IPCI) database, a GP research database in The Netherlands, during the period 1995-2000. All males, > or =45 years, without a history of AUR or radical cystectomy were included in the study. In addition, we followed a sub-cohort of men, newly diagnosed with LUTS/BPH. AUR was defined as the sudden inability to urinate, requiring catheterization.

RESULTS

Amongst 56,958 males with a mean follow-up of 2.8 years, 344 AUR cases occurred (incidence rate 2.2/1000 man-years) of whom more than 40% were precipitated. AUR was the first symptom of LUTS/BPH in 73 (49%) of the 149 AUR cases that occurred in men newly diagnosed with LUTS/BPH. The risk of AUR was 11-fold higher in patients newly diagnosed with LUTS/BPH (RR 11.5; 95%CI: 8.4-15.6) with an overall incidence rate of 18.3/1000 man-years (95%CI: 14.5-22.8).

CONCLUSIONS

The incidence rate of AUR is low in the general population but substantial in a population of men newly diagnosed with LUTS/BPH. The incidence rate increases with age and AUR is precipitated in approximately 40% of all cases. Within the LUTS/BPH cohort, AUR is the first presenting symptom of BPH in 50% of all AUR cases.

THE RELATIONSHIP AMONG LOWER URINARY TRACT SYMPTOMS, PROSTATE SPECIFIC ANTIGEN AND ERECTILE DYSFUNCTION IN MEN WITH BENIGN PROSTATIC HYPERPLASIA: RESULTS FROM THE PROSCAR LONG-TERM EFFICACY AND SAFETY STUDY

PURPOSE

We evaluated the associations among lower urinary tract symptoms, prostate specific antigen (PSA) and erectile dysfunction (ED) in men with benign prostatic enlargement enrolled in the Proscar (Merck, Whitehouse Station, New Jersey) Long-Term Efficacy and Safety Study.

MATERIALS AND METHODS

The Proscar Long-Term Efficacy and Safety Study was a 4-year, randomized, double-blind, placebo controlled study that enrolled 3,040 men with moderate to severe lower urinary tract symptoms and an enlarged prostate gland. Two questions assessed ED. A logistic regression model, including the effect of patient age, was used to examine the relationships among quasi-American Urological Association Symptom Score (AUASS), PSA, and ED at baseline. Changes in ED scores from baseline to study closeout were analyzed with ANOVA.

RESULTS

A total of 2,981 patients had baseline data available for analysis. Mean age was 64 years, mean quasi-AUASS was 15, mean PSA was 2.8 ng/ml and mean prostate volume was 55 cm. At baseline every 1 point increase in quasi-AUASS was associated with a 2% increased risk of ED even after controlling for age (p <0.001). At 48 months in placebo but not in finasteride treated men a 1-unit decrease in quasi-AUASS was associated with a slight but statistically significant decrease in ED. No association existed between increasing PSA and ED on baseline or longitudinal analysis.

CONCLUSIONS

We found a moderately strong association between baseline quasi-AUASS and the ED rate in men with an enlarged prostate, a finding that was supported by longitudinal data in the placebo arm. The absence of a relationship between PSA and ED highlights the need for further investigation into the mechanisms of benign prostatic hyperplasia related sexual dysfunction.

Finasteride, a Type 2 5α-reductase inhibitor, in the treatment of men with androgenetic alopecia

In men who are genetically predisposed to develop androgenetic alopecia (AGA; male pattern hair loss), endogenous androgens alter scalp hair follicles, resulting in production of vellus-like, miniaturised hair, rather than cosmetically significant terminal hair. This change leads to a progressive decline in visible scalp hair density, readily perceived by the patient as thinning and, eventually, baldness. Dihydrotestosterone (DHT), a metabolite of testosterone produced by the enzyme 5alpha-reductase, has been implicated as the specific androgen in the pathogenesis of AGA. Men genetically deficient in the Type 2 isoenzyme of 5alpha-reductase do not develop AGA. Moreover, Type 2 5alpha-reductase has been detected in scalp hair follicles, and balding scalps contain increased Type 2 5alpha-reductase activity and DHT levels. Taken together, these findings provide a rationale for the use of Type 2 5alpha-reductase inhibitors in the treatment of men with AGA. Finasteride, a specific and potent inhibitor of human Type 2 5alpha-reductase, decreases the formation of DHT from testosterone. Originally developed for the treatment of men with benign prostatic hyperplasia (BPH) as a 5 mg tablet, finasteride was subsequently evaluated as a treatment for AGA. Clinical studies in balding men demonstrated that finasteride reduced scalp DHT levels and improved hair growth, confirming the role of DHT in the pathophysiology of AGA. Dose-ranging studies established the optimal dose of 1 mg/day for the treatment of men with this disorder. Large, multicentre studies established the safety and efficacy of finasteride 1 mg, leading to marketing of Propecia (finasteride 1 mg) as a new treatment for men with AGA.

EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines)

OBJECTIVE

To provide the first update of the EAU guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO).

METHODS

A systematic literature review was conducted based on the results of a MEDLINE search concentrating on the years 1999-2003. In combination with expert opinions recommendations were made on the usefulness of diagnostic tests, therapeutic options and follow-up.

RESULTS

During initial assessment the following tests are recommended: medical history, physical examination including digital-rectal examination, International Prostate Symptom Score, urinalysis, serum creatinine and prostate specific antigen measurement, uroflowmetry and post-void residual volume. All other tests are optional or not recommended. Aim of treatment is to improve LUTS and quality of life and to prevent severe BPE-related complications. Development of a 5alpha-reductase type I and II inhibitor and the data of the MTOPS trial providing scientific evidence for a combination therapy were the most significant innovations since the first version. Finally a more detailed knowledge on the natural history with identification of several risk factors for progression is the basis for a risk-profile orientated (preventive) therapy.

CONCLUSIONS

Updated recommendations for assessment, treatment, and follow-up of patients with LUTS due to BPO are presented.

Serum prostate-specific antigen to predict the presence of bladder outlet obstruction in men with urinary symptoms

OBJECTIVE

To determine whether prostate specific antigen (PSA) level can usefully predict or exclude bladder outlet obstruction (BOO), in men with lower urinary tract symptoms (LUTS).

PATIENTS AND METHODS

A cohort of men from 1996 to 1999 who had LUTS caused by BPH was evaluated by serum PSA and pressure-flow urodynamic studies, and a blinded comparison made. The settings were teaching hospitals in London, UK and L'Aquila, Italy. Men (302) were referred by primary-care practitioners with LUTS and a PSA of < 10 ng/mL. Regression analysis was used to predict the extent of BOO, and create likelihood ratios and predictive values for BOO according to the PSA value.

RESULTS

PSA was significantly associated with BOO (P < 0.001; r2 0.07), with significant likelihood ratios altering the probability of BOO. If the PSA was > 4 ng/mL, mild or definite BOO was likely (89%), whereas if the PSA was <2 ng/mL, there was about a one-third chance each of no, mild and definite BOO.

CONCLUSION

High PSA levels in patients with LUTS are significantly associated with BOO; low PSA levels mean that definite BOO is unlikely.

RELATIONSHIP BETWEEN PROSTATE SPECIFIC ANTIGEN AND INDEXES OF PROSTATE VOLUME IN JAPANESE MEN

PURPOSE

We determined the relationship between serum prostate specific antigen (PSA) and indexes of prostate volume in Japanese men, and compared that relationship with the one in white men.

MATERIALS AND METHODS

Data on a clinical cohort of 535 Japanese men with at least moderate lower urinary tract symptoms (LUTS) and clinical benign prostatic hyperplasia were examined. PSA, and total and transition zone prostate volume were related to age and linear regression analyses were performed to analyze the relationship between PSA and volume indexes.

RESULTS

The group of 535 men with a median age of 68 years had a median serum PSA of 1.5 ng/ml, and a median total and transition zone volume of 26.8 and 8.8 ml, respectively. PSA, total prostate volume and transition zone volume increased almost linearly with age. On univariate regression with age with each successive decade total prostate volume increased by 10.65% (95% CI 5.4 to 16.2), transition zone volume increased by 20.84% (95% CI 11.84 to 30.56) and the transition zone index increased by 3.1% (95% CI 1.66 to 4.57). On multivariate analysis the PSA-total prostate volume relationship was statistically independent of age. The study suggests that Japanese men might produce or release more PSA per unit prostate volume than white men.

CONCLUSIONS

Japanese men with LUTS and clinical benign prostatic hyperplasia but no evidence of prostate cancer might produce and/or release more PSA per unit prostate volume than white men. To our knowledge the cutoffs for PSA and prostate volume to predict the response to LUTS therapy and the development of complications in Japanese men are unknown. Future studies in Japanese men are needed to identify these cutoffs.

