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

Clinical predictors of spontaneous acute urinary retention in men with LUTS and clinical BPH: a comprehensive analysis of the pooled placebo groups of several large clinical trials

OBJECTIVES

To comprehensively evaluate clinical predictors of spontaneous acute urinary retention (AUR) across pooled data of placebo-treated patients from clinical trials conducted in men with lower urinary tract symptoms and clinically diagnosed benign prostatic hyperplasia.

METHODS

Data from the placebo-treatment groups of several prospective, randomized clinical trials conducted in the United States (n = 3040), Scandinavia, Canada, and worldwide (n = 2295) were combined in the analyses. More than 110 variables were considered individually and in combination as predictors of AUR using logistic regression analysis and classification and regression tree methods with a split-sample approach to cross-validation.

RESULTS

The different methods of analysis identified consistent potential predictors of episodes of AUR. When prostate volume was included in the analyses, it was selected as the initial variable discriminating men with and without subsequent AUR. Omitting prostate volume because of its availability in only a subset of men, a logistic model including serum prostate-specific antigen (PSA), urinating more than every 2 hours, symptom problem index, maximum urinary flow rate, and hesitancy of urination had good predictive properties (area under the receiver-operating characteristic curve [AUC] = 0.742 +/- 0.047), as did a model with PSA (AUC = 0.716 +/- 0.045). A classification and regression decision tree with the same variables predicted AUR (AUC = 0.74, sensitivity = 72%, specificity = 67%) as well as did a tree with PSA alone (AUC = 0.70, sensitivity = 75%, specificity = 64%).

CONCLUSIONS

Prostate volume and serum PSA are strong predictors of AUR in placebo-treated men with lower urinary tract symptoms and clinically diagnosed benign prostatic hyperplasia who were screened for prostate cancer. From more than 110 variables, logistic models and decision trees with PSA alone were comparable to expanded models that included PSA, urinary frequency and hesitancy, flow rate parameters, and symptom problem index, and to a scoring algorithm.

Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin for bladder outlet obstruction

OBJECTIVES

Patients with symptomatic bladder outlet obstruction and moderately enlarged prostates can receive durable relief from finasteride. However, the delayed onset of action has led many clinicians to prescribe an alpha-blocker in addition to finasteride early in therapy for more rapid symptom relief. Our goal was to determine when to discontinue the alpha-blocker in this group of patients.

METHODS

We enrolled 100 consecutive men with an estimated prostate size of >40 g and an AUA symptom score of > or =20, who reported an initially favorable response to combination therapy with 5 mg finasteride and 2 mg doxazosin daily. The average symptom score reduction at 1 month was 3.3. We discontinued the doxazosin at 3, 6, 9, or 12 months, while continuing finasteride, then reevaluated patients 1 month later to determine if the patients reported any worsening of symptoms.

RESULTS

Twenty-five patients discontinued doxazosin at 3 months. Five (20%) were successfully discontinued, reporting no change in symptom score. Twenty reported worsening symptoms. Twenty-five patients discontinued doxazosin at 6 months. Twelve (48%) were successfully discontinued, reporting no change in symptom scores. Thirteen (52%) reported worsening symptoms. Twenty-five patients discontinued doxazosin at 9 months. Twenty-one (84%) were successfully discontinued, reporting no change in symptom scores. Four (16%) reported worsening symptoms. Twenty-five patients discontinued doxazosin at 12 months. Twenty-one (84%) were successfully discontinued, reporting no change in symptom scores. Four (16%) reported worsening symptoms.

CONCLUSION

Patients with symptomatic bladder outlet obstruction and moderately enlarged prostates who are placed initially on combination therapy using finasteride and an alpha-blocker are likely to tolerate discontinuation of the alpha-blocker after 9 months of combination therapy.

A double-blind, randomized, placebo-controlled pilot study to investigate the effects of finasteride combined with a biodegradable self-reinforced poly L-lactic acid spiral stent in patients with urinary retention caused by bladder outlet obstruction from benign prostatic hyperplasia

OBJECTIVE

To assess whether patients in acute urinary retention from benign prostatic enlargement can be treated with a combined therapy comprising finasteride and a bioabsorbable self-reinforced poly L-lactic acid (SR-PLLA) urethral stent.

PATIENTS AND METHODS

Fifty-five patients in acute urinary retention were treated as outpatients; they had a suprapubic catheter inserted and the SR-PLLA stent placed cystoscopically. After 2 weeks the patients were randomized to receive either finasteride 5 mg daily or placebo. They were assessed at baseline and at 6, 12 and 18 months for maximum urinary flow rate, prostate volume and serum prostate-specific antigen (PSA).

RESULTS

Nineteen patients completed the study while 36 discontinued. There was a statistically significant increase in the mean maximum flow rate, and a statistically significant decrease in the prostatic volume and serum PSA in the finasteride group. The same number of patients discontinued in both groups; the major reason for discontinuation was insufficient therapeutic response.

CONCLUSIONS

The major problems were discontinuation of treatment because the response to therapy was insufficient, and uncontrolled breakdown of the spiral stent. To solve these problems, new configurations of bioabsorbable stents are needed.

Impact of medical therapy on transurethral resection of the prostate: a decade of change

OBJECTIVES

To assess whether medical therapy has delayed the need for eventual transurethral prostatectomy (TURP), causing a shift in the population characteristics of men undergoing TURP (ie, older, more comorbidities, more advanced disease), resulting in more complications and poorer outcomes. The introduction of medical therapy for symptomatic benign prostatic hyperplasia (BPH) during the past decade may have changed the indications for TURP.

METHODS

All patients who underwent TURP for symptomatic BPH at our institution in 1988 (before general introduction of medical therapy for BPH) and 1998 (medical therapy the primary initial therapy for BPH) were reviewed. We compared the two groups with respect to the total number of TURPs, indications for surgery, patient age, health status, weight of resected tissue, and preoperative and postoperative complications.

RESULTS

Despite a 16% increase in men at risk of BPH-related events, a 60% decrease in the total number of TURPs performed for symptomatic BPH occurred in 1998 (n = 64) compared with 10 years earlier (n = 157). No significant difference was found in age between the two groups, and no increase in comorbid status was observed. Previous medical management had failed in 36% of men who required TURP in 1998. A significantly higher percentage of patients presented in acute urinary retention (55%) and upper tract obstructive uropathy (12.5%) in 1998 compared with 1988 (23% acute urinary retention and 1.3% obstructive uropathy). Patients in 1998 were healthier, underwent smaller resections, had their catheters removed earlier, and were discharged home earlier. Although they were more likely to be discharged home with a catheter in situ, no significant difference was observed in the incidence of postoperative complications.

