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

Management of Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) commonly affect older men. Age-related changes associated with metabolic disturbances, changes in hormone balance, and chronic inflammation may cause BPH development. The diagnosis of BPH hinges on a thorough medical history and focused physical examination, with attention to other conditions that may be causing LUTS. Digital rectal examination and urinalysis should be performed. Other testing may be considered depending on presentation of symptoms, including prostate-specific antigen, serum creatinine, urine cytology, imaging, cystourethroscopy, post-void residual, and pressure-flow studies. Many medical and surgical treatment options exist. Surgery should be reserved for patients who either have failed medical management or have complications from BPH, such as recurrent urinary tract infections, refractory urinary retention, bladder stones, or renal insufficiency as a result of obstructive uropathy.

Adverse effects of 5α-reductase inhibitors: What do we know, don't know, and need to know?

Steroids are important physiological orchestrators of endocrine as well as peripheral and central nervous system functions. One of the key processes for regulation of these molecules lies in their enzymatic processing by a family of 5α-reductase (5α-Rs) isozymes. By catalyzing a key rate-limiting step in steroidogenesis, this family of enzymes exerts a crucial role not only in the physiological control but also in pathological events. Indeed, both 5α-R inhibition and supplementation of 5α-reduced metabolites are currently used or have been proposed as therapeutic strategies for a wide array of pathological conditions. In particular, the potent 5α-R inhibitors finasteride and dutasteride are used in the treatments of benign prostatic hyperplasia (BPH), as well as in male pattern hair loss (MPHL) known as androgenetic alopecia (AGA). Recent preclinical and clinical findings indicate that 5α-R inhibitors evoke not only beneficial, but also adverse effects. Future studies should investigate the biochemical and physiological mechanisms that underlie the persistence of the adverse sexual side effects to determine why a subset of patients is afflicted with such persistence or irreversible adverse effects. Also a better focus of clinical research is urgently needed to better define those subjects who are likely to be adversely affected by such agents. Furthermore, research on the non-sexual adverse effects such as diabetes, psychosis, depression, and cognitive function are needed to better understand the broad spectrum of the effects these drugs may elicit during their use in treatment of AGA or BPH. In this review, we will summarize the state of art on this topic, overview the key unresolved questions that have emerged on the pharmacological targeting of these enzymes and their products, and highlight the need for further studies to ascertain the severity and duration of the adverse effects of 5α-R inhibitors, as well as their biological underpinnings.

Establishment of Reference Ranges for Prostate Volume and Annual Prostate Volume Change Rate in Korean Adult Men: Analyses of a Nationwide Screening Population

We aimed to determine normal reference ranges for prostate volume (PV) and annual PV change rate in a Korean nationwide screening population. Data from men who underwent a routine health check-up were collected from 13 university hospitals. The cohort comprised men aged ≥40 yr who had undergone 2 or more serial transrectal ultrasonographies. Men with initial PV>100 mL; serum PSA level>10 ng/mL; PV reduction>20% compared with initial PV, or who had history of prostate cancer or prostate surgery, were excluded. Linear regression and mixed effects regression analyses were used to predict mean PV and longitudinal change in PV over time. A total of 2,967 men formed the study cohort. Age, body mass index (BMI), and serum prostate-specific antigen (PSA) level were found to be significant predictors of PV. A predicted PV table, with a 95% confidence interval (CIs), was developed after adjusting for these 3 variables. Annual PV change rate was 0.51 mL/year (95% CI, 0.47-0.55). Annual PV change rate according to age was 0.68 mL/year, 0.84 mL/year, 1.09 mL/year, and 0.50 mL/year for subjects in their 40s, 50s, 60s, and ≥70 yr, respectively. Predicted annual PV change rate differed depending on age, BMI, serum PSA level and baseline PV. From a nationwide screening database, we established age-, PSA-, and BMI-specific reference ranges for PV and annual PV change rate in Korean men. Our newly established reference ranges for PV and annual PV change rate will be valuable in interpreting PV data in Korean men.

Comparative Effectiveness and Safety of Monodrug Therapies for Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia: A Network Meta-analysis