[Potential sexual consequences associated with benign prostatic hyperplasia and its treatments]

In this article, an updated review of the potential consequences of treatment of benign prostatic hyperplasia (BPH) on sexual function is proposed in the light of recent data. Differences exist between the different therapeutic options available for the treatment of lower urinary tract symptoms (LUTS) when we want to analyze the impact on sexuality. Surgical procedures including minimally invasive techniques are associated with ejaculation and also erection disorders. Drug treatments also have repercussions on sexuality though there are significant differences between the various classes of these drugs. In daily practice, the relation between the prostate and sexuality must be assessed during any medical examination for one of these diseases and before any decision on treatment.

Prevention of Hormone-Related Cancers: Prostate Cancer

Androgens are known to play an important role in normal prostate development, benign prostatic hyperplasia, established prostate cancer, and in prostate carcinogenesis. However, despite convincing experimental and clinical evidence, the epidemiologic data correlating sex steroid levels with disease risk is inconsistent. More recent work has focused on studies of polymorphisms in germ-line DNA in an effort to develop polygenic models of prostate cancer susceptibility and prognosis. Such models have the potential to aid in the selection of men for specific chemopreventive interventions and to help determine which men with localized prostate cancer are most likely to benefit from aggressive therapy. In this review, we will provide a brief summary of androgen metabolic pathways followed by an assessment of the epidemiology literature addressing the relationship between androgens and prostate cancer. Finally, we will address the two major questions that have arisen in response to the recently published results from the Prostate Cancer Prevention Trial: Who are the best candidates for finasteride chemoprevention, and what are the clinical implications of the high prevalence of prostate cancer that was detected in men with prostate-specific antigen levels in the so-called “normal” range?

The Role of 5αR Inhibitors in the Early Growth of Pca Cells

Aim of this study is to investigate the efficacy of Finasteride (MK906), a selective 5α reductase type 2(5αR2) inhibitor, and of MK386, a selective 5α reductase type 1 (5αR1), on the cellular proliferation of primary cell cultures derived from patients with prostatic diseases.

Methods

We evaluated the effects of Finasteride and MK386 in 30 primary cultures obtained from prostatic carcinoma (PCa), 6 from high grade intraepithelial neoplasia (HGPIN) and 10 from benign prostatic hyperplasia (BPH).

Results

Primary cultures require testosterone (T) for optimal growth and both 5αR inhibitors decreased cell proliferation of primary cultures of PCa cells. IC50 values of Finasteride were lower when compared to those of MK386. In particular, Finasteride was more active in cultures derived from Gleason 2–6 PCa, compared to those derived from Gleason 7–10 PCa. On the contrary, we observed higher effectiveness of MK386 in Gleason 7–10 PCa derived cultures compared to those derived from Gleason 2–6 PCa tissues. The growth of PCa primary cultures was down-modulated by MK386 through a direct inhibition of the epithelial 5αR1, whereas the anti-proliferative activity of Finasteride seems to be mediated by stromal cells present in the primary cultures.

Conclusions

We found biological evidence for an important role of 5αR inhibitors in the early growth of PCa cells and for the necessity of combining anti-hormonal treatment for a sustained inhibition of PCa through the inhibition of stromal cell function even in advanced and androgen-resistant tumor progression phases.

Natural history and clinical predictors of clinical progression in benign prostatic hyperplasia

PURPOSE OF REVIEW

Prevalence of benign prostatic hyperplasia (BPH) is increasing with the aging population worldwide. Knowledge of the natural history of BPH is crucial for primary, secondary and tertiary prevention of its progression. This review examines the evidence of the natural history of BPH, highlighting the group of patients with mild symptoms and the risk factors for progression.

RECENT FINDINGS

Several community and clinical studies have demonstrated the progressive nature of BPH. Different surrogate endpoints, which include symptom score, peak urinary flow rate, prostate volume, and the occurrence of acute urinary retention and need for surgery, have been described. Prostatic specific antigen and prostate volume are the two most common predictors of clinical progression and are helpful to the clinician for identifying high-risk patients.

SUMMARY

With further understanding of the natural history and the predictors of progression of BPH, management can be better tailored according to risk stratification and the results of clinical trials of effectiveness can be better interpreted.