CONCLUSIONS

There has been a dramatic decrease in the number of TURPs performed for symptomatic BPH at our institution since the advent of medical therapy. The proportion of TURP patients presenting with urinary retention and hydronephrosis increased, but the average age, medical comorbidities, operative parameters, and postoperative complications have not significantly changed.

Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia

OBJECTIVES

To compare the efficacy and safety of finasteride 5 mg in older (65 years old or older) versus younger (45 to younger than 65 years old) men with benign prostatic hyperplasia (BPH).

METHODS

The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men 45 to 78 years old with symptomatic BPH, enlarged prostates, and no evidence of prostate cancer. The endpoints included urinary symptoms, prostate volume, occurrence of acute urinary retention and/or BPH-related surgery, and safety.

RESULTS

In both age cohorts, finasteride treatment led to a 51% reduction (P <0.001) in the relative risk for acute urinary retention and/or BPH-related surgery, a significant (P <0.001) and durable improvement in symptom score, and a significant (P <0.001) and sustained reduction in prostate volume. Within each age cohort, no significant differences were found between the placebo and finasteride-treated patients in the incidence of cardiovascular adverse events. Significant differences were evident between the placebo and finasteride groups in the incidence of the typical, known, drug-related adverse events, but no specific differences were associated with age. No drug interactions of clinical importance were observed in the finasteride-treated patients.

CONCLUSIONS

The present analysis from PLESS demonstrates that in both older (65 years old or older) and younger men with symptomatic BPH and enlarged prostates, finasteride is highly effective in improving symptoms and reducing prostate volume in many men and in reducing the risk of acute urinary retention and BPH-related surgery. In addition, the safety profile of finasteride in both older and younger men is similar and no drug interactions of clinical importance were observed.

A 6-month large-scale study into the safety of tamsulosin

AIMS

Tamsulosin is an alpha1-adrenoceptor antagonist for the treatment of symptomatic benign prostatic hyperplasia with a tolerability similar to that of placebo in short-term, placebo-controlled studies with limited patient numbers. The present study was designed to test the safety of tamsulosin treatment in a large cohort of men during a prolonged period of time, particularly with regard to comedications.

METHODS

A multicentre, open-label phase IIIb study with 1784 patients receiving 0.4 mg o.d. tamsulosin for 6 months was performed according to good clinical practice guidelines. The analysis was performed on an intention-to-treat basis and powered to detect adverse events (AE) occurring in 0.15% of patients with 95% confidence.

RESULTS

During a total drug exposure time of 811 patient years, 386 AE were recorded in 253 patients (14.2%; 95% confidence intervals [CI] 12.0-15.2%). Twenty-nine patients suffered 44 serious AE including five fatal events (CI 0.12-0.73%) due to myocardial infarction (n = 3) and to pneumonia and a car accident (one each), but all deaths were judged to be unlikely to be related to study medication. The frequency of AE in patients without any comedication (n = 1095) was 13.0% (CI 11.3-14.9%). In a logistic regression analysis beta-adrenoceptor blockers, converting enzyme inhibitors, antidiabetics and diuretics did not significantly affect the odds ratio for having AE. However, concomitant alpha-adrenoceptor antagonists (a protocol violation) and treatment with verapamil (which also has alpha-adrenoceptor antagonist activity) significantly enhanced the odds ratio for having AE to 3.87 (CI 1.52-9.85) and 3.17 (CI 1.52-6.58), respectively. Minor increases in the odds ratio, which did not reach statistical significance, were also observed for Ca2+ antagonists other than verapamil and for nitrates.

CONCLUSIONS

We conclude that tamsulosin has a good safety profile relative to AE rates in the placebo arms of previous studies on tamsulosin even in the presence of most potentially complicating comedications. No major unexpected severe AE were recorded during our 6 months study.

Initiation of nonselective alpha1-antagonist therapy and occurrence of hypotension-related adverse events among men with benign prostatic hyperplasia: a retrospective cohort study

BACKGROUND

Treatment of benign prostatic hyperplasia (BPH) with nonselective alpha1 antagonists such as terazosin, doxazosin, and prazosin results in blood pressure reduction due to vasodilation.

OBJECTIVE

Using claims data from a large Medigap plan, we examined the effect of initiating nonselective alpha1-antagonist therapy on the incidence of hypotension-related adverse events likely to be associated with vascular alpha-adrenoreceptor antagonism in patients with BPH.

METHODS

Medical and prescription claims data were obtained from the MEDSTAT Group for 53,824 men with a diagnosis code for BPH during the study period (January 1995-December 1997). We examined the rate of possible hypotension-related adverse events (diagnosis codes for hypotension, syncope, dizziness, fractures, and other injuries) per 10,000 person-days for men who began therapy with alpha1 antagonists and for a random sample of nonusers, stratified by prior use of other antihypertensive agents.

RESULTS

After adjusting for baseline differences in event rates, those who initiated alpha1-antagonist therapy (n = 1564) had a significantly greater increase in hypotension-related adverse-event rates in the 4 months after initiation (vs the 4 months before initiation) than randomly selected nonusers (n = 8641) (increase of 1.82 vs decrease of 0.02 events per 10,000 person-days among those not taking antihypertensive agents; increase of 0.94 vs 0.69 events per 10,000 person-days among those taking other antihypertensive agents; P < 0.01). This increase began earlier and lasted longer among patients taking other antihypertensive agents. Those who discontinued their alpha1 antagonist had a higher rate of hypotensive events at baseline than those who did not (5.09 vs 3.19 events per 10,000 person-days among those using other antihypertensive agents; 3.62 vs 2.27 events per 10,000 person-days among those not using other antihypertensive agents; P < 0.05).

CONCLUSIONS

Initiation of nonselective alpha1-antagonist therapy for the treatment of BPH increases the risk of a cluster of clinical events consistent with vascular alpha-adrenoreceptor antagonism. This effect is seen during a 4-month period around the initiation date. Prior initiation of other antihypertensive medication increases this effect. Urologists should consult with a patient's primary care physician about use of other antihypertensive agents before initiating nonselective alpha1-antagonist therapy for BPH.