A wide array of drugs are available for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH), but the evidence for the comparative effectiveness is controversial.The objective of this study is to evaluate the comparative effectiveness and safety of monodrug therapies for BPH.Data sources are MEDLINE, EMBASE, and the Cochrane Library.We included randomized controlled trials that compared α-blockers, 5-alpha reductase inhibitors (5ARIs), muscarinic receptor antagonists (MRAs), phosphodiesterase-5 inhibitor (PDE5-Is), or placebo for the treatment of BPH.Comparative effectiveness and safety were pooled by both traditional meta-analysis and network meta-analysis. Summary effect size was calculated as mean difference (MD) and relative risk (RR), together with the 95% confidence intervals (CIs).This study included 58,548 participants from 124 trials in total. When compared with placebo, α-blockers, 5ARIs, and PDE5-Is reduced International Prostate Symptom Score (IPSS) by -1.35 to -3.67 points and increased peak urinary flow rate (PUF) by -0.02 to 1.95 mL/s, with doxazosin (IPSS: MD, -3.67[-4.33 to -3.02]; PUF: MD, 1.95[1.61 to 2.30]) and terazosin (IPSS: MD, -3.37 [-4.24 to -2.50]; PUF: MD, 1.21[0.74 to 1.66]) showing the greatest improvement. The improvement in the IPSS was comparable among tamsulosin, alfuzosin, naftopidil, silodosin, dutasteride, sildenafil, vardenafil, and tadalafil. The incidence of total adverse events and withdraws due to adverse events were generally comparable among various agents.In conclusion, α-blockers, 5ARIs, and PDE5-Is are effective for BPH, with doxazosin and terazosin appearing to be the most effective agents. Drug therapies for BPH are generally safe and well-tolerated, with no major difference regarding the overall safety profile.

5-α reductase inhibitors, benign prostatic hyperplasia, and risk of male breast cancer

Purpose

5-α reductase inhibitors (5-ARI) have been suggested to increase the risk of male breast cancer. The aim of this study was to study the risk of breast cancer in men on 5-ARI, in men with benign prostatic hyperplasia (BPH) not on 5-ARI, and in men without BPH.

Methods

We performed a population-based cohort study in Sweden with data from The Prescribed Drug Register, The Patient Register, and The Cancer Register. Men on 5-ARI, men on α-blockers, or men who had undergone a transurethral resection of the prostate (TUR-P) prior to or during 2006–2008 were included as exposed to BPH and a specific treatment thereof. For each exposed man, five unexposed men were selected. Risk of breast cancer was calculated in Cox proportional hazard models.

Results

There were 124,183 exposed men and 545,293 unexposed men, and during follow-up (median 6 years), 99 men with breast cancer were diagnosed. Compared to unexposed men, men on 5-ARI had a hazard ratio (HR) of breast cancer of 0.74 (95 % confidence interval (CI) 0.27–2.03), men on α-blockers had HR 1.47 (95 % CI 0.73–2.95), and men with a TUR-P had HR 1.99 (95 % CI 1.05–3.75).

Conclusion

No increased risk of breast cancer was observed for men on 5-ARI. However, the increased risk of breast cancer among men who had undergone a TUR-P, a strong indicator of BPH, suggests that the endocrine milieu conducive to BPH is associated with male breast cancer.

Impact of alpha blockers, 5-alpha reductase inhibitors and combination therapy on sexual function

Medical treatments for lower urinary tract symptoms due to benign prostatic hyperplasia are frequently associated with changes in sexual function. While these medications are generally well-tolerated and have both reduced and delayed more invasive surgical options, the ramifications of long-term chronic use are largely unknown. Sexual side effects of these medications are frequently either reported as part of a short-term initial drug study or have inflexible endpoints that are not able to gauge more subtle changes in sexual performance. This review will delineate the currently known effects of these medications on sexual function and will consider mechanisms of dysfunction.

Living with a 100 ml prostate: Outcomes over a decade

Objective:

The objective of this article is to determine outcomes and guide the management of patients with a prostate volume of 100 ml or greater.

Patients and methods:

A database of patients undergoing transrectal ultrasound (TRUS)-guided biopsy from 1994 to 1999 was analysed. Records of those with a prostate of 100 ml or greater were reviewed.

Results:

A total of 63 patients were included in the study with a mean follow-up of 11 years. Initial TRUS-guided biopsy yielded prostate cancer (CaP) in six of 63 (10%). Twenty-six of 63 (41%) underwent repeat biopsies. CaP was ultimately diagnosed in 13/63 (21%). Prostate-specific antigen (PSA) levels were erratic over time, making monitoring difficult. The PSA coefficient of variation in benign prostates ranged from 8.9% to 48.6% in the year following biopsy. Twenty-one of 50 (42%) with benign prostates experienced acute urinary retention (AUR), 31/50 (62%) haematuria and 43/50 (86%) received treatment for lower urinary tract symptoms (LUTS). Twenty-six of 50 (52%) received 5-alpha reductase inhibitors (5ARI), 11/50 (22%) α-blockers and 28/50 (56%) surgery. Thirteen of 15 (87%) experienced further symptoms when treated for less than two years with 5ARI versus five of 16 (31%) receiving long-term treatment (mean duration 8.1 years). Fifteen of 25 (60%) experienced haematuria following TURP and 14/25 (56%) required further treatment.

Conclusion:

Large prostates cause considerable symptoms prompting multiple medical consultations and investigations. PSA monitoring in this group is difficult, leading to repeated biopsies of benign prostates. Long-term 5ARI treatment should be considered to reduce progression to AUR, the incidence of haematuria and to facilitate PSA monitoring. Newer treatment modalities such as holmium laser enucleation (HoLEP) should be considered ahead of TURP. When TURP is performed, 5ARI treatment should be considered post-operatively. This group of men should have close urological follow-up.