The use of baseline clinical measures to predict those at risk for progression of benign prostatic hyperplasia

Although histologic changes of benign prostatic hyperplasia (BPH) begin in men when they are in their thirties, symptomatic BPH characterized by lower urinary tract symptoms (LUTS) typically do not develop for several decades. Progression of BPH may lead to significant voiding symptoms, acute urinary retention, and the need for prostate surgery. However, developing LUTS is not inevitable for men with histologic evidence of BPH. The ability to predict those men who are at risk for BPH progression is increasingly important because of recent evidence provided by the Medical Therapy of Prostate Symptoms study. This landmark study demonstrated that 5alpha-reductase inhibitors, alone or in combination with selective alpha-blockers, can delay or prevent the progression of BPH. In addition, the most important and consistent predictive factors for BPH progression are baseline prostate-specific antigen and prostate volume. Integration of these clinical parameters into clinical practice is influencing the decision regarding which men should observe or initiate treatment. This article highlights recent studies regarding the use of baseline clinical parameters on predicting BPH progression.

[Arguments for deciding to change treatment in benign prostatic hyperplasia]

Insufficient efficacy above all, but also the appearance of side effects or the occurrence of complications may motivate a change in the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (HBP). In terms of efficacy, surgery remains superior to all medical treatments including alphablockers which are the most active. 5-alpha-reductase inhibitors have a slow efficacy which is all the more marked when the prostatic volume is large. Phytotherapy has a slight activity which is higher than that of placebo. Drug combinations are currently being studied and, although a benefit has been shown in certain publications, their clinical efficacy remains to be specified. They may become an alternative in case of failure of single-agent therapy to prevent or delay surgery. The incidence of side effects is low and varies with the treatment used and within a same therapeutic class. With alphablockers for instance, orthostatic hypotension, which is the main side effect, varies from 1% to 8% approximately depending on the study and molecule. The side effects of 5-alpha-reductase inhibitors are mainly sexual disorders, observed in 1 to 4% of cases approximately. Hence, the occurrence of a drug side effect causing treatment discontinuation should incite a change of molecule, even within the same class for alphablockers. On the other hand, if complications of HBP occur, it is then necessary to resort to surgery.

Review article Testosterone therapy in the ageing male: what about the prostate?

The concerns about testosterone therapy in ageing men with late-onset hypogonadism mainly address the risk of prostatic disease, i.e. either benign prostatic hyperplasia (BPH) or prostate cancer (PCa). Both conditions are highly dependent on androgen action and recent clinical data on the cancer-preventive effect of the 5alpha-reductase inhibitor finasteride have supported the possible role of androgens in PCa. However, the clinical data especially on the long-term effects of exogenous androgen substitution in regard to prostate safety are nonconclusive in many respects. As sufficient clinical studies on these risks will not be available in the near future, the approach of testosterone therapy towards prostate complications should be kept on a safe but practical basis. This review includes some recommendations in regard to testosterone therapy and prostate monitoring in patients with BPH and bladder outlet obstruction, with previous history of curative treatment for PCa or with prostatic intraepithelial neoplasia.

Comparison of the pharmacological effects of a novel selective androgen receptor modulator, the 5alpha-reductase inhibitor finasteride, and the antiandrogen hydroxyflutamide in intact rats: new approach for benign prostate hyperplasia

Tissue-selective androgen receptor modulators (SARMs) demonstrate tissue selectivity in both castrated and intact male rats, behaving as partial agonists in androgenic tissues (i.e. prostate and seminal vesicle), but full agonists in anabolic tissues (i.e. levator ani muscle). The partial agonist activity of SARMs (compounds S-1 and S-4) in the prostate of intact rats suggested that SARM could be used for androgen suppression in the treatment of benign prostate hyperplasia (BPH). This study was designed to explore the mechanisms of action of SARM and to characterize the tissue selectivity of S-1 in intact male rats compared with that of hydroxyflutamide (antiandrogen) and finasteride (5alpha-reductase inhibitor), two major drugs used for androgen suppression treatment of BPH. In intact male rats, S-1 (5, 10, and 25 mg/kg) selectively decreased the prostate weight with similar efficacy to finasteride (5 mg/kg), without affecting the levator ani muscle or increasing the plasma levels of testosterone, LH, and FSH. Hydroxyflutamide (0.5, 1, 5, 10, and 25 mg/kg), however, decreased both the prostate and levator ani muscle weights without any selectivity and increased plasma hormone levels in a dose-dependent manner. Furthermore, S-1 and S-4 showed very weak inhibitory effects toward transiently expressed type I and II human 5alpha-reductase (Ki, >20 microm) during in vitro assays. Therefore, although S-1 and finasteride showed very similar suppressive effects in the prostate of intact male rats, they decreased prostate size via different mechanisms of action. S-1 simply worked as androgen receptor partial agonist, whereas finasteride inhibited prostatic 5alpha-reductase. These studies indicate that SARMs may demonstrate clinical utility as single agent or combination therapy for BPH.

