Lower Urinary Tract Symptoms Revisited: A Broader Clinical Perspective

Prostatic inflammation: a potential treatment target for male LUTS due to benign prostatic obstruction

BACKGROUND

The purpose of this narrative review is to evaluate the role of prostatic inflammation as a treatment target for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) and provide an update on the available therapies.

METHODS

An extensive literature search was conducted for studies on established and investigational treatments with anti-inflammatory mechanism of action that has been assessed for the management of male LUTS due to BPO.

RESULTS

Data on phosphodiesterase 5 inhibitors, nonsteroidal anti-inflammatory drugs, vitamin D3 receptor analogs, phytotherapy, statins, and lifestyle changes have been reviewed and analyzed. Preclinical evidence has shown the anti-inflammatory effect of these treatments on prostate. However, there is a wide variation in the degree of mature of each therapy. In addition, there are significant differences between the studies in terms of design, number of patients, and duration of follow-up.

CONCLUSIONS

Several drugs classes have been investigated for their impact on prostatic inflammation and improvement of male LUTS. The reviewed data support the rationale for use of agents that may alter and improve the inflammatory environment in the prostate in men with LUTS, but further high-quality long-term studies are required for the exact positioning of the new drugs in daily practice.

Effect of lower urinary tract symptoms on the quality of life and sexual function of males in China, Taiwan, and South Korea: Subgroup analysis of a cross-sectional, population-based study

Objective

Lower urinary tract symptoms (LUTS) in males can reduce patients’ quality of life (QoL) and affect sexual function and satisfaction. Although this has been documented in the US, Canada, Germany, Italy, UK, and Sweden, data are limited on the effects of LUTS on QoL and sexual function in Asian men. The present subgroup analysis of an Internet‐based survey correlated the incidence of male LUTS by severity and category with self‐assessed QoL and sexual function and satisfaction measures.

Methods

Males aged ≥40 years were randomly selected from consumer survey panels in China, Taiwan, and South Korea. LUTS were defined using the International Continence Society (ICS) 2002 symptom definitions; symptom severity was assessed by the International Prostate Symptom Score (IPSS). The effect of LUTS on QoL was assessed using Patient Perception of Bladder Condition (PPBC) and IPSS QoL scores. Sexual function and satisfaction were assessed using the International Index of Erectile Function (IIEF).

Results

Men with moderate‐to‐severe LUTS and overlap of voiding, storage, and post‐micturition symptom categories reported dissatisfaction with their QoL and sexual function. LUTS severity was negatively correlated with IIEF scores. Overlap of LUTS categories had a greater effect on QoL and sexual satisfaction than the incidence of just 1 LUTS.

Conclusion

The findings of the present study suggest that LUTS is prevalent in >60% of Asian males aged ≥40 years and is associated with reduced QoL and sexual function, particularly in those with overlap of LUTS categories and greater symptom severity.

The use of Mechanical Diagnosis and Therapy (MDT) in patients with lower urinary tract symptoms (LUTS): case series

Lower urinary tract symptoms (LUTS) are highly prevalent among men over the age of 40. Even though associations between lumbar spine conditions and LUTS have been documented in the literature, no studies have detailed a specific lumbar assessment and classification process, and the related treatment effects in patients with LUTS. In this case series, we present three male patients with LUTS as primary complaints, who were evaluated and treated with Mechanical Diagnosis and Therapy (MDT) for the lumbar spine. The duration of their symptoms was between 4 months and 7 years. Urogenital pathologies were ruled out for all patients. The Chronic Prostatitis Symptom Index was used as a functional outcome measure. All patients were classified as having lumbar derangements. Treatment of derangements with directional preference exercises resulted in the improvement of their LUTS, with clinically significant improvements (56.0%-77.4%) in functional outcome measures over an average of six sessions. Preliminary indications suggest that these LUTS cases may possibly have had a lumbar spine origin and "mechanical" nature. Therefore, they may be within the scope of MDT assessments and interventions. With careful monitoring of symptoms, MDT may serve as a screening tool and conservative treatment option.

Best practice in the management of storage symptoms in male lower urinary tract symptoms: a review of the evidence base

Storage lower urinary tract symptoms (LUTS) are characterized by an altered bladder sensation, increased daytime frequency, nocturia, urgency and urgency incontinence. Some evidence underlines the role of metabolic factors, pelvic ischemia, prostatic chronic inflammation and associated comorbidities in the pathophysiology of storage LUTS. A detailed evaluation of the severity of storage LUTS, and the concomitance of these symptoms with voiding and postmicturition symptoms, is mandatory for improving the diagnosis and personalizing treatment. A detailed medical history with comorbidities and associated risk factors, a physical examination, a comprehensive analysis of all the features of LUTS, including their impact on quality of life, and a frequency-volume chart (FVC) or bladder diary, are recommended for men with storage LUTS. Several drugs are available for the treatment of LUTS secondary to benign prostatic obstruction (BPO). Alpha-blockers (α-blockers), 5-α-reductase inhibitors and phosphodiesterase type 5 inhibitors are commonly used to manage storage LUTS occurring with voiding symptoms associated with BPO. Muscarinic receptor antagonists and Beta 3-agonists (β3-agonists) alone, or in combination with α-blockers, represent the gold standard of treatment in men with predominant storage LUTS. There is no specific recommendation regarding the best treatment options for storage LUTS after prostatic surgery.

Effect of Calcium Channel Blockers on Lower Urinary Tract Symptoms: A Systematic Review

Background

Numerous medications are known to be associated with the development of lower urinary tract symptoms (LUTS). One such medication group is calcium channel blockers (CCB).

Objective

To critically examine the literature regarding the involvement of CCB in manifestation of LUTS in humans.

Methods

A systematic literature search was conducted on PubMed, SciELO, Scopus, and OpenGrey databases to find all potentially relevant research studies before August 2016.

Results

Five studies met the inclusion criteria and were included in this review. Three out of five studies stated that CCB were involved in either precipitation or exacerbation of LUTS. As for the remaining two studies, one study found out that only the monotherapy of CCB was associated with increased prevalence of nocturia and voiding symptoms in young females, whereas the other study reported an inverse association of CCB with LUTS. The methodological quality of studies was considered high for four studies and low for one study.

Conclusion

Healthcare providers should make efforts for an earlier identification of the individuals at risk of LUTS prior to the commencement of CCB therapy. Moreover, patients should be counselled to notify their healthcare provider if they notice urinary symptoms after the initiation of CCB.

Is testosterone important in LUT function in men and women? ICI-RS 2015

AIM

This review article is a collaborative report based upon the Authors' presentations and Group discussion on the role of testosterone (T) in the male and female lower urinary tract (LUT) which took place at the 6th International Consultation on Incontinence Research Society's (ICI-RS) annual meeting, in Bristol, UK (September 8-10, 2015).

METHODS

It comprises overviews and opinions on both the current state of knowledge of the role of T in LUT function and dysfunction in both sexes.