Age and Obesity Promote Methylation and Suppression of 5α-Reductase 2: Implications for Personalized Therapy of Benign Prostatic Hyperplasia

PURPOSE

In men with symptomatic benign prostatic hyperplasia 5α-reductase inhibitors are a main modality of treatment. More than 30% of men do not respond to the therapeutic effects of 5α-reductase inhibitors. We have found that a third of adult prostate samples do not express 5α-reductase type 2 secondary to epigenetic modifications. We evaluated whether 5α-reductase type 2 expression in benign prostatic hyperplasia specimens from symptomatic men was linked to methylation of the 5α-reductase type 2 gene promoter. We also identified associations with age, obesity, cardiac risk factors and prostate specific antigen.

MATERIALS AND METHODS

Prostate samples from men undergoing transurethral prostate resection were used. We determined 5α-reductase type 2 protein expression and gene promoter methylation status by common assays. Clinical variables included age, body mass index, hypertension, hyperlipidemia, diabetes, prostate specific antigen and prostate volume. Univariate and multivariate statistical analyses were performed followed by stepwise logistic regression modeling.

RESULTS

Body mass index and age significantly correlated with methylation of the 5α-reductase type 2 gene promoter (p <0.05) whereas prostate volume, prostate specific antigen or benign prostatic hyperplasia medication did not correlate. Methylation highly correlated with 5α-reductase protein expression (p <0.0001). In a predictive model increasing age and body mass index significantly predicted methylation status and protein expression (p <0.01).

CONCLUSIONS

Increasing age and body mass index correlate with increased 5α-reductase type 2 gene promoter methylation and decreased protein expression in men with symptomatic benign prostatic hyperplasia. These results highlight the interplay among age, obesity and gene regulation. Our findings suggest an individualized epigenetic signature for symptomatic benign prostatic hyperplasia, which may be important to choose appropriate personalized treatment options.

Prostate Biopsy Using Transrectal Ultrasonography; The Optimal Number of Cores Regarding Cancer Detection Rate and Complications

BACKGROUND

Transrectal ultrasound guided biopsy of the prostate is the most common modality used to diagnose prostate cancer.

OBJECTIVES

The aim of this study was to evaluate the optimal number of cores at prostate biopsy, which have the most diagnostic value with least adverse effects.

PATIENTS AND MATERIALS

Transrectal ultrasonography (TRUS) guided biopsy was performed in 180 patients suspicious for prostate cancer due to either abnormal rectal examination or elevated PSA. The patients were divided randomly into three groups of six-core, twelve-core and eighteen-core biopsies. The detection rate of prostate cancer in each group with the rate of post biopsy urinary infection and prostatitis were compared.

RESULTS

Prostate cancer was diagnosed in 8 (13.3%), 21 (35%) and 24 (40%) patients in six, twelve and eighteen core biopsy groups, respectively. Urinary tract infection and prostatitis occurred in 17 (28.3%), 23 (38.3%) and 35 (58.3%) patients in six, twelve and eighteen core biopsy groups, respectively. Considering the detection rate of prostate cancer, there was a significant difference between 6 and 12 core biopsy groups (P = 0.006) and 12-core biopsies detected more cases of prostate cancer, but there was no significant difference between 12 and 18 core biopsy groups (P = 0.572). Considering the infection rate, there was no significant difference between 6 and 12 core biopsy groups (P = 0.254), but there was a significant difference between 12 and 18 core biopsy groups (P = 0.028) and infectious complications occurred more frequently in 18-core biopsy group.

CONCLUSIONS

The best balance between detection rate of prostate cancer and infectious complications of biopsies achieved in twelve-core biopsy protocol. Twelve-core biopsy enhances the rate of prostate cancer detection with minimum adverse effects.

A population-based nested case-control study: the use of 5-alpha-reductase inhibitors and the increased risk of osteoporosis diagnosis in patients with benign prostate hyperplasia

BACKGROUND

5-alpha-reductase inhibitors (5ARIs) are the potent androgen responsible for the development and enlargement of the prostate gland by decreasing dihydrotestosterone (DHT). This results in inhibition of the conversion of testosterone to dihydrotestosterone and markedly suppresses serum dihydrotestosterone levels. Testosterone replacement therapy improves bone density in men with hypogonadal osteoporosis. This study explores the possible association between the use of two typical 5ARIs (finasteride and dutasteride) and the subsequent risk of osteoporosis diagnosis.