Validity of Digital Rectal Examination and Serum Prostate Specific Antigen in the Estimation of Prostate Volume in Community-Based Men Aged 50 to 78 Years: The Krimpen Study

BACKGROUND

In men with symptoms suggestive of BPH, an accurate estimation of the degree of prostate volume enlargement is important for the choice of treatment, and for prediction of treatment effect, the risk of acute urinary retention and the need for surgery. In a community-based population of men, the performance of digital rectal examination (DRE) and serum prostate specific antigen (PSA) is compared to planimetric transrectal ultrasonometry (planimetric TRUS) of the prostate. In this way we search for a practical, reliable, and reproducible alternative to TRUS that can be applied in a primary care setting and in the initial evaluation of men with lower urinary tract symptoms.

METHODS

Data were collected from 1688 men aged 50 to 78 years recruited in a population-based study. Measurements included serum PSA, DRE, and planimetric TRUS for the estimation of prostate volume.

RESULTS

The AUC values of the receiver-operating curves (ROC) curves for serum PSA as a method for the discrimination of prostate volumes above or below 30, 40 and 50 cc are 0.79, 0.86 and 0.92, respectively. DRE has limited value in the estimation of prostate volume and is only good in identifying very large prostates (>50 cc).

CONCLUSIONS

In the general male population serum PSA performs reasonably well compared with planimetric TRUS, and better than DRE, in estimating whether prostate volume is greater or smaller than 30, 40 or 50 cc. Serum PSA is an acceptable alternative method to estimate the degree of prostatic enlargement in clinical settings where TRUS is not available and when prostate cancer has been excluded.

Dihydrotestosterone and the prostate: the scientific rationale for 5alpha-reductase inhibitors in the treatment of benign prostatic hyperplasia

PURPOSE

We reviewed the physiological and pathogenic role of dihydrotestosterone (DHT), evidence for the beneficial effects of decreasing DHT through 5alpha-reductase inhibition and the effects of altering the androgen balance with these agents.

MATERIALS AND METHODS

A review of the relevant literature was done using published studies identified from the MEDLINE database.

RESULTS

The androgens DHT and testosterone have complementary roles in male physiology. Each is mediated through the intracellular androgen receptor. It has been hypothesized that DHT may provide an amplification mechanism for testosterone, which could be a beneficial adaptation in men with low circulating testosterone. The recognition of the central role of DHT in benign prostatic hyperplasia (BPH) has changed the way the disease is viewed and has led to the introduction of 5alpha-reductase inhibitors, which can prevent and retard the progression of BPH by suppressing DHT synthesis. The 5alpha-reductase inhibitors decrease prostate volume. In doing so they improve symptoms and urinary flow, and decrease the risks of acute urinary retention and the need for BPH related surgery. The predominant drug related adverse events with 5alpha-reductase inhibitors are reproductive events, that is typically decreased libido, impotence and ejaculatory dysfunction. These events occur in a minority of men and tend to decrease with a longer treatment duration.

CONCLUSIONS

DHT appears to have an obligatory role in the development of BPH. The role of 5alpha-reductase inhibitors in the treatment of BPH has been firmly established with an adverse events profile that is suitable for long-term use.

Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract symptoms: an overview for the practising clinician

Less than 10 years ago surgery and watchful-waiting were the only widely accepted management options for lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO). There has been an enormous decline in the popularity of surgery and it is now apparent that medication is the most frequently used treatment for BPH/LUTS; this has arguably therefore been the most major change in urological clinical practice in the last decade. Currently alpha(1)-adrenoceptor antagonists are the commonest medical therapy, and are thought to act by relaxing prostatic smooth muscle, the neural or so-called 'dynamic' component of BPO. 5alpha-reductase inhibitors (finasteride, dutasteride) are another option for BPH/LUTS, which reduce prostatic mass and therefore the mechanical or 'static' component of BPO. In the last 10 years there have been four direct comparative studies between alpha(1)-adrenoceptor antagonists and finasteride, including their combination, the results of which, and their implications for therapy, are discussed. Another group of agents are the phytotherapeutic extracts, which act via various mechanisms, many as yet poorly defined. This review critically assesses existing publications relating to the medical management of BPH/LUTS.