RESULTS

Results from animal studies suggest that T treatment may be beneficial for disorders of the LUT in women including urinary incontinence and pelvic organ prolapse. The need for clinical studies to evaluate the effect of T treatment in peri- and post-menopausal women, taking into account the type of applied androgen, the application form, timing and dosage, is especially emphasized. In males, findings on the impact of T on the male external urethral sphincter underscores that there is still much to learn about its role in male LUT physiology. The important topic of the use of T therapy in the treatment of enuresis in the young, both sexes, is also discussed. The importance of understanding the steroidogenic pathways linking T with estradiol is discussed as being of paramount importance in researching the unique actions of T in the LUT.

CONCLUSION

The overall conclusion is that further research into the role of T in LUT function and dysfunction across genders and age groups (young to old) is extremely important. Neurourol. Urodynam. 36:859-862, 2017. © 2017 Wiley Periodicals, Inc.

The use of a Swedish telephone medical advice service by the elderly - a population-based study

OBJECTIVE

The present study aimed to describe contact made by the elderly to Sweden's nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres.

DESIGN

De-identified data from recorded calls to HGP was extracted for analysis (n = 7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.

SETTING

Västerbotten County, Sweden.

SUBJECTS

Patients over 80 years.

MAIN OUTCOME MEASURES

Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations.

RESULTS

The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r = 0.30, p < 0.05) and calls that were given advice correlated with acute primary healthcare visits (r = 0.38, p = 0.005).

CONCLUSION

The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service's present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly's medication regimens. Key points Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups. Drug-related questions were the most common reason for contact. A significant proportion of all calls made resulted in further heatlhcare contacts.

A possible relationship between serum sex hormones and benign prostatic hyperplasia/lower urinary tract symptoms in men who underwent transurethral prostate resection

In this study, we examined the relationship between sex hormone levels and lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH) who underwent transurethral surgery. The study was conducted in 158 patients who came to our hospital for surgery. Clinical conditions were assessed by body mass index (BMI), digital rectal examination, International Prostate Symptom Score (IPSS) and transrectal ultrasound (TRUS). The levels of sex hormones (including total testosterone (TT), estradiol (E₂), progesterone (P), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin (PRL)) and prostate-specific antigen (PSA) were reviewed. Correlations were determined through statistical analysis. The mean age was 72.06 ± 8.68 years. The total IPSS was significantly associated with the TT level (r = −0.21, P= 0.01). Other sex hormone levels were not correlated with total IPSS. However, some ratios such as E₂/TT (r = 0.23, P= 0.00) and FSH/LH (r = −0.17, P = 0.04) were associated with total IPSS. Further analysis showed that the nocturia was associated with age (r = 0.16, P= 0.04), BMI (r = 0.21, P = 0.01), and TT (r = −0.19, P= 0.02). Moreover, we divided the patients into two subgroups based on IPSS severity (<20 or ≥20). The mean TT level was in the normal range, but it was significantly related to the presence of severe LUTS. In summary, our study has shown that the severity of LUTS is associated with TT, E₂/TT and FSH/LH in men who underwent prostate surgery. Increasing nocturia was observed in lower testosterone patients. Additional larger studies are needed to elucidate the potential mechanisms.

Prevalence of storage lower urinary tract symptoms in male patients attending Spanish urology office. Urinary urgency as predictor of quality of life

INTRODUCTION

The study sought to determine the symptomatic profile of men with lower urinary tract symptoms (LUTS) who visited a urology clinic in Spain and its impact on their health-related quality of life (HRQL).

MATERIALS AND METHODS

A national, epidemiological cross-sectional study was conducted and included 291 urology clinics. The prevalence of storage LUTS was investigated in 25,482 men. The study collected sociodemographic and clinical data from a subgroup of 1015 patients with storage LUTS who filled out the International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire Short Form (OABq-SF) and Patient Perception of Bladder Condition (PPBC) questionnaires. The impact of urinary urgency on HRQL was analysed.

RESULTS

The prevalence of storage LUTS was 41%, increasing with age: 14.1%, 41.5% and 60.8% for patients aged 18-49, 50-64 and ≥65 years, respectively. Of the 1015 selected patients, only 2.6% had storage symptoms exclusively. Symptom severity (IPSS) increased with age. Nocturia, frequency and urgency were the most common symptoms and had the most impact on HRQL (IPSS and OABq-SF). The number of urgency episodes was inversely correlated with the HRQL (r=-.773; P<.0001). In the multivariate analysis, only the IPSS and OABq-SF bother scores were significant predictors of HRQL (P<.001).

CONCLUSION

Storage LUTS are highly prevalent among patients attending urology clinics in Spain. The severity of the urgency (number of urgency episodes) predicted a poorer quality of life for the patient.

Does uroflowmetry parameter facilitate discrimination between detrusor underactivity and bladder outlet obstruction?

Purpose

Though urodynamic study (UDS) is the current established standard to distinguish between detrusor underactivity (DU) and bladder outlet obstruction (BOO), concerns of patient discomfort and potential complications of catheterization deters its use. We inspected clinical variables to discriminate between DU and BOO in uroflowmetry, which can be more easily performed in clinical practice.

Materials and Methods

Total 240 men who both underwent UDS and uroflowmetry were reviewed. The patients were divided into 2 groups by a single experienced urologist based on UDS outcome; DU (n=111) and BOO (n=129). From uroflowmetry, 5 variables including maximal flow rate (Qmax), average flow rate (Qave), voiding volume (VV), postvoid residual urine (PVR), and value of Qmax minus Qave (DeltaQ) was obtained. Multivariable analysis including receiver operating characteristic (ROC) curve analysis was performed to identify the important diagnostic predictors.

Results

The mean age (±standard deviation) was 65.3±9.2 years. Except Qave, all uroflowmetry components were significantly different between DU and BOO groups. DeltaQ was smaller in DU group (8.71 mL/s vs. 5.26 mL/s, p<0.001). By logistic regression analysis, DeltaQ (Exp(B)=0.648, p<0.001) and PVR (Exp(B)=1.009, p<0.001) significantly discriminate DU and BOO diagnosis. In diagnosing DU using a single variable, the area under the curve of ROC from DeltaQ (0.806) was significantly higher than that from Qmax (0.763, p=0.0126) and Qave (0.574, p<0.0001).

Conclusions

Our findings suggest that DeltaQ is a novel predictor capable of discriminating DU from BOO in men with obstructive lower urinary tract symptom.

Toileting behaviours and lower urinary tract symptoms among female nurses: A cross-sectional questionnaire survey

BACKGROUND

Unhealthy toileting behaviours exist among women, and lower urinary tract symptoms have a high prevalence and significant effects on quality of life. However, the relationship between toileting behaviours and lower urinary tract symptoms is unclear.

OBJECTIVES

This study aimed to investigate the prevalence of lower urinary tract symptoms among female nurses, and the association between toileting behaviours and lower urinary tract symptoms.

DESIGN

A cross-sectional stratified cluster sampling study.

PARTICIPANTS

A total of 636 female clinical nurses from tertiary hospitals in Jinan (the capital city of Shandong Province, China).

METHODS

The Toileting Behaviour-Women's Elimination Behaviours and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms scales were used to assess the participants' toileting behaviours and lower urinary tract symptoms, respectively. Multiple linear regression analysis was used to evaluate the association between toileting behaviours and lower urinary tract symptoms.