Kidney ultrasound and Doppler ultrasound findings during and after acute urinary retention

OBJECTIVE

To evaluate changes in kidney ultrasound and Doppler ultrasound images during and subsequent to acute urinary retention (AUR).

METHODS

Twenty-five men with a mean age of 69 years suffering AUR for a mean of 31 h were studied by measuring serum creatinine, creatinine clearance and renal ultrasound. Renal Doppler ultrasound was applied in 19 of these cases and all patients were followed for 6 months after acute retention was relieved.

RESULTS

During AUR hydronephrosis was noted in three patients; this disappeared during follow-up. During the acute period, after 1 month and after 6 months the average resistive indexes (RI) were 0.71, 0.70 and 0.69, respectively. The changes were not statistically significant. During follow-up, the proportion of patients with normal RI increased from 42 to 64%. Median serum creatinine was normal during retention and follow-up. Median creatinine clearance was reduced during retention and became normal during follow-up (P < 0.05). No correlation was found between RI and serum creatinine at any time-point, nor was any correlation noted between RI and creatinine clearance during retention or at the 1-month follow-up; at 6 months, however, there was a significant inverse correlation between them (P = 0.01).

CONCLUSION

AUR caused elevation of RI, which may be interpreted as diminished renal blood flow. Although in the majority of patients it recovered after treatment, elevated RI was still found in one third of the patients, possibly due to previous chronic bladder outlet obstruction. Our findings stress the importance of both fast release of AUR and effective treatment of its cause.

Characteristics of protein excretion in patients with acute urinary retention

OBJECTIVE

To evaluate changes in protein leakage in the glomerular filtration barrier, and in the ability of the tubule to reabsorb proteins during and after acute urinary retention (AUR).

PATIENTS AND METHODS

Glomerular and tubular function was investigated in 24 men during AUR (mean age 68 years, mean retention time 31 h and mean retention volume 1140 mL) who were then followed for 6 months by measuring the urinary excretion of glomerular and tubular proteins, and the glomerular filtration rate (GFR). Retention was relieved by inserting a suprapubic catheter and the cause of retention treated one month later. No patient had a previous renal disease or diabetes.

RESULTS

During AUR, and after 1 and 6 months, albuminuria was detected in 100%, 92% and 54% of patients, and increased excretion of alpha1-microglobulin in 52%, 36% and 58%, of IgG in 79%, 58% and 40%, and of IgG4 in 67%, 42% and 20%, respectively. The mean GFR was normal during retention and during the follow-up.

CONCLUSION

AUR causes disturbances in both the glomerular filtration and tubular reabsorption of proteins. Albuminuria and increased excretion of IgG, IgG4 and alpha1-microglobulin occurred in most patients during AUR. After relieving retention, the albuminuria and elevated alpha1-microglobulin excretion persisted, indicating slight glomerular dysfunction and a permanent defect in the proximal tubule to reabsorb proteins. This could be caused partly by previous chronic obstruction. AUR should be relieved immediately and the basic cause treated effectively to prevent further deterioration of renal function.

Minimally invasive procedures as an alternative to medical management for lower urinary tract symptoms of benign prostatic hyperplasia

Data are reviewed relating to the safety and efficacy of minimally invasive transurethral microwave thermotherapy and medical management in patients with lower urinary tract symptoms of benign prostatic hyperplasia. Recent evidence is summarized indicating more pronounced long-term beneficial effects of microwave treatment. alpha-Blockade, however, offers the advantage of more rapid action than microwave treatment. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement in patients receiving microwave treatment. Compared with medical management, microwave treatment possesses greater versatility, allowing patients with severe baseline symptoms and small prostate sizes to be treated with a high probability of success.

Changing therapeutic regimens in benign prostatic hyperplasia. Clinical and economic considerations

About one-quarter of men aged 50 years and older experience voiding problems due to benign prostatic hyperplasia (BPH). Until about 10 years ago, surgery (particularly transurethral resection of the prostate) was the only effective treatment for symptomatic BPH. Over the last decade, several new treatments have been introduced. These include different types of medication (alpha-blockers and finasteride), thermotherapy, laser prostatectomy, needle ablation and vaporisation methods. The diffusion of these less invasive treatment modalities has resulted not only in a decrease in the age-adjusted surgery rates, but also in an increase of the total number of men treated for BPH. A large number of studies on clinical benefits and risks reveal that the conventional types of surgery remain the most effective treatments, whereas new interventional therapies require a shorter hospital stay and result in fewer short term complications. The efficacy of medication is lower than that of interventional treatments. Adverse effects include dizziness and orthostatic hypotension (alpha-blockers) and decreased sexual function (finasteride), but are generally mild. There is some evidence that medication and minimally invasive treatments may preclude eventual surgical treatment, but the precise effect is difficult to estimate because of differences in the study populations and the relatively short study periods. As a result of the dynamic nature of BPH treatment and the lack of long term data, the cost effects of the introduction of the various new treatments are also difficult to assess. Given the aging of the population and the growing percentage of patients with BPH for whom any type of treatment can be considered, a considerable increase of total costs can be expected. Long term prospective studies are necessary to gain insight into the most cost-effective treatment for different patient groups.

Diagnosis and management of urinary incontinence in the older patient

OBJECTIVES

To review the various causes of urinary incontinence (UI) in elderly patients and to outline a therapeutic approach to the clinical management of UI.

DATA SOURCES

Online search of MEDLINE and additional references selected from the articles found during the search.

STUDY SELECTION

All peer-reviewed articles and review articles listed on MEDLINE published between 1966 and 1999. Key search terms included urinary incontinence, geriatric, aging, pelvic floor rehabilitation, and indwelling catheter.

DATA EXTRACTION

Articles with clinical relevance to the geriatric population were selected based on the robustness of the studies and reviews. If applicable, data from studies of healthier or younger populations was extrapolated to the elderly population examined in this review.

DATA SYNTHESIS

UI is a common occurrence among older adults treated in rehabilitation settings. The causes of UI in the elderly vary, including transient causes, established pathologic states of the urinary tract, and systemic multifactorial influences. Both behavioral and pharmacologic management strategies can successfully be implemented for UI, even in the frail elderly.