Efficacy and Safety of Long-Term Treatment with the Dual 5α-Reductase Inhibitor Dutasteride in Men with Symptomatic Benign Prostatic Hyperplasia

OBJECTIVES

Dutasteride, a dual inhibitor of Type 1 and Type 2 5 alpha-reductase, has been shown to improve disease measures in patients with symptomatic benign prostatic hyperplasia (BPH) in three randomised, placebo-controlled, large-scale, 2-year Phase III clinical studies. This paper reports the pooled results of a 2-year open-label extension of the three randomised studies assessing the long-term efficacy and safety of dutasteride.

METHODS

Patients randomised to dutasteride or placebo in the double-blind portion of the Phase III studies were eligible for a 2-year open-label extension, where all patients received dutasteride 0.5mg daily (dutasteride/dutasteride [D/D] group and placebo/dutasteride [P/D group]).

RESULTS

Significant improvements in AUA-SI score and Q(max) were observed from Month 24 to 48 in both study groups. At Month 48, patients in the D/D group had significantly greater improvements in AUA-SI score and Q(max), and significantly greater reductions in prostate volume, than those in the P/D group. Acute urinary retention and BPH-related surgery occurred in a small percentage of patients during the open-label phase. No new safety issues were noted with long-term therapy. Onset of new drug-related adverse events were reported most frequently at the start of therapy and declined over time in patients receiving dutasteride.

CONCLUSIONS

Long-term treatment with dutasteride results in continuing improvements in urinary symptoms and flow rate, and further reductions in TPV, in men with symptomatic BPH. The reduction in risk of AUR and BPH-related surgery, seen in the double-blind phase, was durable over 4-year treatment. Dutasteride was also well tolerated in long-term use.

What Is the Relationship between Male Sexual Function and Lower Urinary Tract Symptoms (LUTS)?

INTRODUCTION

There is considerable current interest in the relationship between LUTS and sexual function in men, and in particular whether there is a causative relationship between them. This observational study, performed in a single centre, seeks to explore this area further.

METHODS

1,420 patients attending a prostate assessment clinic were assessed by International Prostate Symptoms Score (IPSS), BPH impact index (BPH-II), Urinary flow rate (Q(max)), post-void residual volume (PVR) and the O'Leary sexual questionnaire (which assesses erectile, ejaculatory and sexual drive). The results were analyzed using univariate and multivariate techniques.

RESULTS

Following exclusion of those with incomplete data, those who were not sexually active, those with PSA >20 ng/ml and those who refused to fill in the questionnaire, there were 696 evaluable patients. Using univariate techniques, age, IPSS, Quality of life (QOL), BPH-II, Q(max) and PVR all correlated with differing domains of sexual function including erectile and ejaculatory function. Multiple regression analysis demonstrated that age was overwhelmingly the most important predictor of sexual function, but that BPH-II and QOL were also predictive for some domains, while the IPSS score was not.

CONCLUSION

This study confirms that a significant proportion of men with LUTS have sexual dysfunction. The relationship is complex and differs according to the type of sexual dysfunction.

Effect of permixon on human prostate cell growth: lack of apoptotic action

BACKGROUND

Permixon, a phytotherapeutic agent derived from the saw palmetto or Serenoa repens plant, is a lipid/sterol extract that is believed to interfere with 5alpha-reductase activity, thus inhibiting prostate growth. In this study, we investigated the magnitude and specificity of the effect of Permixon on cell proliferation and apoptosis in human prostate cancer cells.

METHODS

The effect of Permixon was examined in androgen-independent PC-3 prostate cancer cells, androgen-sensitive LNCaP prostate cancer cells, and MCF-7 breast cancer cells in vitro. Cell growth, apoptosis induction, and cell proliferation was studied after exposure to Permixon at two concentrations (10 and 100 microg/ml). Cell proliferation and cell cycle progression were determined after 24 hr on the basis of (3)[H]-thymidine incorporation assay and flowcytometric analysis, respectively. Apoptosis induction was evaluated in treated and untreated cultures using the Hoescht staining and caspase-3 activation.

RESULTS

Exposure of prostate and breast cancer cells to a high dose of Permixon (100 microg/ml) resulted in a significant decrease in the rate of cell growth; an effect that was not time-dependent and was not associated with cell cycle arrest. Permixon treatment (at either high or low dose) had no effect on apoptosis induction in prostate cancer cell lines (P > 0.6). Furthermore, in vitro Permixon was a weak inhibitor of 5alpha-reductase activity type 2 in prostatic homogenates.