RESULTS

Unhealthy toileting behaviours were common among the female nurses, with delayed voiding being the unhealthiest toileting behaviour, which was followed by place and position preference for voiding. Nearly 68% of the female nurses had at least one lower urinary tract symptom, nearly 50% had incontinence symptoms, 40% had filling symptoms, and 18% had voiding symptoms. Unhealthy toileting behaviours (premature voiding, delayed voiding, and straining to void) were positively associated with lower urinary tract symptoms. However, lower urinary tract symptoms were not significantly associated with voiding place or position preference. Among the control variables, being married or having a history of a urinary tract infection was associated with lower urinary tract symptoms. Having a higher income and regular menstrual period were negatively associated with lower urinary tract symptoms. Compared with vaginal delivery, caesarean delivery had a protective association with lower urinary tract symptoms.

CONCLUSION

Lower urinary tract symptoms among female nurses should not be overlooked, because their prevalence among female clinical nurses exceeded that among the general population of women. These findings highlight the importance of avoiding unhealthy toileting behaviours (especially premature voiding, delayed voiding, and straining to void), as these unhealthy toileting behaviours were significantly associated with susceptibility to lower urinary tract symptoms.

Association of Prostate Blood Flow with Male Lower Urinary Tract Symptoms

PURPOSE

To investigate the association of prostate blood flow (PBF) with lower urinary tract symptoms (LUTS) in aged males using Doppler spectral waveform (DSW) analysis.

PATIENTS AND METHODS

We performed a prospective analysis involving 133 aged males with clinical diagnosis of LUTS. DSW parameters (peak-systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI)) were measured at bilateral neurovascular bundles (NVB), periurethral, and capsular branches by Doppler transrectal ultrasound with the patient in the right lateral decubitus position. The associations of PBF parameters and the International Prostate Symptom Score (IPSS) were analyzed.

RESULTS

Overall, total IPSS scores were significantly correlated with the RI of bilateral NVB vessels (r2 = 0.03, 0.04; p = 0.04, 0.02, respectively), and PSV of left NVB vessels. PSV of bilateral NVB vessels were associated with the storage score (p = 0.022 and p = 0.016), but not with the voiding score. The sum of the frequency and urgency score was also associated with EDV of both capsular and urethral branches (p = 0.043 and p = 0.009, respectively), and PSV of NVB vessels on both sides (p = 0.045 and p = 0.019, respectively).

CONCLUSIONS

There is an association between PBF and LUTS, especially with storage symptoms. The findings may provide some insights in understanding the underlying pathophysiology of lower urinary tract dysfunction.

A systematic review of the association between lower urinary tract symptoms and falls, injuries, and fractures in community-dwelling older men

BACKGROUND

Lower urinary tract symptoms (LUTS) have been associated with falls in studies either exclusively or predominantly of women. It is, therefore, less clear if LUTS are risk factors for falls in men.

METHODS

We conducted a systematic review of the literature on the association between LUTS and falls, injuries, and fractures in community-dwelling older men. Medline, Embase, and Cinahl were searched for any type of observational study that has been published in a peer-reviewed journal in English language. Studies were excluded if they did not report male-specific data or targeted specific patient populations. Results were summarized qualitatively.

RESULTS

Three prospective cohort studies and six cross-sectional studies were identified. Incontinence, urgency, nocturia, and frequency were consistently shown to have weak to moderate association with falls (the point estimates of odds ratio and relative risk ranged from 1.31 to 1.67) in studies with low risk of bias for confounding. Only frequency was shown to be associated with fractures.

CONCLUSIONS

Urinary incontinence and lower urinary tract storage symptoms are associated with falls in community-dwelling older men. The circumstances of falls in men with LUTS need to be investigated to generate hypotheses about what types of interventions may be effective in reducing falls.

Positive association of female overactive bladder symptoms and estrogen deprivation: A nationwide population-based cohort study in Taiwan

OBJECTIVE

Estrogen is considered to be a unique hormone in females that has an impact on voiding function. Animal models and clinical epidemiologic studies showed high correlation between estrogen deficiency and female overactive bladder (OAB) symptoms. We designed a population-based cohort study from a national health database to assess the association of estrogen deprivation therapy and female OAB.

MATERIALS AND METHODS

This study examined the records of 16,128 patients ranging in age from 18 to 40 that were included in the Taiwan National Health Insurance Research Database (NHIRD) in the years between 2001 and 2010. Of these, 1008 had breast cancer with hormone therapy only and the other 15,120 controls did not have breast cancer or hormone therapy. All patients with neurologic diseases and those with pre-existing OAB identified by information in the NHIRD database were excluded. OAB was defined by medications prescribed for at least 1 month. Risk of new onset OAB in the breast cancer and nonbreast cancer groups was estimated. Fourteen patients (1.4%) experienced OAB in the breast cancer group. Overall, breast cancer with estrogen deprivation therapy increased the risk of OAB by 14.37-fold (adjusted hazard ratio, 95% confidence interval 7.06-29.27). Subgroup analysis showed that in the older age breast cancer group (36-40), a lower Charlson comorbidity index (CCI) score and antidepressant medication use for at least 30 days had an impact on the increase of OAB risk. After adjustment of variables, the higher CCI and the use of antipsychotic drugs increased risk of OAB 3.45-fold and 7.45-fold, respectively. The Kaplan-Meier analysis of OAB-free survival in the breast cancer group showed a significant time-dependent increase in incidence of OAB.

CONCLUSION

Estrogen deprivation in young patients with breast cancer increased the risk of OAB. The OAB development rate was steady and fast in the beginning 3 years after estrogen deprivation. This result indicates a role of estrogen in the modulation of female voiding function.

Population-level and Individual-level Bother of Lower Urinary Tract Symptoms Among 30- to 80-year-old Men

OBJECTIVE

To estimate the bother using both population- and individual-level bother of lower urinary tract symptoms (LUTS) across a wide age range among men.

MATERIALS AND METHODS

A total of 7470 men aged 30-80 years were approached using a postal questionnaire in 2004. The overall response was 58.7% (4384 respondents). The Danish Prostatic Symptom Score was used to evaluate bother of 12 LUTS. In the population-level analysis, prevalence of bother was calculated by relating the number of men with bother to the population size (instead of only affected men). To evaluate the bother at individual level, its prevalence among the men experiencing the symptom was assessed.

RESULTS

In the population-level analysis, postmicturition dribble was the most common cause of bother among 30- and 40-year-old men, as 25% of the men experienced small bother and 4.5% had moderate to major bother. Men aged 70-80 years experienced the most bother from urgency followed closely by nocturia, with about 40% reporting small bother and roughly 20% moderate or major bother. When only symptomatic men were evaluated, incontinence symptoms, especially urge incontinence, were the most bothersome as more than 80% of the men with incontinence reported bother.

CONCLUSION

At population level, the most bothersome symptom varied by age. Men aged 30-40 years experienced bother most commonly from postmicturition dribble. With increasing age, urgency and nocturia became the most bothersome symptoms by age 70-80 years. At individual level, incontinence symptoms were the most bothersome LUTS, with less influence by age.

Lower Urinary Tract Symptoms and Incident Falls in Community Dwelling Older Men: The Concord Health and Ageing in Men Project

PURPOSE

We sought to determine which lower urinary tract symptoms are associated with incident falls in community dwelling older men.