CONCLUSION

UI can be effectively investigated and treated by rehabilitation practitioners by following a simple, stepwise approach.

Combined effect of terazosin and finasteride on apoptosis, cell proliferation, and transforming growth factor-beta expression in benign prostatic hyperplasia

BACKGROUND

Medical treatment of benign prostatic hyperplasia (BPH) targets relief of symptoms by causing either relaxation of the prostatic smooth muscle with alpha1 adrenergic blockade, or shrinkage of the gland with 5alpha-reductase inhibitors. We recently demonstrated that alpha1-blockers, such as terazosin, induce apoptosis in prostatic cells. In this study, we examined the combined effect of finasteride and terazosin on the rate of apoptosis and cellular proliferation to investigate their potential synergy at the cellular level.

METHODS

Prostate specimens were obtained from men who were treated with either finasteride (n = 24), terazosin (n = 42), or combination therapy (n = 10) for varying time periods (1 week to 36 months) for the relief of the symptoms of BPH. The proliferative and apoptotic indices of both stromal and epithelial prostatic cell populations were determined. Antibodies against TGF-beta1 and TbetaRII were used to examine the immunoreactivity of TGF-beta1 and TbetaRII, respectively, in all prostate tissue sections.

RESULTS

The apoptotic index in both prostate cell populations was significantly higher following the combination treatment compared to terazosin or finasteride alone. There were no significant changes in the rate of cellular proliferation with any treatment. Furthermore, there was a significant increase in TGF-beta1 expression in the prostates of patients treated with terazosin or combination therapy, while there was no change in TbetaRII expression.

CONCLUSIONS

These results support the concept that induction of prostate apoptosis is a potential molecular mechanism underlying the combination effect of alpha1 blockade with 5alpha-reductase inhibitors in the effective treatment of BPH. The upregulation of TGF-beta1 implies a role for this ligand as an effector of apoptosis induction in response to alpha1-blockade or finasteride therapy of BPH patients.

Relationship of prostate-specific antigen and prostate volume in patients with biopsy proven benign prostatic hyperplasia

BACKGROUND

Emerging data suggest a direct correlation between prostate-specific antigen (PSA) and prostate volume in patients with lower urinary tract symptoms (LUTS) and clinical evidence of benign prostatic hyperplasia (BPH). We attempt to confirm that a similar correlation exists between PSA and prostate volume in patients with biopsy-proven BPH.

METHODS

Over a 5 year period, 2,270 patients were confirmed to have BPH as the only histological diagnosis after evaluation with serum PSA, trans-rectal ultrasound (TRUS) biopsy, and prostate volume measurement. PSA and prostate volume were statistically analyzed by age-stratified cohorts, including multiple regression analysis and assessment of correlation using the Pearson correlation coefficient (r).

RESULTS

Mean PSA and prostate volume increased with each advancing cohort of age, and the correlation of PSA and prostate volume was determined to be statistically significant (P < 0.001) in each cohort with a correlation coefficient ranging from 0.33 to 0.41.

CONCLUSIONS

We confirm that the relationship between PSA and prostate volume in a large series of patients with biopsy-proven BPH provides a comparable correlation to data for patients with LUTS and clinical BPH. As such, PSA represents a valuable approximation of prostate volume, and may prove to be clinically useful in the management of patients with BPH.

Phytotherapy for benign prostatic hyperplasia

OBJECTIVE

To systematically review the existing evidence regarding the efficacy and safety of phytotherapeutic compounds used to treat men with symptomatic benign prostatic hyperplasia (BPH).

DESIGN

Randomized trials were identified searching MEDLINE (1966--1997), EMBASE, Phytodok, the Cochrane Library, bibliographies of identified trials and review articles, and contact with relevant authors and drug companies. The studies were included if men had symptomatic benign prostatic hyperplasia, the intervention was a phytotherapeutic preparation alone or combined, a control group received placebo or other pharmacologic therapies for BPH, and the treatment duration was at least 30 days. Key data were extracted independently by two investigators.

RESULTS

A total of 44 studies of six phytotherapeutic agents (Serenoa repens, Hypoxis rooperi, Secale cereale, Pygeum africanum, Urtica dioica, Curcubita pepo) met inclusion criteria and were reviewed. Many studies did not report results in a method allowing meta-analysis. Serenoa repens, extracted from the saw palmetto, is the most widely used phytotherapeutic agent for BPH. A total of 18 trials involving 2939 men were reviewed. Compared with men receiving placebo, men taking Serenoa repens reported greater improvement of urinary tract symptoms and flow measures. Serenoa repens decreased nocturia (weighted mean difference (WMD) = -0.76 times per evening; 95% CI = -1.22 to -0.32; n = 10 studies) and improved peak urine flow (WMD = 1.93 ml s(-1); 95% CI = 0.72 to 3.14, n = 8 studies). Men treated with Serenoa repens rated greater improvement of their urinary tract symptoms versus men taking placebo (risk ratio of improvement = 1.72; 95% CI = 1.21 to 2.44, n = 8 studies). Improvement in symptoms of BPH was comparable to men receiving the finasteride. Hypoxis rooperi (n = 4 studies, 519 men) was also demonstrated to be effective in improving symptom scores and flow measures compared with placebo. For the two studies reporting the International Prostate Symptom Score, the WMD was -4.9 IPSS points (95% CI = -6.3 to -3.5, n = 2 studies) and the WMD for peak urine flow was 3.91 ml s(-1) (95% CI = 0.91 to 6.90, n = 4 studies). Secale cereale (n = 4 studies, 444 men) was found to modestly improve overall urological symptoms. Pygeum africanum (n = 17 studies, 900 men) may be a useful treatment option for BPH. However, review of the literature has found inadequate reporting of outcomes which currently limit the ability to estimate its safety and efficacy. The studies involving Urtica dioica and Curcubita pepo are limited although these agents may be effective combined with other plant extracts such as Serenoa and Pygeum. Adverse events due to phytotherapies were reported to be generally mild and infrequent.