METHODS

We identified 1352 osteoporosis diagnosis cases and 5387 control cases without osteoporosis diagnosis from the claims data for patients with benign prostate hyperplasia (BPH), which are collected in the Taiwanese National Health Insurance Research Database (NHIRD). Four controls were frequency matched to each case according to age (every 5 years) and diagnosis date. We measured the effect of 5ARIs and determined the adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We observed a 1·52-fold increase in osteoporosis diagnosis among patients with BPH using finasteride (95% CI, 1·01-2·30). Furthermore, a dosage analysis showed that higher doses of finasteride were associated with higher osteoporosis diagnosis risk (OR = 1·68; 95% CI, 1·01-2·81), relative to the patients not using 5ARIs.

CONCLUSION

This population-based nested case-control study suggests that the use of finasteride can increase the risk of osteoporosis diagnosis among patients with BPH. The effects were more prominent in patients using higher doses of finasteride.

Combination of tadalafil and finasteride for improving the symptoms of benign prostatic hyperplasia: critical appraisal and patient focus

The evidence suggests that combination therapy for benign prostatic hyperplasia (BPH)-lower urinary tract symptoms (LUTS) using an α-blocker and a 5α-reductase inhibitor has become well accepted. The combination of daily tadalafil and an α-blocker has also demonstrated benefit. This paper addresses combination therapy with daily tadalafil and finasteride for the treatment of BPH-LUTS. Our results demonstrate that use of tadalafil and finasteride represents a logical extension of combination therapies. We analyze a landmark study by Casabé et al that demonstrates improved voiding symptoms as assessed by International Prostate Symptom Scores with a combination of tadalafil and finasteride compared with finasteride and placebo. Study patients had moderate to severe LUTS and prostate volumes >30 g. The additional benefit of improved erectile function as assessed by International Index of Erectile Function-erectile function domain scores with the addition of tadalafil was a secondary benefit. We propose that the ideal patient for combination therapy with tadalafil and finasteride has a prostate volume >30 g and desires additional benefit over monotherapy. For these men, improved erectile function without sexual side effects was a secondary benefit.

Lessons learned about prostatic transformation from the age-related methylation of 5α-reductase type 2 gene

This commentary highlights the article by Ge et al, which proposes the use of methylation and expression of SRD5A2 as a gene signature to tailor therapies for prostatic diseases.

DNA methyl transferase 1 reduces expression of SRD5A2 in the aging adult prostate

5-α Reductase type 2 (SRD5A2) is a critical enzyme for prostatic development and growth. Inhibition of SRD5A2 by finasteride is used commonly for the management of urinary obstruction caused by benign prostatic hyperplasia. Contrary to common belief, we have found that expression of SRD5A2 is variable and absent in one third of benign adult prostates. In human samples, absent SRD5A2 expression is associated with hypermethylation of the SRD5A2 promoter, and in vitro SRD5A2 promoter activity is suppressed by methylation. We show that methylation of SRD5A2 is regulated by DNA methyltransferase 1, and inflammatory mediators such as tumor necrosis factor α, NF-κB, and IL-6 regulate DNA methyltransferase 1 expression and thereby affect SRD5A2 promoter methylation and gene expression. Furthermore, we show that increasing age in mice and humans is associated with increased methylation of the SRD5A2 promoter and concomitantly decreased protein expression. Artificial induction of inflammation in prostate primary epithelial cells leads to hypermethylation of the SRD5A2 promoter and silencing of SRD5A2, whereas inhibition with tumor necrosis factor α inhibitor reactivates SRD5A2 expression. Therefore, expression of SRD5A2 is not static and ubiquitous in benign adult prostate tissues. Methylation and expression of SRD5A2 may be used as a gene signature to tailor therapies for more effective treatment of prostatic diseases.

[Negative effects on sexual function of medications for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia]

PURPOSE

The aim of this review is to discuss the negative effects on sexual function of medications for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS-BPH).

METHODS

An international non-systematic literature review was performed. It included randomized trials of seven drugs of interest and the summaries of the characteristics of these products. This work did not aim comparison between the drugs.

RESULTS

Only maximal reported frequencies are presented in this abstract. With prolonged-release alfuzosin, they were 2.8% vs. 1.3% for erectile dysfunction, compared to placebo and 1% vs. 0% for ejaculatory dysfunction. With doxazosin, the incidence was 5.8% vs. 3.3% for erectile dysfunction, 3.6% vs. 1.9% for reduced libido and 0.4% vs. 1.4% for ejaculatory disorders. The incidence of ejaculatory disorders with tamsulosin, was 11% vs. <1% with the placebo and with silodosin, it was 28.1% vs. 1.1%. With finasteride, at 12 months, the highest frequency was 9% vs. 5% for erectile dysfunction, 4.4% vs. 1.5% for ejaculatory disorders and 6.4% vs. 3.4% for reduced libido. At 24 months, for dutatsteride, frequencies were 7.3% vs. 4.0% for erectile dysfunction, 2.2% vs. 0.8% for ejaculatory disorders and 4.2% vs. 2.1% for reduced libido. For tadalafil, a phosphodiesterase-5 inhibitor, and tolerodine, an anticholinergic drug, no negative effect on ejaculation or libido has been reported. For plant extracts, no sexual adverse effects (AEs) were reported among the most common AEs.