MATERIALS AND METHODS

The Concord Health and Ageing in Men Project involves a representative sample of community dwelling men 70 years old or older in a defined geographic region in Sydney, New South Wales, Australia. Included in analysis were 1,090 men without neurological diseases, poor mobility or dementia at baseline. Lower urinary tract symptoms were assessed using I-PSS (International Prostate Symptom Score) and incontinence was assessed using ICIQ (International Consultation on Incontinence Questionnaire) at baseline. I-PSS subscores were calculated for storage and voiding symptoms. Incident falls in 1 year were determined by telephone followup every 4 months.

RESULTS

I-PSS storage and voiding subscores were associated with falls. Urgency incontinence was associated with falls (adjusted incidence rate ratio 2.57, 95% CI 1.54-4.30). In addition, intermediate to high I-PSS storage subscores without urgency incontinence were associated with falls (adjusted incidence rate ratio 1.72, 95% CI 1.24-2.38). Other types of incontinence and urgency alone without urgency incontinence were not associated with falls.

CONCLUSIONS

Lower urinary tract storage and voiding symptoms were associated with falls in community dwelling older men. Of the symptoms of overactive bladder urgency incontinence carried a high risk of falls. Storage symptoms also contributed to the fall risk independently of urgency incontinence. Circumstances of falls among men with lower urinary tract symptoms should be explored to understand how lower urinary tract symptoms increase the fall risk and generate hypotheses regarding potential interventions. Furthermore, trials to treat lower urinary tract symptoms in older men should include falls as an end point.

New therapeutic strategies for the treatment of male lower urinary tract symptoms

Male lower urinary tract symptoms (LUTS) are prevalent in the general population, especially in those of advanced age, and are characterized by notable diversity in etiology and presentation, and have been proven to cause various degrees of impairment on quality of life. The prostate has traditionally been regarded as the core cause of male LUTS. As a result, medical treatment aims to provide symptomatic relief and effective management of progression of male LUTS due to benign prostatic enlargement. In this context, α₁-blockers, phosphodiesterase-5 inhibitors, and 5α-reductase inhibitors have long been used as monotherapies or in combination treatment to control voiding LUTS. There is accumulating evidence, however, that highlights the role of the bladder in the pathogenesis of male LUTS. Current research interests have shifted to bladder disorders, and medical management is aimed at the bladder. Muscarinic receptor antagonists and the newly approved β₃-adrenergic agonist mirabegron aim to alleviate the most bothersome storage LUTS and thus improve quality of life. As voiding and storage LUTS frequently coexist, combination therapeutic strategies with α₁-blockers and antimuscarinics or β₃-agonists have been introduced to manage symptoms effectively. Anti-inflammatory agents, vitamin D₃-receptor analogs, and cannabinoids represent treatment modalities currently under investigation for use in LUTS patients. Furthermore, luteinizing hormone-releasing hormone antagonists, transient receptor-potential channel blockers, purinergic neurotransmission antagonists, Rho-kinase inhibitors, and inhibitors of endothelin-converting enzymes could have therapeutic potential in LUTS management, but still remain in the experimental setting. This article reviews new strategies for the medical treatment of male LUTS, which are dictated by the potential role of the bladder and the risk of benign prostatic hyperplasia progression. Moreover, combination treatments and therapies currently under investigation are also presented.

Recent advances in the understanding of male lower urinary tract symptoms (LUTS)

In this review, we have looked at three important areas in understanding male lower urinary tract symptoms. These are improvement in terminology, detrusor underactivity, and nocturia. Benign prostatic hyperplasia leading to bladder outlet obstruction has been covered in a previous review.

Fixed-dose combination therapy with dutasteride and tamsulosin in the management of benign prostatic hyperplasia

Despite their multifactorial etiology, male lower urinary tract symptoms (LUTS) have been traditionally associated with benign prostatic enlargement (BPE) because of benign prostatic hyperplasia (BPH). Several pharmaceutical therapies have been used to manage LUTS, with α1-adrenergic receptor antagonists (α1-blockers) and inhibitors of 5α-reductase (5α-RIs) representing the most commonly prescribed agents currently in use for LUTS treatment. Due to their different modes of action, combined use of α1-blockers and 5α-RIs has been proven to offer more optimal control of symptoms and better associated quality of life, even though higher rates of adverse events have been shown. Following previous studies on the separate administration of dutasteride and tamsulosin, a fixed-dose combination capsule of tamsulosin 0.4 mg and dutasteride 0.5 mg has been approved and released for clinical use in men with BPH. The present review aims to discuss the rationale behind the combined use of tamsulosin and dutasteride for treating male LUTS, and to present the available data on the role of combination therapy in the management of BPH-related symptoms in terms of efficacy and safety. Special attention is given to the impact of combination treatment on the prevention of clinical progression of BPH. Cost-effectiveness of fixed-dose combination and patients' adherence to treatment are also discussed.

Latest Evidence on the Use of Phosphodiesterase Type 5 Inhibitors for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

CONTEXT

Several preclinical reports, randomized controlled trials, systematic reviews, and posthoc analyses corroborate the role of phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of men with lower urinary tract symptoms (LUTS) associated with benign prostatic enlargement (BPE).

OBJECTIVE

Update of the latest evidence on the mechanisms of action, evaluate the current meta-analyses, and emphasize the results of pooled data analyses of PDE5-Is in LUTS/BPE.

EVIDENCE ACQUISITION

Literature analysis of basic researches on PDE5-Is, systematic literature search in PubMed and Scopus until May 2015 on reviews of trials on PDE5-Is, and collection of pooled data available on tadalafil 5mg.

EVIDENCE SYNTHESIS

Latest evidences on the pathophysiology of LUTS/BPE has provided the rationale for use of PDE5-Is: (1) improvement of LUT oxygenation, (2) smooth muscle relaxation, (3) negative regulation of proliferation and transdifferentiation of LUT stroma, (4) reduction of bladder afferent nerve activity, and (5) down-regulation of prostate inflammation are the proven mechanisms of action of PDE5-Is. Data from eight systematic reviews demonstrated that PDE5-Is allow to improve LUTS (International Prostate Symptom Score mean difference vs placebo: 2.35-4.21) and erectile function (International Index of Erectile Function mean difference vs placebo: 2.25-5.66), with negligible change in flow rate (Qmax mean difference vs placebo: 0.01-1.43). Pooled data analyses revealed that tadalafil 5mg once daily allows the clinically-meaningful improvement of LUTS and nocturnal voiding frequency independent of both erectile dysfunction severity and improvement.

CONCLUSIONS

PDE5-Is are safe and effective in improving both LUTS and erectile function in appropriately selected men with LUTS/BPE. Data on the reduction of disease progression, long-term outcomes, and cost-effectiveness analyses are still lacking.

PATIENT SUMMARY

We reviewed recent literature on phosphodiesterase type 5 inhibitors in men with lower urinary tract symptoms associated with prostatic enlargement. We found evidence to confirm that phosphodiesterase type 5 inhibitors are a valid treatment option for men affected by bothersome urinary symptoms with or without erectile dysfunction.