CONCLUSIONS

Randomized studies of Serenoa repens, alone or in combination with other plant extracts, have provided the strongest evidence for efficacy and tolerability in treatment of BPH in comparison with other phytotherapies. Serenoa repens appears to be a useful option for improving lower urinary tract symptoms and flow measures. Hypoxis rooperi and Secale cereale also appear to improve BPH symptoms although the evidence is less strong for these products. Pygeum africanum has been studied extensively but inadequate reporting of outcomes limits the ability to conclusively recommend it. There is no convincing evidence supporting the use of Urtica dioica or Curcubita pepo alone for treatment of BPH. Overall, phytotherapies are less costly, well tolerated and adverse events are generally mild and infrequent. Future randomized controlled trials using standardized preparations of phytotherapeutic agents with longer study durations are needed to determine their long-term effectiveness in the treatment of BPH.

A prospective study of conservatively managed acute urinary retention: prostate size matters

OBJECTIVE

To evaluate in a prospective study the medium- to long-term outcome of a policy of conservatively managing acute urinary retention (AUR), arising solely by bladder outlet obstruction caused by benign prostatic enlargement (BPE), and to identify the factors favouring a positive outcome of a trial without catheter (TWOC).

PATIENTS AND METHODS

All men admitted as an emergency with primary AUR caused by BPE (from August 1997 to March 2000) underwent a TWOC. The following variables were recorded; the nature and duration of any preceding lower urinary tract symptoms, previous episodes of retention, concomitant anticholinergic medication, coexisting constipation, alcohol as a precipitating cause of AUR, previous prostatectomy, confirmed urinary tract infection, residual urine drained on catheterization and prostate size, as determined by a digital rectal examination (DRE) carried out by one consultant urologist in all patients. Those voiding successfully were followed up prospectively using the International Prostate Symptom Score (IPSS), quality-of-life score, urinary flow rate measurement and ultrasonographic measurement of the postvoid residual (PVR).

RESULTS

Of the 40 men with AUR, 22 (55%) voided spontaneously after removing the catheter and continued to do so with mean peak flow rates of 12.2 mL/s and mean PVRs of 69.6 mL over a follow-up of 8-24 months. These patients remained asymptomatic, with a mean IPSS of 5.2 and quality-of-life score of 0.9. These men had a mean prostatic size of 15.9 g and a mean catheterized residual volume of 814 mL, while in those who had an unsuccessful TWOC the mean prostate size was 27.5 g (P = 0.006) and a mean catheterized residual volume of 1062 mL (P = 0.09). Prostate size as assessed by the DRE was the most significant factor in predicting the outcome of a TWOC.

CONCLUSION

A TWOC is justified in the long-term for men presenting with AUR caused by BPE. Prostate size is the most important factor for predicting the outcome of such a trial.

The natural history of benign prostatic hyperplasia: what have we learned in the last decade?

Benign prostatic hyperplasia (BPH) frequently has a significant detrimental impact on a patient's quality of life. If the disease is left untreated, it may progress in severity, leading to recurrent bladder infections, bladder calculi, and acute urinary retention (AUR), necessitating surgical treatment. The Forth Valley, Scotland, study reported that 14% of men aged 40 to 50 years have BPH. This increases to 43% of men >60 years old. BPH has been shown to be nearly as prevalent as hypertension and diabetes among patients seeking treatment for erectile dysfunction. The effects of BPH on quality of life include lack of sleep, anxiety, reduced mobility, interference with leisure activities and usual daily activities, and a compromised sense of well-being. Three symptoms are associated with an increased risk of AUR in men with BPH: a reduction in the force of the urinary stream, a sensation of incomplete bladder emptying, and an enlarged prostate gland on digital rectal examination. Age is a strong independent risk factor for the development of AUR. Transurethral resection of the prostate was more effective than watchful waiting in preventing AUR, as shown in the Veteran's Affairs Cooperative Study. Data from the Olmsted County study revealed that urinary flow decreases and prostate size increases with advanced age. This study also showed that lower urinary tract symptoms have a negative impact on parameters of physical and mental aspects of health. More recently, studies have shown that medical treatment with 5alpha-reductase inhibitors and possibly also alpha-blockers may alter the natural history and progression of BPH.

Transurethral microwave thermotherapy: an alternative to medical management in patients with benign prostatic hyperplasia?

Transurethral microwave thermotherapy (TUMT) is being increasingly considered as an alternative to medical management with alpha-blockers or finasteride in patients with lower urinary tract symptoms (LUTS) of benign prostate hyperplasia (BPH). Enduring clinical benefits have been demonstrated after a single 1-hour microwave treatment session under topical anesthesia, and the associated morbidity is low. Optimal results are obtained with the delivery of high thermal doses and accurate targeting of microwave energy. Extensive evidence from randomized clinical trials supports the safety and efficacy of both microwave treatment and medical management, but randomized trial data have only recently become available directly comparing these two approaches to BPH treatment. These data indicate that greater long-term improvements in symptoms, peak urinary flow rates, and quality of life are attained with microwave treatment than with alpha-blockade. Furthermore, the actuarial rate of treatment failure is markedly lower in patients undergoing microwave v alpha-blocker treatment. However, the onset of action of alpha-blocker treatment is more rapid. The principal limitations of alpha-blockade are side effects and lack of efficacy leading to treatment failure in some patients. The maximal effects of finasteride are modest and require a period of months to be manifested, although the side effect profile and tolerability of this agent are favorable. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement after TUMT. In contrast to medical management, microwave treatment is highly versatile, allowing patients over a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success.

Impact of baseline symptom severity on future risk of benign prostatic hyperplasia-related outcomes and long-term response to finasteride. The Pless Study Group

OBJECTIVES

To evaluate the long-term effects of finasteride on symptoms, acute urinary retention (AUR), and the need for benign prostatic hyperplasia (BPH)-related surgery in relationship to baseline symptom severity.

METHODS

A total of 3040 men with BPH were treated for 4 years with finasteride or placebo. The changes from baseline in symptoms and the incidence of BPH-related surgery and AUR were determined in men with mild (less than 8), low-moderate (8 to 12), high-moderate (13 to 19), and severe (greater than 19) baseline quasi-American Urological Association symptoms for all patients and for the subgroup with a baseline prostate-specific antigen (PSA) level of 1.4 ng/mL or greater.