CONCLUSION

The medications for LUTS-BPH may alter erection, ejaculation or libido. A greater knowledge of the adverse effects of each of these drugs could guide physicians in the clinical management of men with BPH-LUTS.

5-Alpha-reductase inhibitors in diseases of the prostate

PURPOSE OF REVIEW

To summarize the history of the use of 5-alpha-reductase inhibitors in the treatment of urologic diseases and discuss the current practices and indications for therapy.

RECENT FINDINGS

5-Alpha-reductase inhibitors (5-ARIs) are indicated in the treatment of benign prostatic hyperplasia (BPH) with obstructive urinary symptoms to reduce symptoms, reduce the risk of acute urinary retention, and reduce the risk of needing surgical management for this condition. These drugs have also been employed in the treatment of recurrent and refractory hematuria of prostatic origin because of their effect on the androgen-mediated angiogenic pathways in the prostate. Data support the use of 5-ARIs for this indication, though this is off-label use. There is no role for the use of 5-ARIs in primary prostate cancer chemoprevention and they may increase the risk of developing high-grade prostate cancer. Current investigations are underway to determine the efficacy of 5-ARIs in the secondary treatment of localized prostate cancer as adjunctive therapy, which may decrease the likelihood of prostate cancer progression and increase the likelihood that patients will remain on active surveillance.

SUMMARY

5-ARIs have significantly impacted the medical treatment of urologic disease, in particular BPH, and prostatic hematuria. Their use in the secondary treatment of prostate cancer is currently under investigation.

Differential expression of 5-alpha reductase isozymes in the prostate and its clinical implications

The development of human benign or malignant prostatic diseases is closely associated with androgens, primarily testosterone (T) and dihydrotestosterone (DHT). T is converted to DHT by 5-alpha reductase (5-AR) isozymes. Differential expression of 5-AR isozymes is observed in both human benign and malignant prostatic tissues. 5-AR inhibitors (5-ARI) are commonly used for the treatment of benign prostatic hyperplasia (BPH) and were once promoted as chemopreventive agents for prostate cancer (PCa). This review discusses the role of the differential expression of 5-AR in the normal development of the human prostate and in the pathogenesis and progression of BPH and PCa.

Diagnostic accuracy of 18F choline PET/CT using time-of-flight reconstruction algorithm in prostate cancer patients with biochemical recurrence

PURPOSE

Image quality (IQ) of PET in voluminous body regions can be limited, which impairs the assessment of small metastatic lesions. Time-of-flight (TOF) reconstruction algorithm may deliver an increase of spatial resolution. The purpose of this study was to evaluate the impact of TOF on IQ, lesion detection rate, lesion volume (V) and SUVmax in F choline PET/CT of prostate cancer patients with biochemical recurrence compared to standard PET/CT reconstruction (standard).

PATIENTS AND MATERIALS

During a period of 9 months, 32 patients with prostate cancer (mean [SD] age, 71 [7.8] years) and biochemical recurrence were included in this prospective institutional review board-approved study. Each patient underwent a state-of-the-art 3-dimensional F choline PET/CT. A total of 76 lesions were assessed by 2 board-certified nuclear medicine physicians and a third-year resident. Lesion volume and SUVmax of local recurrence, lymph nodes, and organ metastases were compared between TOF and standard. Image quality and lesion demarcation were rated according to a 5-point Likert-type scale. Interobserver agreement was assessed.

RESULTS

Eight additional lesions were detected using TOF (SUVmax, 3.64 [0.95]; V, 0.58 cm [0.50]). Image quality was reduced (IQ standard, 1.28; TOF, 1.77; P < 0.01) in calculated TOF images, although quality of lesion demarcation was improved (lesion demarcation: standard, 1.66; TOF, 1.26; P < 0.01). SUVmax was significantly increased in TOF images (SUVmax standard, 6.9 [4.1]; TOF, 8.1 [4.1]; P < 0.01), whereas V did not show significant differences (V standard, 5.3 [10.4] cm; TOF, 5.4 [10.3] cm; P = 0.41). Interobserver agreement was good for combined ratings (1 + 2 and 3 + 4).

CONCLUSIONS

Application of TOF seems to be of additional value to detect small metastatic lesions in patients with prostate cancer and biochemical recurrence, which may have further clinical implications for secondary treatment.

Update on medical therapy for male LUTS

The medical management of lower urinary tract symptoms (LUTS) is aimed at addressing voiding and storage symptoms in patients with benign prostate hyperplasia (BPH) symptoms with or without an over-active bladder (OAB). Current available options for BPH include alpha-blockers, 5-alpha reductase inhibitors and phosphodiesterase type 5 inhibitors. For OAB, options include antimuscarinics, with or without an alpha-blocker, the beta-3-adrenergic agonist mirabegron and the synthetic diuretic desmopressin. With the availability of numerous options and combinations available for the treatment of LUTS, individual patient assessment is the key to optimal symptom control and management of adverse effects.