Combination therapy with tamsulosin and solifenacin for male lower urinary tract symptoms with predominant filling symptoms: a new approach to an old problem

Benign prostatic enlargement is the main cause of male lower urinary tract symptoms (LUTS). The distinction and quantification of voiding, storage and postmicturition symptoms help clinicians decide on a modern pharmacological therapeutic approach for male LUTS. Muscarinic receptors antagonists are now considered safe therapy in males and a fixed-dose combination of oral controlled absorbed system solifenacin and tamsulosin is advantageous compared to tamsulosin monotherapy in males with predominant storage symptoms when validated instruments such as International Prostatic Score Symptoms (IPSS) or Total Urgency Frequency Score (TUFS) are used. This combination therapy is well tolerated and maintains symptomatic improvement in the long term. Different options of managing male LUTS with predominant storage symptoms include a combination of tamsulosin and solifenacin, antimuscarinics alone - some with flexible dosing, and the beta-3 agonist mirabegron. Tailored pharmacological therapy for the particular patient is not a reality yet, but judicious use of the different alternatives could bring varied new therapeutic solutions for male LUTS including benign prostatic enlargement and benign prostatic obstruction.

Lower Urinary Tract Symptoms, Depression, Anxiety and Systemic Inflammatory Factors in Men: A Population-Based Cohort Study

Background

The relationship between lower urinary tract symptoms (LUTS) and common mental health disorders such as depression and anxiety in men remains unclear. Inflammation has recently been identified as an independent risk factor for LUTS and depression. This study aimed to assess the association between depression, anxiety and LUTS, and the moderating influence of systemic inflammation, in the presence of other biopsychosocial confounders.

Methods

Participants were randomly-selected from urban, community-dwelling males aged 35–80 years at recruitment (n = 1195; sample response rate:67.8%). Of these, 730 men who attended baseline (2002–5) and follow-up clinic visits (2007–10), with complete outcome measures, and without prostate or bladder cancer and/or surgery, neurodegenerative conditions, or antipsychotic medications use, were selected for the present study. Unadjusted and multi-adjusted regression models of incident storage and voiding LUTS and incident depression and anxiety were combined with serum inflammatory markers (high-sensitive C-reactive protein (hsCRP), tumor necrosis factor-alpha (TNF-α), interleukin–6 (IL–6), myeloperoxidase (MPO), soluble e-selectin (e-Sel)) and socio-demographic, lifestyle, and health-related factors. Hierarchical multiple regression was used to assessed the moderating effect of inflammatory markers.

Results

The incidence of storage, voiding LUTS, depression and anxiety was 16.3% (n = 108), 12.1% (n = 88), 14.5% (n = 108), and 12.2% (n = 107). Regression models demonstrated that men with depression and anxiety at baseline were more likely to have incident storage, but not voiding LUTS (OR: 1.26, 99%CI: 1.01–4.02; and OR:1.74; 99%CI:1.05–2.21, respectively). Men with anxiety and storage LUTS at baseline were more likely to have incident depression (OR: 2.77, 99%CI: 1.65–7.89; and OR:1.45; 99%CI:1.05–2.36, respectively), while men with depression and voiding LUTS were more likely to have anxiety at follow-up (OR: 5.06, 99%CI: 2.81–9.11; and OR:2.40; 99%CI:1.16–4.98, respectively). CRP, TNF-α, and e-Sel were found to have significant moderating effects on the development of storage LUTS (1.06, 0.91–1.96, R² change: 12.7%), depression (1.17, 1.01–1.54, R² change: 9.8%), and anxiety (1.35, 1.03–1.76, R² change: 10.6%), respectively.

Conclusions

There is a bidirectional relationship between storage, but not voiding, LUTS and both depression and anxiety. We observed variable moderation effects for selected inflammatory markers on the development of depression, anxiety and storage LUTS.

Atherosclerosis as a predictor of delayed recovery from lower urinary tract dysfunction after robot-assisted laparoscopic radical prostatectomy

AIMS

The aim of the present study was to investigate whether atherosclerosis could be associated with lower urinary tract dysfunction in the early postoperative period after robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

Eighty consecutive patients undergoing RARP were investigated. The severity of atherosclerosis was evaluated by the cardio-ankle vascular index (CAVI) before RARP. Patients were divided into two groups, the atherosclerotic group (CAVI ≥9.0) and the control group (CAVI <9.0). International Prostate Symptom Score (IPSS), quality of life (QOL) index, uroflowmetry, post-void residual urine volume (PVR), frequency-volume charts, and the 1-hr pad test were compared between the two groups. Assessments were performed before RARP, and then at 1, 3, and 6 months after RARP.

RESULTS

Preoperative subjective and objective parameters were not significantly different between the two groups. The voiding symptom score of the IPSS and the QOL index was significantly higher in the atherosclerotic group at 3 months after RARP (P = 0.035, P = 0.001, respectively). The maximum flow rate was consistently lower in the atherosclerotic group, reaching a significant difference at 6 months after RARP (P = 0.027). IPSS total and storage symptom scores, PVR, frequency, and urine loss were not significantly different between the groups after RARP.

CONCLUSIONS

Atherosclerosis delayed the improvement of both voiding symptoms and voiding function after RARP, leading to aggravation of QOL in the early postoperative period. Atherosclerosis may be a predictor of slower recovery from transient lower urinary tract dysfunction immediately after RARP. Neurourol. Urodynam. 35:920-925, 2016. © 2015 Wiley Periodicals, Inc.

The Impact of Lower Urinary Tract Symptoms on Quality of Life, Work Productivity, Depressive Symptoms, and Sexuality in Korean Men Aged 40 Years and Older: A Population-Based Survey

Purpose:

To examine the impact of lower urinary tract symptoms (LUTS) on health-related quality of life (HRQoL) in Korean men aged ≥40 years.

Methods:

A population-based, cross-sectional door-to-door survey was conducted among men aged ≥40 years. Individuals with LUTS were defined as men reporting at least one LUTS using 2002 International Continence Society definitions. Structuredquestionnaires were used to assess several dimensions of HRQoL, including generic health status (EuroQoL-five-dimensions questionnaire), work productivity (work productivity and activity impairment questionnaire), depressive symptoms (center for epidemiologic studies depression scale), and sexual health (sexual satisfaction and erectile dysfunction). The impact of LUTS was assessed by comparing several dimensions of HRQoL among men with and without LUTS.

Results:

Of the 1,842 participants, 1,536 (83.4%) reported having at least one LUTS. The prevalence of LUTS increased with age (78.3% among those aged 40–49 years to 89.6% among those aged 60 years or older). Those with LUTS reported a significantlylower level of generic health status and worse work productivity compared with those without LUTS. Significantly more individuals with LUTS reported having a higher level of major depressive symptoms compared with those without LUTS.Those with LUTS reported worse sexual activity and enjoyment, and were significantly more likely to have erectile dysfunction than those without LUTS.

Conclusions:

LUTS seem to have a substantial impact on several dimensions of HRQoL in Korean men aged ≥40 years.