RESULTS

In patients who completed the 4-year study, the change in symptom score, stratified by baseline symptom severity, was +1.4 +/- 0.5 (mild), -0.8 +/- 0.3 (low-moderate), -3.6 +/- 0.3 (high-moderate), and -7.7 +/- 0.5 (severe) in finasteride-treated patients and, respectively, +3.4 +/- 0.5, +0.7 +/- 0.3, -1.4 +/- 0.3, and -5.3 +/- 0.6 in placebo-treated patients (between-group P <0.01). The between-group differences were greater in the subgroup of patients with a baseline PSA of 1.4 ng/mL or greater. The risk of BPH-related surgery increased among placebo patients with increasing baseline symptom severity to a greater extent than the risk of AUR. Finasteride reduced the risk of AUR or the need for BPH-related surgery in all subgroups (P <0.001), especially in men with a baseline PSA of 1.4 ng/mL or greater.

CONCLUSIONS

Compared with placebo, finasteride had a beneficial effect on symptoms, AUR, and BPH-related surgery in all symptom categories. BPH-related surgery, but not AUR, occurred more commonly in placebo-treated men with more severe baseline symptoms. The greatest absolute benefit of finasteride on symptoms and the reduction in risk of AUR and surgery was in men with higher baseline symptom scores and a baseline PSA level of 1.4 ng/mL or greater.

Transurethral microwave thermotherapy in the management of lower urinary tract symptoms from benign prostatic obstruction: follow-up after five years

OBJECTIVE

This study reports on a 5-year follow-up after transurethral microwave thermotherapy (TUMT) from benign prostatic obstruction using a lower power treatment protocol.

MATERIAL AND METHODS

Ninety-one patients with uncomplicated benign prostatic obstruction were treated in a 1-h session using the PRIMUS U + R device.

RESULTS

Twenty-nine (32%) of the patients were evaluable after 5 years, while 42 had received additional treatment for their lower urinary tract symptoms. In the 29 patients without additional therapy after TUMT, the decrease in the International Prostate Symptom Score was 37% compared with the pretreatment value. A moderate increase in peak uroflow, seen 1 year after TUMT, was not confirmed in an extended follow-up. Patients still on TUMT monotherapy after 5 years had smaller prostates from the outset than the group receiving additional treatment. No serious side-effects were observed.

CONCLUSION

Lower power TUMT has a symptomatic effect of limited duration in most cases; in the long-term perspective only a minority of patients will benefit from this treatment.

Selective alpha1a adrenergic receptor antagonists based on 4-aryl-3,4-dihydropyridine-2-ones

A series of alpha1a receptor antagonists derived from a 4-aryl-3,4-dihydropyridine-2-one heterocycle is disclosed. Potency in the low nanomolar to picomolar range along with high selectivity was obtained. In vivo efficacy in a prostate contraction model in rats was observed with a few derivatives.

In vitro and in vivo evaluation of dihydropyrimidinone C-5 amides as potent and selective alpha(1A) receptor antagonists for the treatment of benign prostatic hyperplasia

alpha(1) Adrenergic receptors mediate both vascular and lower urinary tract tone, and alpha(1) receptor antagonists such as terazosin (1b) are used to treat both hypertension and benign prostatic hyperplasia (BPH). Recently, three different subtypes of this receptor have been identified, with the alpha(1A) receptor being most prevalent in lower urinary tract tissue. This paper explores 4-aryldihydropyrimidinones attached to an aminopropyl-4-arylpiperidine via a C-5 amide as selective alpha(1A) receptor subtype antagonists. In receptor binding assays, these types of compounds generally display K(i) values for the alpha(1a) receptor subtype <1 nM while being greater than 100-fold selective versus the alpha(1b) and alpha(1d) receptor subtypes. Many of these compounds were also evaluated in vivo and found to be more potent than terazosin in both a rat model of prostate tone and a dog model of intra-urethral pressure without significantly affecting blood pressure. While many of the compounds tested displayed poor pharmacokinetics, compound 48 was found to have adequate bioavailability (>20%) and half-life (>6 h) in both rats and dogs. Due to its selectivity for the alpha(1a) over the alpha(1b) and alpha(1d) receptors as well as its favorable pharmacokinetic profile, 48 has the potential to relieve the symptoms of BPH without eliciting effects on the cardiovascular system.

Treatment of symptomatic benign prostatic hyperplasia with beta-sitosterol: an 18-month follow-up

OBJECTIVES

To determine the long-term effects of phytotherapy with beta-sitosterol (the trade name for beta-sitosterol used in this study is Harzol(R)) for symptomatic benign prostatic hyperplasia (BPH). Patient and methods At 18 months after enrolment in a 6-month multicentre double-blind placebo-controlled clinical trial with beta-sitosterol (reported previously), patients were re-evaluated using the modified Boyarsky score, the International Prostate Symptom Score and quality-of-life index, the maximum urinary flow rate (Qmax) and postvoid residual urine volume (PVR). In this open extension of the original trial (after 6 months of treatment or placebo), patients were free to chose their further treatment for BPH.

RESULTS

In all, 117 patients (59%) were eligible for analysis during the follow-up. Of the formerbeta-sitosterol group, 38 patients who continued beta-sitosterol treatment had stable values for all outcome variables between the end of the double-blind study and after 18 months of follow-up. The 41 patients choosing no further therapy had slightly worse symptom scores and PVR, but no changes in Qmax. Of the former placebo group, 27 patients who started beta-sitosterol after the double-blind trial improved to the same extent as the treated group for all outcome variables. The 18 patients choosing no further therapy showed no signs of improvement.

CONCLUSION

The beneficial effects of beta-sitosterol treatment recorded in the 6-month double-blind trial were maintained for 18 months. Further clinical trials should be conducted to confirm these results before concluding that phytotherapy with beta-sitosterol is effective.

Use of a prostate model to assist in training for digital rectal examination

OBJECTIVES

To assess the accuracy of prostate size estimation on digital rectal examination (DRE) before and after training with a three-dimensional prostate model relative to prostate volume by transrectal ultrasound (TRUS).

METHODS

A total of 100 subjects underwent DRE by one of four family physicians (FP1, n = 34; FP2, n = 26; FP3, n = 22; and FP4, n = 18). One half were examined before any training on DRE prostate size examination and one half after the physicians were trained. Training involved teaching with a three-dimensional prostate model having posterior surface areas corresponding to the average dimensions of six different prostate volumes. The FPs were instructed to estimate the prostate size on the DRE to the nearest 5 g. A single urologist unaware of the DRE results performed TRUS on all patients to measure the prostate volume.