Seidlitzia rosmarinus for lower urinary tract symptoms associated with benign prostatic hyperplasia: a pilot randomized controlled clinical trial

OBJECTIVE

This study was performed to investigate the effect of Seidlitzia rosmarinus on the clinical symptoms of benign prostatic hyperplasia.

METHODS

This single-blind clinical trial included 98 patients with voiding and storage symptoms in Shohada Ashayer Hospital of Khorramabad. The patients were randomly divided into two groups of treatment with prazosin 1mg/day plus Seidlitzia rosmarinus 3g/day and treatment with prazosin 1mg/day. The clinical symptoms were measured using the International Prostate Symptoms Score (IPSS) questionnaire. Serum prostate-specific antigen (PSA) level, prostate volume, and residual urine volume before and 2 months after the intervention were measured.

RESULTS

The results of the study before the intervention did not show significant differences between the prazosin and Seidlitzia rosmarinus plus prazosin groups for the scores of clinical symptoms, PSA level, prostate volume, and residual urine volume (p>0.05). However, significant differences were found between the two groups after the intervention for the mean change scores of clinical symptoms (6.8 scores in the Seidlitzia rosmarinus group vs. 2 scores in the control group) (p<0.001), while no significant differences were found for the mean change scores of PSA level, prostate volume, and residual urine volume (p>0.05).

CONCLUSION

The results of the study showed that the simultaneous consumption of Seidlitzia rosmarinus and prazosin, compared to the consumption of prazosin alone, results in significant improvements in the clinical symptoms of benign prostatic hyperplasia.

Cross-sectional and longitudinal associations of sexual function with lower urinary tract symptoms in men with benign prostatic hyperplasia

PURPOSE

We examine the cross-sectional associations between baseline characteristics and sexual function and the longitudinal associations between change in lower urinary tract symptoms and change in sexual function among men with benign prostatic hyperplasia.

MATERIALS AND METHODS

We studied lower urinary tract symptoms assessed by the AUA-SI and sexual function determined by the BMSFI in men enrolled in the MTOPS study. The cross-sectional cohort included 2,916 men who completed the BMSFI at baseline. The longitudinal cohort included 672 men who were randomized to placebo and had completed the BMSFI at baseline and at least once during a 4-year followup. Multiple adjusted linear modeling for each domain of the BMSFI was performed to assess associations of sexual function with lower urinary tract symptoms.

RESULTS

After adjustment for baseline demographic and clinical characteristics, increased age, less education, obesity and severe lower urinary tract symptoms were each significantly associated with poorer sexual drive, erectile function, ejaculatory function, sexual problem assessment and overall satisfaction in the cross-sectional cohort. However, none of these baseline characteristics predicted change in sexual function in the longitudinal cohort. Decline in sexual function in all sexual function domains associated with worsening of lower urinary tract symptoms in this group was small.

CONCLUSIONS

Increased age, less education, obesity and more severe lower urinary tract symptoms were individually associated cross-sectionally, but not longitudinally, with poorer sexual function in men with lower urinary tract symptoms/benign prostatic hyperplasia. The decline in sexual function associated with worsening of lower urinary tract symptoms in men assigned to placebo was small.

Long-term use of 5α-reductase inhibitors and the risk of male breast cancer

BACKGROUND

The 5α-reductase inhibitors (5-ARI) finasteride and dutasteride are indicated for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia. Case reports have suggested that 5-ARIs increase the risk for male breast cancer, with no conclusive evidence. The objective of this study was to quantify the association between use of 5-ARIs and the risk for male breast cancer.

METHODS

A case-control study was conducted with data from the United Kingdom Clinical Practice Research Datalink database among all men aged 45 years and older in the period 1 January 1992 to 31 December 2011. Cases of men diagnosed with breast cancer were matched to up 10 controls on age and general practice. Crude and adjusted odds ratios were estimated for the risk of breast cancer associated with the use of 5-ARIs.

RESULTS

Three hundred and ninety-eight cases were identified and matched to 3,930 controls. Ever use of 5-ARIs was associated with an adjusted odds ratio for breast cancer of 1.08 (95 % CI 0.62-1.87) compared to non-users. Increasing cumulative duration of treatment showed no increasing risks: adjusted odds ratios for use for less than 280, for 280 to 1,036 and for more than 1,036 days were 1.21 (95 % CI 0.47-3.10), 0.94 (95 % CI 0.36-2.41) and 1.29 (95 % CI 0.54-3.08), respectively.

CONCLUSIONS

In this study, there was no evidence of an association between short- or long-term treatment with 5-ARIs and the risk for breast cancer in older men.