The Impact of Increased Bladder Blood Flow on Storage Symptoms after Holmium Laser Enucleation of the Prostate

In order to investigate how holmium laser enucleation of the prostate (HoLEP) improves urinary storage symptoms, we assessed blood flow in the urinary bladder mucosa of patients with benign prostatic hyperplasia (BPH) before and after laser surgery. Seventy-four consecutive patients with BPH (median age 69 years, range; 53–88) underwent HoLEP at our institution and are included in this study. We prospectively assessed the International Prostate Symptom Score (IPSS), IPSS-QOL Score, the Overactive Bladder Symptom Score (OABSS), uroflowmetry, and blood flow in the urinary bladder, before and after surgery. Blood flow in the bladder mucosa was measured using the OMEGA FLOW (OMEGAWAVE, Tokyo, Japan) laser Doppler flowmeter. The median volume of the enucleated adenomas was 45.0 g (range: 25.0 to 83.2). The median IPSS improved significantly from 20 (range: 6–35) to 3 (0–22) (p<0.001; Wilcoxon signed-rank test), as did the storage symptoms score, which decreased from 13 (2–20) to 3 (1–8) (p<0.001). Median bladder blood flow increased at the trigone from 9.57±0.83 ml/sec to 17.60±1.08 ml/sec. Multiple regression analysis for the improved storage symptom score eliminated all explanatory variables except increased bladder perfusion. The data suggest that HoLEP improves blood flow in the bladder mucosa, which independently leads to the improvement of storage symptoms.

Do lower urinary tract symptoms predict cardiovascular diseases in older men? A systematic review and meta-analysis

Purpose

To study the incidence of CVD in men at risk, with and without LUTS.

Methods

We searched all longitudinal studies describing the association between LUTS and CVD (mortality) in October 2013 and December 2014 using MEDLINE, EMBASE, and the Cochrane Library Central Register. PRISMA criteria were met.

Results

We included five studies with 6027 men with LUTS and 18,993 men without LUTS in the meta-analyses, with a follow-up period varying from 5 to 17 years. Studies totalled 2780 CVD events. No clear association between CVD and LUTS was demonstrated [pooled effect size: hazard ratio 1.09 (95 % CI 0.90–1.31); p = 0.40]. Two other studies reported the association between nocturia and (CVD) mortality. CVD-specific mortality risk was approximately two times higher for Japanese men with nocturia (357 men aged 70 years and over, 5-year follow-up). A univariable association between nocturia and all-cause mortality was found in Dutch men, but not in age-adjusted analyses (1114 men aged 50–78 years, 13-year follow-up).

Conclusion

This meta-analysis conducted on longitudinal studies does not confirm LUTS to be a predictor of CVD in men without a history of CVD, despite the observed association between LUTS and CVD in cross-sectional studies.

Solifenacin/tamsulosin fixed-dose combination therapy to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia

Treatment of male lower urinary tract symptoms (LUTS) has traditionally focused on the management of benign prostatic obstruction, but the contribution of bladder dysfunction has been recently recognized. Therefore, it is well understood that LUTS have multifactorial etiology and often occur in clusters and not in isolation. Voiding LUTS are highly prevalent in men, but storage LUTS have been proved to be more bothersome. α₁-Blockers are the most widely used pharmacologic agents for the treatment of symptoms relating to benign prostatic enlargement due to benign prostatic hyperplasia (BPH), while antimuscarinics are the drug class of choice for overactive bladder symptoms. A combination of the two drug classes would be a reasonable approach to treat men with both storage and voiding symptoms, and several short-term studies have proved the efficacy and safety of different combinations with an α₁-blocker and an antimuscarinic. Following previous studies on the separate administration of solifenacin and tamsulosin, a fixed-dose combination tablet of tamsulosin oral controlled absorption system (OCAS) 0.4 mg and solifenacin succinate 6 mg has been recently introduced, and the current review evaluates the available data on the use of this fixed-dose combination in the treatment of LUTS in men with BPH.

Urgency and other lower urinary tract symptoms in men aged ≥ 40 years: a Belgian epidemiological survey using the ICIQ-MLUTS questionnaire

BACKGROUND AND AIMS

The aim of this study was to assess prevalence and associated bother of male lower urinary tract symptoms (LUTS), especially of urgency and other storage symptoms, since these are generally assumed to be underdiagnosed/undertreated in men.

METHODS

Data on bladder condition of men ≥ 40 years were prospectively collected by 124 general practitioners (GPs) during a regular visit for any reason, using the validated ICIQ-MLUTS questionnaire. For 13 symptoms, prevalence (scale 0-4) and bother (scale 0-10) were scored. General bladder-related quality of life (scale 0-3) was also assessed.

RESULTS

Data from 5890 men (mean age: 61.2 years) were analysed. A total of 7.7% had urgency most or all of the time (score ≥ 3) and 6.2% had bothersome urgency (score ≥ 3 + bother score ≥ 5). Nocturia (69.2%) and urgency (58.3%) were the most prevalent and bothersome symptoms. Both prevalence and bother of all LUTS increased with age. Additionally, 28.9% of men reported to be a little bothered by their bladder condition in everyday life, while 11.9% were bothered a lot/very much (2.5% in age group 40-49 years increasing to 29.2% in those > 80 years).

CONCLUSIONS

In the general population of men ≥ 40 years who visited a GP for any reason, 41% indicated to be at least a little bothered by their bladder condition. The prevalence of LUTS, especially nocturia and urgency, is high and a significant number of men indicated to be seriously bothered. Increasing awareness of male LUTS, and storage symptoms in particular, is warranted to discuss management options that could increase quality of life.

The beta-3 adrenoceptor agonist, mirabegron relaxes isolated prostate from human and rabbit: new therapeutic indication?

BACKGROUND

Alpha1 (α1)-blockers, 5-alpha reductase and phosphodiesterase type-5 inhibitors are pharmacological classes currently available for benign prostatic hyperplasia (BPH) treatment. Mirabegron, a beta-3 adrenoceptor (β3-AR) agonist has been approved for the therapy of overactive bladder and may constitute a new therapeutic option for BPH treatment. This study is aimed to evaluate the in vitro effects of mirabegron in human and rabbit prostatic smooth muscle.

METHODS

In rabbit prostate, electrical field stimulation (EFS)-induced contraction and concentration-response curve (CRC) to mirabegron in phenylephrine pre-contracted tissues were carried out. The potency (pEC50 ) and maximal response (Emax ) values were determined. In human prostate, CRC to phenylephrine was carried out in the absence and presence of mirabegron. Immunohistochemistry analysis for β3-AR was also carried out.

RESULTS

In human prostate, immunohistochemistry analysis revealed the presence of β3-AR on the transition zone and mirabegron reduced by 42% the phenylephrine-induced contractions. In rabbit prostate, mirabegron produced concentration-dependent relaxations (pEC50 : 6.01 ± 0.12; Emax : 106 ± 3%), which were fully resistant to the blockade of β1-AR and β2-AR. The β3-AR blocker L748,337 caused a six-fold rightward shift in mirabegron-induced relaxations. Mirabegron (10 μM) reduced by 63% the EFS-induced contractions. Inhibitors of nitric oxide (L-NAME) and of soluble guanylate cyclase (ODQ) along with a cocktail of K+ channel blockers (apamin, charybdotoxin, glibenclamide, tetraethylammonium) all failed to significantly affect the mirabegron-induced rabbit relaxations.