RESULTS

Before training, the DRE size estimates ranged from 10 to 100 g (mean +/- SD 32.8 +/- 21.6), with a TRUS volume of 11 to 122 g (mean +/- SD 38.9 +/- 23.1). The correlation between the DRE and TRUS estimates was 0.25, suggesting low agreement (intraclass correlation coefficient [ICC] 0.35, 95% confidence interval 0.31, 0. 38). After training, 50 different patients had DRE size estimates of 10 to 100 g (mean +/- SD 39.4 +/- 19.7) and TRUS volume of 10 to 119 g (mean +/- SD 41.5 +/- 24.1). The correlation between the techniques was higher in patients examined after training (r = 0. 765), suggesting much better agreement between the techniques (ICC 0. 87; 95% confidence interval 0.86, 0.88). Among the physicians, agreement between DRE and TRUS was higher after training (ICC 0.64 to 0.96) than before training (ICC 0.02 to 0.49).

CONCLUSIONS

Although the subjects examined before and after training differed, the agreement between TRUS and DRE prostate size estimates by the FPs appeared to be stronger after training with a three-dimensional prostate model. This model may be a useful tool to assist in training FPs and medical students to measure prostate size on DRE.

A systematic review of Cernilton for the treatment of benign prostatic hyperplasia

OBJECTIVE

To systematically review the evidence for the clinical effects and safety of the rye-grass pollen extract (Cernilton) in men with symptomatic benign prostatic hyperplasia (BPH).

METHODS

Trials were identified by searching Medline, specialized databases (EMBASE, Cochrane Library, Phytodok), bibliographies, and contacting relevant trialists and manufacturers. Randomized or controlled clinical trials were included if: men with symptomatic BPH were treated with Cernilton; a control group received either placebo or pharmacological therapy; the treatment duration was >/= 30 days; and clinical outcomes were reported.

RESULTS

In all, 444 men were enrolled in two placebo-controlled and two comparative trials lasting 12-24 weeks. Three studies used a double-blind method although the concealment of treatment allocation was unclear in all. Cernilton improved 'self-rated urinary symptoms' (the proportion reporting satisfactory or improving symptoms) vs placebo and another plant product, Tadenan. The weighted mean (95% confidence interval) risk ratio (RR) for self-rated improvement vs placebo was 2.40 (1. 21-4.75) and the weighted RR vs Tadenan was 1.42 (1.21-4.75). Cernilton reduced nocturia compared with placebo or Paraprost (a mixture of amino acids); against placebo, the weighted RR was 2.05 (1.41-3.00), and against Paraprost the weighted mean difference for nocturia was - 0.40 times per evening (- 0.73 to 0.07). Cernilton did not improve urinary flow rates, residual volume or prostate size compared with placebo or the comparative study agents. Adverse events were rare and mild; the withdrawal rate for Cernilton was 4. 8%, compared with 2.7% for placebo and 5.2% for Paraprost.

CONCLUSIONS

The Cernilton trials analysed were limited by their short duration, limited number of enrolees, omissions in reported outcomes, and the unknown quality of the preparations used. The comparative trials had no confirmed active control. The available evidence suggests that Cernilton is well tolerated and modestly improves overall urological symptoms, including nocturia. Additional randomized placebo and active-controlled trials are needed to evaluate the long-term clinical effectiveness and safety of Cernilton.

One-year follow-up of 2829 patients with moderate to severe lower urinary tract symptoms treated with alfuzosin in general practice according to IPSS and a health-related quality-of-life questionnaire. BPM Group in General Practice

OBJECTIVES

To determine the effectiveness of alfuzosin on symptom reduction, patients' perceived health-related quality of life (HRQL) improvement, adverse outcomes, treatment failure, and progression to acute urinary retention and prostate surgery in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) in a 1-year prospective, open-labeled study.

METHODS

A total of 2829 patients (mean age 65.9 years) were included in the study and received either alfuzosin 2.5 mg three times daily or alfuzosin slow release 5 mg twice daily. The evaluation was based on the International Prostate Symptom Score (IPSS), the eighth IPSS question, and a nine-item BPH HRQL questionnaire (BPHQL9) exploring well-being, the patient's perceived sexual life, and BPH-specific interferences with activities.

RESULTS

A total of 2442 patients (86. 3%) completed the study; the main reasons for noncompletion were adverse events (n = 141, 5.0%), lack of efficacy (n = 136, 4.8%), and death (n = 48, 1.7%); 121 patients (4.3%) underwent prostate surgery, and 33 patients (1.2%) experienced acute urinary retention. No correlation was found between noncompletion and prostate volume or baseline severity. The distribution of patients (in percentages) according to the IPSS, IPSS question 8, and BPHQL9 classes of severity (mild/moderate/severe) at baseline was 1.9/49.0/49.1, 0. 7/65.5/33.8, and 7.7/50.4/41.9, respectively, and at 1 year was 47. 4/50.3/2.4, 34.1/64.9/1.0, and 39.0/50.9/10.1, respectively. The IPSS (19.5 +/- 0.1) was reduced by 49.6% (9.9 +/- 0.1) at 6 months and by 53.8% (11.1 +/- 0.1) at 12 months. Symptom reduction strongly correlated with the initial symptom severity (P <0.0001). The BPHQL9 score (34.6 +/- 0.3) gradually improved up to 12 months (52 +/- 0.4; +93.3%), and this improvement involved all three dimensions. Vertigo (n = 53, 1.9%), hypotension (n = 47, 1.6%), and dizziness (n = 16, 0. 6%) were the most frequent adverse events.

CONCLUSIONS

This study confirms the effectiveness of alfuzosin and the need to include HRQL measurement in the decision-making process when assessing patients with lower urinary tract symptoms.

Relationship between benign prostatic hyperplasia and history of coronary artery disease in elderly men

STUDY OBJECTIVE

To assess the relationship between the occurrence of benign prostatic hyperplasia (BPH), an androgen-dependent disease, and coronary artery disease (defined as history of coronary artery bypass grafting, coronary angioplasty, myocardial infarction) in elderly men.

DESIGN

Retrospective chart review.

SETTING

Urology practice.

PATIENTS

Seven hundred two elderly men aged 65-80 years.