Lower urinary tract symptoms in men

Benign prostatic hyperplasia (BPH) is a highly prevalent and costly condition that affects older men worldwide. Many affected men develop lower urinary tract symptoms, which can have a negative impact on their quality of life. In the past, transurethral resection of the prostate (TURP) was the mainstay of treatment. However, several efficacious drug treatments have been developed, which have transformed BPH from an acute surgical entity to a chronic medical condition. Specifically, multiple clinical trials have shown that α adrenoceptor antagonists can significantly ameliorate lower urinary tract symptoms. Moreover, 5α reductase inhibitors, alone or combined with an α adrenoceptor antagonist, can reverse the natural course of BPH, reducing the risk of urinary retention and the need for surgical intervention. Newer medical regimens including the use of antimuscarinic agents or phosphodiesterase type 5 inhibitors, have shown promise in men with predominantly storage symptoms and concomitant erectile dysfunction, respectively. For men who do not adequately respond to conservative measures or pharmacotherapy, minimally invasive surgical techniques (such as transurethral needle ablation, microwave thermotherapy, and prostatic urethral lift) may be of benefit, although they lack the durability of TURP. A variety of laser procedures have also been introduced, whose improved hemostatic properties abrogate many of the complications associated with traditional surgery.

5α-Reductase inhibitors and risk of high-grade or lethal prostate cancer

IMPORTANCE

5α-Reductase inhibitors (5ARIs) are widely used for benign prostatic hyperplasia despite controversy regarding potential risk of high-grade prostate cancer with use. Furthermore, the effect of 5ARIs on progression and prostate cancer death remains unclear.

OBJECTIVE

To determine the association between 5ARI use and development of high-grade or lethal prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

Prospective observational study of 38,058 men followed up for prostate cancer diagnosis and outcomes between 1996 and 2010 in the Health Professionals Follow-up Study.

EXPOSURES

Use of 5ARIs between 1996 and 2010.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards models were used to estimate risk of prostate cancer diagnosis or development of lethal disease with 5ARI use, adjusting for possible confounders including prostate specific antigen testing.

RESULTS

During 448,803 person-years of follow-up, we ascertained 3681 incident prostate cancer cases. Of these, 289 were lethal (metastatic or fatal), 456 were high grade (Gleason sum [GS] 8-10), 1238 were GS 7, and 1600 were low grade (GS 2-6). A total of 2878 (7.6%) men reported use of 5ARIs between 1996 and 2010. After adjusting for confounders, men who reported ever using 5ARIs over the study period had a reduced risk of overall prostate cancer (hazard ratio [HR], 0.77; 95% CI, 0.65-0.91). 5ARI users had a reduced risk of GS 7 (HR, 0.67; 95% CI, 0.49-0.91) and low-grade (GS 2-6) prostate cancer (HR, 0.74; 95% CI, 0.57-0.95). 5ARI use was not associated with risk of high-grade (GS 8-10) prostate cancer (HR, 0.97; 95% CI, 0.64-1.46) or lethal disease (HR, 0.99; 95% CI, 0.58-1.69). Increased duration of use was associated with significantly lower risk of overall prostate cancer (HR for 1 year of additional use, 0.95; 95% CI, 0.92-0.99), localized (HR, 0.95; 95% CI, 0.90-1.00), and low-grade disease (HR, 0.92; 95% CI, 0.85-0.99). There was no association for lethal, high-grade, or grade 7 disease.

CONCLUSIONS AND RELEVANCE

While 5ARI use was not associated with developing high-grade or lethal prostate cancer, it was associated with a reduction in low-grade, GS 7, and overall prostate cancer. Because the number of patients with high-grade or lethal prostate cancer in our cohort was limited, we cannot rule out potential risk of harm with 5ARI use.

Evaluation of the clinical indications, adverse drug reactions, and finasteride use in patients with benign prostatic hyperplasia in Poland

BACKGROUND

Benign prostatic hyperplasia (LUTS/BPH) is one of the most common urinary disorders in elderly men. The symptoms of the disease include prostate gland enlargement, bladder outlet obstruction, and lower urinary tract symptoms (LUTSs). BPH predisposes patients to bladder infections and bladder stone formation and increases their risk of urinary retention, which in turn causes renal failure. Hence, the disease requires surgical treatment. However, over the recent years, the number of surgical interventions performed in pharmacotherapy has significantly reduced because of the increased efficacy of conservative therapy, including combination treatment mostly with 2 groups of drugs, namely, alpha-1-adrenolitics and other 5-alpha-reductase blockers, with a different pharmacological activity [5]. The aim of this study was to evaluate the clinical indications, adverse drug reactions, and finasteride use in patients with diagnosed BPH in Poland.

MATERIALS AND METHODS

We conducted a clinical trial from November 2009 to November 2010 that included 5751 patients who were enrolled in 46 urological centres in Poland. The researchers who conducted the clinical trial were urologists from different regions of Poland. The clinical trial involved 6 follow-up visits. The mean age of the patients was 67 years (range, 45-93 years; median, 67.00; SD, 8.507). The inclusion criteria were as follows: LUTSs, finasteride therapy for at least 2 weeks, age>40 years, and BPH.