CONCLUSION

Mirabegron relaxes prostatic smooth muscle, providing an experimental support for the clinical investigation of its combination with an α1-blockers or PDE5 inhibitors in the treatment of BPH. Prostate 75:440-447, 2015. © 2014 Wiley Periodicals, Inc.

Is there a link between overactive bladder and the metabolic syndrome in women? A systematic review of observational studies

OBJECTIVES

To conduct a systematic review to determine whether there is an association between metabolic syndrome (MetS) and lower urinary tract symptoms (LUTS) or overactive bladder (OAB) in women.

METHODS

We systematically reviewed English language observational studies on the effect of MetS (or component factors) on the presence of OAB or LUTS in women. We searched PubMed, Web of Science and The Cochrane Library with no date restrictions, checked reference lists and undertook citation searches in PubMed and Google Scholar. Studies were assessed for risk of bias. Because of heterogeneity, results were not pooled, but are reported narratively.

RESULTS

Of 27 included studies, only three looked at the link between MetS and OAB. The rest looked at links between OAB and components of MetS such as obesity or insulin resistance (n = 10), between MetS and urinary symptoms (n = 3) and between urinary symptoms and components of MetS, such as obesity (n = 14). Evidence is currently limited, but it does suggest that there may be important links between MetS and OAB and components of MetS such as obesity.

CONCLUSIONS

The literature on MetS and OAB or LUTS in women is limited, and poor quality. However, the evidence available on obesity appears to support MetS as a contributor and predictor of LUTS in women. Many of the women with LUTS will be overweight and will have features of the MetS, if looked for. This provides not only an opportunity to encourage weight loss as an adjunct to therapy for the OAB symptoms but also a window of opportunity to address cardiovascular risk factors and prevent future cardiovascular morbidity and mortality.

A Population-based Survey of the Prevalence, Potential Risk Factors, and Symptom-specific Bother of Lower Urinary Tract Symptoms in Adult Chinese Women

BACKGROUND

Epidemiological studies of lower urinary tract symptoms (LUTS) are few in China, and none has been conducted nationwide.

OBJECTIVE

To estimate the prevalence and potential risk factors of LUTS and the bother they impose on adult women in China.

DESIGN, SETTING, AND PARTICIPANTS

This is the second analysis of a population-based cross-sectional survey on urinary incontinence conducted between February and July 2006 in six regions of China. Cluster samples were randomly selected for interviews.

INTERVENTIONS

No intervention was implemented.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A modified Chinese Bristol Female Lower Urinary Tract Symptoms questionnaire was administered. The participants were asked about the presence of individual LUTS and rated their symptom bother. Descriptive statistics, χ(2) tests, receiver operating characteristic curves, and multivariate logistic regressions were used for data analysis.

RESULTS AND LIMITATIONS

A total of 18 992 respondents (94.96%) were included. The prevalence of any LUTS, storage symptoms, or voiding symptoms was 55.5%, 53.9%, and 12.9%, respectively, and increased with age. Nocturia was the most common symptom (23.4%), followed by urgency (23.3%) and stress urinary incontinence (SUI; 18.9%). Nocturia was most frequently rated as bothersome (93.0%) but was generally minor (80.5%). Urgency and urgency urinary incontinence (UUI) were most frequently reported as severe (11.5% and 10.8%) or moderate (18.5% and 16.8%) bothers. Any LUTS were more prevalent in urban women (57.1% vs 53.9%). Multiple factors increased the odds of bother and individual LUTS, and older age and coexisting pelvic organ prolapse were strong predictors (p<0.05). This survey was conducted 8 yr ago and did not assess all LUTS.

CONCLUSIONS

Half of adult women suffered with LUTS; nocturia, urgency, and SUI were more prevalent. Urgency and UUI were most frequently reported as severe or moderate bothers. Multiple factors influenced bother and individual LUTS.

PATIENT SUMMARY

The prevalence of lower urinary tract symptoms is high and increases with age in adult women in China. Urgency and urgency urinary incontinence were most frequently regarded as severe or moderate bothers and should be targeted for medical intervention.

The diagnosis of benign prostatic obstruction: Development of a clinical nomogram

AIMS

To develop a nomogram predicting benign prostatic obstruction (BPO).

METHODS

We included in this study 600 men with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) who underwent standardized pressure flow studies (PFS) between 1996 and 2000. Complete clinical and urodynamic data were available for all patients. Variables assessed in univariate and multivariate logistic regression models consisted of IPSS, PSA, prostate size, maximal urinary flow rate (Qmax) at free flow, residual urine (RU), and bladder wall thickness (BWT). These were used to predict significant BPO (defined as a Schäfer grade ≥ 3 in PFS).

RESULTS

A preliminary multivariate model, including IPSS, Qmax at free flow and RU, suggested that only Qmax at free flow was a statistically significant predictor of BPO (P = 0.00) with a predictive accuracy (PA) of 82%. Further development of the multivariate model showed how the inclusion of BWT did not increase PA. Only transitional zone volume (TZV) proved to be an additional statistically significant predictor for BPO (P = 0.00). The combination of Qmax at free flow and TZV demonstrated a PA of 83.2% and were included in the final nomogram format.

CONCLUSIONS

We developed a clinical nomogram, which is both accurate and well calibrated, which can be helpful in the management of patients with LUTS and BPE. External validation is warranted to confirm our findings.

Inhibition of smooth muscle force generation by focal adhesion kinase inhibitors in the hyperplastic human prostate

Smooth muscle contraction may be critical for lower urinary tract symptoms (LUTS) in patients with benign prostate hyperplasia and requires stable anchorage of the cytoskeleton to the cell membrane. These connections are regulated by focal adhesion kinase (FAK). Here, we addressed the involvement of FAK in the regulation of smooth muscle contraction in hyperplastic human prostate tissues. Prostate tissues were obtained from radical prostatectomy. Expression of FAK and focal adhesion proteins was assessed by Western blot analysis and immunohistochemical stainings. Effects of the FAK inhibitors PF-573228 and Y-11 on contraction of prostate strips were examined in the organ bath. Expression of FAK and focal adhesion proteins (integrin-5α, paxilin, and c-Src) was detected by Western blot analysis in prostate samples. By double immunofluorescence staining with calponin and pan-cytokeratin, expression of FAK was observed in stromal and epithelial cells. Immunoreactivity for FAK colocalized with integrin-5α, paxilin, talin, and c-Src. Stimulation of prostate tissues with the α1-adrenergic agonist phenylephrine increased the phosphorylation state of FAK at Tyr397 and Tyr925 with different kinetics, which was blocked by the α1-adrenoceptor antagonist tamsulosin. Norepinephrine and phenylephrine induced concentration-dependent contractions of prostate strips. Both FAK inhibitors PF-573228 and Y-11 significantly inhibited norepinephrine- and phenylephrine-induced contractions. Finally, PF-573228 and Y-11 inhibited contractions induced by electric field stimulation, which was significant at the highest frequency. In conclusion, α1-adrenergic smooth muscle contraction or its regulation involves FAK in the human prostate. Consequently, FAK may be involved in the pathophysiology of LUTS and in current or future LUTS therapies.