INTERVENTION

The men's charts were reviewed for data pertaining to coronary artery disease, risk factors for coronary artery disease, and serum prostate-specific antigen (PSA) levels. Men who had medical conditions, pharmacologic interventions, or surgical procedures that could alter PSA, and those taking lipid-lowering agents were not included.

MEASUREMENTS AND MAIN RESULTS

PSA levels correlate positively with prostatic volume of BPH. In men with levels under 1.0 pg/L (no BPH) and over 1.0 microg/L (BPH present), the frequency of coronary artery disease was 9% and 29%, respectively (p<0.03). No significant differences were noted between groups in other accepted risk factors for coronary artery disease including age, smoking, diabetes mellitus, or hypertension.

CONCLUSION

Smooth muscle proliferation is an important and possibly androgen-dependent step in the development of atherosclerosis and BPH. Prospective studies are required to assess the effect of antiandrogens on atherosclerosis.

Endocrine status in elderly men with lower urinary tract symptoms: correlation of age, hormonal status, and lower urinary tract function. The Prostate Study Group of the Austrian Society of Urology

OBJECTIVES

To correlate endocrine parameters in elderly men with lower urinary tract symptoms (LUTS) to patient age and clinical parameters such as prostate volume, prostate-specific antigen (PSA) levels, and uroflowmetry and to compare the clinical and endocrinologic parameters in men with or without hypogonadism.

METHODS

Men (40 years old or older) with untreated LUTS as defined by an International Prostate Symptom Score (IPSS) of 7 or greater due to benign prostatic hyperplasia were included in this study and underwent the following investigations: IPSS, free uroflow study, postvoid residual volume, transrectal ultrasound for assessment of prostate volume, serum PSA determination, and an endocrine study, including testosterone, human luteinizing hormone, human follicle-stimulating hormone, prolactin, dehydroepiandrostendione-sulphate (DHEA-S), and prolactin.

RESULTS

Three hundred twelve men (mean age 62.8 +/- 10.6 years, range 40 to 91) were analyzed. The serum levels of estradiol (correlation coefficient [r] = 0.19), human luteinizing hormone (r = 0.32), human follicle-stimulating hormone (r = 0.19), and DHEA-S (r = -0.39) correlated (P <0.05) with age; no such correlation was seen for testosterone (r = 0.04; P0.05) or prolactin (r = 0.09; P0.05). Estradiol (but not testosterone) correlated (r = 0.17, P = 0.01) with prostate volume. The peak flow rate and PSA did not correlate with any endocrinologic parameter. Hypogonadism (serum testosterone less than 3.0 ng/mL) was detected in 22.1% of patients and had no impact on clinical (IPSS, peak flow rate, prostate volume, and PSA level) or endocrine (human luteinizing hormone, human follicle-stimulating hormone, estradiol, prolactin, and DHEA-S) parameters.

CONCLUSIONS

A number of age-related endocrine changes are seen in elderly men with LUTS. Hypogonadism is seen in approximately one fifth of elderly men with LUTS, but in our study it had no impact on symptom status, PSA level, prostate volume, uroflowmetry, or endocrine parameters.

Appropriateness of prostate-specific antigen testing

We established criteria for appropriate use of the prostate-specific antigen (PSA) assay and used them to evaluate PSA test utilization at 1 tertiary care institution. During a 6-month period, 2,330 PSA results were reported for outpatients and 95 for inpatients. We reviewed medical records for a random sample of 338 outpatient results (14.51%) and all 95 inpatient results, of which 21% (71/338) of outpatient and 17% (16/95) of inpatient results were inappropriate according to our test utilization criteria. Among outpatients, 52% of tests were done for screening and 19% for monitoring for cancer recurrence. For inpatients, workup for cancer (53/95 [56%]) was the most frequent indication for testing and screening the second (24/95 [25%]). Of tests failing the criteria, 66 (76%) of 87 resulted from excessively frequent and age-inappropriate screening. We assessed the potential effect on clinical outcome if these tests were not performed. Of the 87 tests considered inappropriate, only 1 test result influenced clinical management for patients younger than 75 years. By instituting simple limits on age and frequency, we estimate that 74% (64/87) of the inappropriate tests could have been eliminated.

Single dose methodology to assess the influence of an alpha1-adrenoceptor antagonist on uroflowmetric parameters in patients with benign prostatic hyperplasia

AIMS

To establish methodology which rapidly and reliably assesses the effect of an alpha1-adrenoceptor antagonist on peak urine flow rates in men with benign prostatic hyperplasia (BPH). This methodology could then be applied to screening new drugs to treat BPH.

METHODS

Twenty-five patients with BPH enrolled in a double-blind, placebo-controlled, two-period crossover study. Patients were either withdrawn from their current alpha1-adrenoceptor antagonist therapy (n = 22) or were untreated prestudy (n = 3) and all met prespecified uroflowmetric criteria including: (1) a peak urine flow rate (Qmax) < 12 ml s-1 off therapy (or < 10 ml s-1 if untreated prestudy) and (2) a decrease in peak urine flow rate (Qmax) of > 2 ml s-1 after withdrawal from therapy. Study treatment consisted of tamsulosin 0.4 mg (or matching placebo) once daily for 8 days in a two-period crossover. Uroflowmetry was performed predose and once postdose (4.5-5.5 h postdose) on day 1, and once postdose (4.5-5.5 h postdose) on day 8 of each treatment period.

RESULTS

After a single dose of tamsulosin, the least-square mean difference between tamsulosin and placebo in the change from baseline Qmax was 2.8 ml s-1 (P = 0.017 vs placebo). After 8 days dosing of tamsulosin, the least-square mean difference between tamsulosin and placebo in the change from baseline Qmax was also 2.8 ml s-1 (P = 0.044 vs placebo). Additionally, there was no significant difference observed between the single and multiple dose results (P > 0.200 for between group difference).

CONCLUSIONS

Both single and multiple doses of tamsulosin 0.4 mg increased Qmax in men with BPH. A single dose produced a comparable response to multiple dose administration. The magnitude of the effect was greater than the effect generally seen in longer term clinical trials, but this difference may be explained by the patient population in this study which was preselected for 'responsiveness' to an alpha1-adrenoceptor antagonist. These results support the utility of single dose uroflowmetric measurements in rapidly providing preliminary data on new investigational agents, specifically agents which act to increase urine flow in men with BPH. However, clinical efficacy would still need to be confirmed with longer term clinical trials.