CONCLUSIONS

The results indicate the ability of Permixon to affect prostate cancer cell growth without inducing apoptosis or cell cycle arrest. This effect was not prostate-specific and was only manifested at high concentrations of Permixon. Furthermore our findings indicate that Permixon is weak inhibitor of 5alpha-reductase compared to finasteride. This study challenges previous evidence on the anti-growth effect of Permixon in the prostate and its ability to inhibit 5alpha-reductase activity, while questioning apoptosis as a mechanism of action of this phytotherapeutic against prostate growth, a concept that may have therapeutic significance.

The effect of combined androgen ablation on the expression of alpha1A-adrenergic receptor in the human prostate

BACKGROUND

This study was designed to determine whether androgen ablation (AA) affects expression of alpha1A-adrenergic receptors (AR) in the human prostate.

METHODS

Concentrations of alpha1A-AR mRNA were determined in benign prostatic tissue from patients undergoing surgery after a 3-month course of combined androgen ablation (CAD) therapy with leuprolide and flutamide, and a matched group of untreated patients with clinical BPH.

RESULTS

Mean concentration of alpha1A-AR in the AA group was 0.53 +/- 0.53 SD (range 0.026-1.55) attomol/mg. Control mean was 0.29 +/- 0.22 SD (range 0.02-0.69; P = 0.3, two tailed t-test). Tissue composition did not statistically differ between the two groups. Expression of alpha1A-AR correlated with concentration of smooth muscle myosin heavy chain (SMMHC) (r = 0.84, P = 0.001). No significant differences were observed after adjusting for SMMHC content.

CONCLUSIONS

A 3-month course of CAD does not appear to have a significant effect on alpha1A-AR mRNA expression in the human prostate.

Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia

OBJECTIVES

To examine the rate of prostate cancer detection in three large randomized placebo-controlled benign prostatic hyperplasia trials of dutasteride. Dutasteride, which lowers serum dihydrotestosterone more than 93% by inhibiting type 1 and type 2 5-alpha-reductase, is effective in the treatment of benign prostatic hyperplasia. However, its effect on the development of prostate cancer is unknown.

METHODS

A total of 4325 men with benign prostatic hyperplasia but without a history, or evidence, of prostate cancer, and a serum prostate-specific antigen level of 1.5 to 10 ng/mL, were randomized to 0.5 mg/day dutasteride or placebo for 24 months. The prostate cancer detection rates for subjects were determined by non-protocol-mandated biopsies, either during the double-blind phase of the study or during the first 3 months of the open-label extension. A follow-up questionnaire was administered to a subset of consenting subjects to ascertain the number, outcomes, and reasons for the prostate biopsies.

RESULTS

The cumulative incidence of prostate cancer as an adverse event was significantly lower in the dutasteride versus placebo group at 24 months (1.1% versus 1.9%, P = 0.025) and 27 months (1.2% versus 2.5%, P = 0.002). There were no differences in the diagnosis rates of prostate cancer during the first 15 months, after which time the detection rate of prostate cancer increased in the placebo group and remained low in the dutasteride group.

CONCLUSIONS

Prostate cancer detection was significantly lower in subjects randomized to dutasteride compared with the placebo group. These results have prompted the initiation of the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) study, which was designed and powered to test the hypothesis that treatment with dutasteride decreases the incidence and progression of prostate cancer.

TRANSURETHRAL ETHANOL INJECTION THERAPY FOR PROSTATIC HYPERPLASIA: 3-YEAR RESULTS

PURPOSE

We assessed the medium-term (3-year) efficacy of transurethral ethanol injection therapy of the prostate (EIP) for benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 34 patients were followed for a median of 4.3 years after EIP. Mean age was 68.1 years and mean baseline prostate volume was 49.3 ml. With the patient under combined sacral and urethral anesthesia, dehydrated ethanol was injected into the prostate with endoscopic guidance. A urethral catheter was inserted postoperatively.