Testosterone and the Prostate

INTRODUCTION

Late-onset hypogonadism, lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE), and prostate cancer commonly coexist in the aging male. Due to a better understanding of the physiology and impact of testosterone on benign and malignant diseases of the prostate, the view toward testosterone replacement therapy (TRT) in these individuals has changed dramatically over time.

AIM

This communication evaluates the effects of testosterone on benign prostatic growth and prostate cancer and reviews the evidence for TRT for men with BPE and prostate cancer.

METHODS

A literature review was performed with regards to TRT in men with prostate cancer as well as the effect of testosterone on the growth of benign prostate tissue and prostate cancer carcinogenesis.

MAIN OUTCOME MEASURE

To evaluate the evidence for an effect of testosterone on the growth of benign prostate tissue and the development of prostate cancer and TRT in men with prostate cancer.

RESULTS

TRT does not exacerbate LUTS. Current evidence is lacking but suggests that TRT may not increase the risk of subsequent diagnosis of prostate cancer, and is unlikely to impact recurrence or progression for men with treated prostate cancer, but longer follow-up is needed.

CONCLUSIONS

There is no evidence to suggest that TRT is contraindicated in men with BPE or effectively treated prostate cancer. Tan RBW, Silberstein JL, and Hellstrom WJG. Testosterone and the prostate. Sex Med Rev 2014;2:112-120.

Urinary Tract Symptoms (LUTS) Secondary to Benign Prostatic Hyperplasia (BPH) and LUTS/BPH with Erectile Dysfunction in Asian Men: A Systematic Review Focusing on Tadalafil

This review assesses lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with or without erectile dysfunction (ED) and related therapies focusing on tadalafil. A literature search was obtained and reviewed for the epidemiology, treatment therapies, pathophysiology, and efficacy and safety of phosphodiesterase type 5 inhibitor (PDE5i) tadalafil in patients with LUTS/BPH. Approximately 42% of men aged 51 to 60 years have BPH. Approximately 90% of men aged 45 to 80 years have LUTS. Occurrence of LUTS increases with age for almost all racial/ethnic groups (range, 32% to 56%) with prevalence of LUTS highest among Hispanic men, then Blacks, Caucasians, and Asians. There is an independent relationship with LUTS/BPH and ED, with approximately 70% of men with LUTS/BPH having ED with severity of one disease often correlating with the other. The European Urological Association guidelines include the use of the PDE5i tadalafil. Tadalafil is the only therapy recommended for treatment of co-existing BPH and ED, while other therapies have unwanted ED side effects. The mode of action of tadalafil may involve different areas of the lower urinary tract such as smooth muscle cell relaxation in the bladder neck, prostate, and urethra, but there may also be resulting modulation of the afferent nerve activity. Tadalafil (5 mg) in Asian men with LUTS/BPH, similar to global studies, is efficacious and safe. Tadalafil (5 mg) improves co-existing LUTS/BPH and ED, independently. Men with LUTS/BPH likely also have ED. Asian men with LUTS/BPH have similar incidence rates, co-existing ED, comorbid diseases, and risks as non-Asian men. Tadalafil can improve co-existing LUTS/BPH and ED.

Enterococcus faecalis subverts and invades the host urothelium in patients with chronic urinary tract infection

Bacterial urinary tract infections (UTI) are a major growing concern worldwide. Uropathogenic Escherichia coli has been shown to invade the urothelium during acute UTI in mice and humans, forming intracellular reservoirs that can evade antibiotics and the immune response, allowing recurrence at a later date. Other bacterial species, such as Staphylococcus saprophyticus, Klebsiella pneumonia and Salmonella enterica have also been shown to be invasive in acute UTI. However, the role of intracellular infection in chronic UTI causing more subtle lower urinary tract symptoms (LUTS), a particular problem in the elderly population, is poorly understood. Moreover, the species of bacteria involved remains largely unknown. A previous study of a large cohort of non-acute LUTS patients found that Enterococcus faecalis was frequently found in urine specimens. E. faecalis accounts for a significant proportion of chronic bladder infections worldwide, although the invasive lifestyle of this uropathogen has yet to be reported. Here, we wanted to explore this question in more detail. We harvested urothelial cells shed in response to inflammation and, using advanced imaging techniques, inspected them for signs of bacterial pathology and invasion. We found strong evidence of intracellular E. faecalis harboured within urothelial cells shed from the bladder of LUTS patients. Furthermore, using a culture model system, these patient-isolated strains of E. faecalis were able to invade a transitional carcinoma cell line. In contrast, we found no evidence of cellular invasion by E. coli in the patient cells or the culture model system. Our data show that E. faecalis is highly competent to invade in this context; therefore, these results have implications for both the diagnosis and treatment of chronic LUTS.

Functional consequences of chronic bladder ischemia

The pathophysiology of lower urinary tract symptoms (LUTS), particularly in the elderly, seems to be multifactorial. One of the factors involved may be chronic ischemia of the bladder caused by bladder outflow obstruction (male) or atherosclerosis (male/female). The mechanisms by which chronic ischemia initiates and causes LUTS and progressive bladder dysfunction, and the time course of the effects, are incompletely known. Bladder ischemia and repeated ischemia/reperfusion during a micturition cycle may produce oxidative stress, leading to denervation of the bladder and the expression of tissue damaging molecules in the bladder wall. This may be responsible for the development of detrusor overactivity progressing to detrusor underactivity and inability to empty the bladder. The extent of bladder dysfunction in chronic bladder ischemia may depend on the degree and duration of ischemia. To prevent chronic bladder ischemia caused by atherosclerosis and to treat its consequences, more pathophysiological knowledge is needed. Several animal models of atherosclerosis-induced chronic bladder ischemia are available and should be useful tools for further research.

Progressive vascular damage may lead to bladder underactivity in rats

PURPOSE

We assessed whether progressive vascular damage causes bladder underactivity in rats.

MATERIALS AND METHODS

Adult male Sprague Dawley® rats were divided into 4 groups. Controls received a regular diet and tap water. The L-NAME group received a 2% cholesterol diet and L-NAME (3 mg/ml) dissolved in drinking water. The arterial injury group underwent balloon endothelial injury of the common iliac arteries and received a 2% cholesterol diet and tap water after injury. The arterial injury/L-NAME group also received L-NAME dissolved in drinking water. At 8 weeks urodynamics were performed, bladder tissue was harvested for pharmacological studies, and the iliac arteries and bladders were histologically examined.

RESULTS

Iliac arteries from the injury and injury/L-NAME groups showed neointimal formation and luminal occlusion but arteries from the L-NAME group did not. In the L-NAME and injury groups bladder capacity and voided volume were less than in controls. Conversely, in the injury/L-NAME group these cystometric parameters were significantly greater than in the other groups. Post-void residual volume in the injury/L-NAME group tended to increase compared with the other groups. Contractile responses of bladder strips to various stimuli in the L-NAME, injury and injury/L-NAME groups were significantly less than in controls and the lowest in the injury/L-NAME group. The injury and injury/L-NAME groups showed a significantly increased percent of collagen compared to controls.

CONCLUSIONS

Pelvic arterial occlusive disease plus vascular endothelial dysfunction may cause progressive vascular damage resulting in bladder dysfunction that develops from bladder hyperactivity to bladder underactivity.