RESULTS

Mean total ethanol dose was 6.4 ml and a catheter was required for a mean of 7.6 days postoperatively. Mean International Prostate Symptom Score was 21.8 points before EIP (in 34 patients), and decreased to 13.1 points after 3 years (in 17, p <0.01). Mean quality of life index decreased from 5.0 points before EIP to 2.8 points after 3 years (p <0.001). Mean peak urine flow rate was 8.3 ml per second before EIP and increased to 12.7 ml per second after 3 years (p <0.01). Mean residual urine volume decreased from 93 ml before EIP to 28 ml after 3 years (p <0.01). Mean prostate volume decreased from 49.3 ml before EIP to 45.7 ml after 1 year (p <0.001), but increased to 51.4 ml after 3 years. No major complications were experienced. By 3 years after surgery 59.0% of patients had not required further treatment.

CONCLUSIONS

Transurethral EIP caused minimal complications while maintaining improvement of the prostate symptom score and an increased peak urine flow after 3 years.

A comparison of the efficacy and tolerability of tamsulosin and finasteride in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

In this multicentre, double-blind study, patients with LUTS/BPH were randomised to 26 weeks with finasteride 5 mg once daily (n=204) or tamsulosin 0.4 mg once daily (n=199). Double-blind treatment was continued for another 26 weeks (total treatment duration: 1 y). The primary efficacy parameter was the difference in mean change in total Symptom Problem Index (SPI) from baseline to end point at week-26 in the intention-to-treat (ITT) and per protocol (PP) populations. Tamsulosin induced a greater improvement in total SPI (-5.2 points or -37%) compared to finasteride (-4.5 points or -31%) at week-26 (P=0.055 in ITT and P=0.032 in PP). Tamsulosin improved urinary symptoms (particularly the more bothersome storage symptoms) and flow more quickly than finasteride. The difference was statistically significant for the SPI from week-1 (reduction, respectively, -2.5 vs -1.8 points, P=0.043) to week-18 and for Qmax from week-1 (increase, respectively, 2.3 vs 0.7 ml/s, P=0.0007) to week-12. Both treatments were well tolerated with a comparable incidence of adverse events, including urinary retention.

The role of 5-α-reductase inhibition as monotherapy in view of the MTOPS data

Medical treatment for the symptoms of benign prostatic hyperplasia (BPH) consists of a blockers and 5-alpha-reductase inhibitors. Data suggest that 5-alpha-reductase inhibitors can prevent progression of BPH and reduce the risk of BPH-related surgery, especially in men with large-volume prostates. Results from the largest randomized, prospective, placebo-controlled trial, the Medical Therapy of Prostatic Symptoms trial, have been presented. These results support the notion of using 5-alpha-reductase inhibitors for the prevention of BPH progression and BPH-related surgery. Furthermore, long-term 5-alpha-reductase inhibitor monotherapy, although slow in onset, is a viable therapy for symptom relief in men with mild to moderate symptoms.

Chronic prostatitis/chronic pelvic pain syndrome in elderly men: toward better understanding and treatment

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common of the prostatitis syndromes. It is characterised by pelvic pain, with or without voiding symptoms. CP/CPPS accounts for 2 million office visits in the US alone. Recent epidemiological studies have shown that CP/CPPS can affect men at any age, including those in their 80s. The aetiology is unknown but proposals include infectious, autoimmune, neurologic and psychiatric causes. Men with CP/CPPS are much more likely to have had a past medical history of cardiovascular, neurologic, psychiatric or infectious disease (particularly sinusitis) as compared with asymptomatic individuals. Although leucocytes are commonly found in the prostatic fluid of these men, they do not correlate with the symptoms. The clinical evaluation now includes a validated, self administered symptom score, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), which was designed as an outcome measure for treatment trials. This can aid in diagnosis and follow-up of patients' response to therapy. Treatment for CP/CPPS is empiric and limited by a lack of randomised, placebo-controlled clinical trials. Antimicrobials are commonly used to treat the symptoms of CP/CPPS. However, the finding that asymptomatic men have equal or greater numbers of bacteria which localise to the prostatic fluid, compared with men with CP/CPPS, has raised doubts about the contribution of infection to the symptoms. Other commonly used drugs include alpha-adrenoceptor antagonists, anti-inflammatory drugs, tricyclic antidepressants and anticholinergic agents. The adverse effects of these medications are a concern in older men with CP/CPPS. Other therapies available include minimally invasive procedures such as microwave thermotherapy and transurethral needle ablation, and now neuromodulation devices.Although much progress has been made, particularly in the last 7 years, considerable work still remains to be done to determine the aetiology and pathogenesis of CP/CPPS, and to develop mechanism based therapy that is shown to be effective in controlled trials.