RESULTS

Patients self-reported data on LUTSs, the symptom frequency, concurrent diseases, and intensification of urinary system symptoms. In addition, additional examinations were performed, including prostate-specific antigen test, urinary tract ultrasonography with evaluation of residual urine and prostate, and uroflowmetry. The study did not exclude data on the combined treatment with finasteride and alpha-1-adrenolitics.

CONCLUSION

Finasteride was demonstrated to be effective, as evidenced by the significant decrease in TPV by 40% even after 12 months. It was also found to contribute to the attenuation of LUTSs, improvement in maximum flow rate, decrease in nocturia, and improvement in QoL.

The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men

BACKGROUND

Acute urinary retention is a urological emergency in men and requires urgent catheterisation. Any intervention which aims at improving urinary symptoms following an acute urinary retention episode could be potentially beneficial. Alpha blockers relax prostatic smooth muscle cells thereby decreasing the resistance to urinary flow and by doing so could improve urinary symptoms.

OBJECTIVES

To assess the effectiveness of alpha blockers on successful resumption of micturition following removal of a urethral urinary catheter after an episode of acute urinary retention in men. In the absence of internationally agreed outcome measures for the success of a trial without catheter, success was defined as the return to satisfactory voiding without need for re-catheterisation within 24 hours.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 9 October 2013), CENTRAL (2013, Issue 5) (searched 5 June 2013), MEDLINE 1946 to May Week 4 2013, MEDLINE in Process (covering to 3 June 2013), EMBASE Classic and EMBASE 1947 to 2013 Week 22 (all searched 4 June 2013) and the reference lists of relevant articles. No language or other restrictions were imposed on the searches.

SELECTION CRITERIA

Only randomised and quasi-randomised clinical trials of alpha blockers for trial without a urethral catheter following an episode of acute urinary retention in men were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined all the citations and abstracts derived from the search strategy. Any disagreement about trial selection and inclusion was resolved by discussion. A third independent judgement was sought where disagreement persisted. Two review authors extracted independently, cross-checked and processed the data as described in the Cochrane Handbook for Systematic Reviews of Intervention. Quality of evidence of the critical outcomes was assessed by adopting the GRADE approach.

MAIN RESULTS

Nine randomised clinical trials were included in this review. Eight trials compared alpha blockers versus placebo (five trials tested alfuzosin and two trials tested tamsulosin, one trial tested both alfuzosin and tamsulosin, one trial tested silodosin) and one trial compared an alpha blocker (doxazosin) versus no treatment. Trial without catheter was performed after treatment with the drug for one to three days in seven trials and for eight and 32 days in two other trials respectively. There was moderate quality evidence to suggest that the rate of successful trial without catheter favoured alpha blockers over placebo ( 366/608, 60.2%, of men using an alpha blocker were able to void spontaneously after catheter removal compared with 185/486, 38.1%, using placebo, risk ratio (RR) 1.55, 95% confidence interval (CI) 1.36 to 1.76). The incidence of recurrent acute urinary retention was lower in groups treated with an alpha blocker (RR 0.69, 95% CI 0.60 to 0.79). This evidence was of moderate quality and was statistically significant for alfuzosin, tamsulosin and silodosin, though not for doxazosin. Of the trials mentioning adverse effects (for example, postural hypotension, dizziness), there was not enough information to detect statistically significant differences between the groups (RR 1.19, 95% CI 0.75 to 1.89) and the evidence was of low quality. Overall, adverse effect rates were low for both placebo and alpha blockers and, for example, vasodilatation-related adverse effects did not often result in discontinuation.

AUTHORS' CONCLUSIONS

There was some evidence to suggest that alpha blockers increase the success rates of trial without catheter, and the incidence of adverse effects was low. There was some evidence of a decreased incidence of acute urinary retention. The need for further surgery, cost effectiveness and recommended duration of alpha blocker treatment after successful trial without catheter remain unknown as these were not reported by any trial. There is a lack of internationally agreed outcome measures for what constitutes successful trial without catheter. This makes meta-analysis difficult. Large, well-designed controlled trials, which use the recommendations set out in the CONSORT statement, and include clinically important outcome measures, are required.

Hormonal manipulation of lower urinary tract symptoms secondary to benign prostatic obstruction

Although the etiology of lower urinary tract symptoms (LUTS) is often multifactorial, a significant proportion of men over the age of 50 suffer from benign prostatic obstruction (BPO) secondary to benign prostatic hyperplasia. Prostate, being an androgen responsive organ is dependent on the male sex hormone, testosterone, for growth. Thus, treatment strategies that manipulate the levels of circulating hormones that influence the level of testosterone and/or prostatic growth represent an important potential option for patients suffering with troublesome LUTS due to BPO. Despite this, the only hormonal treatment that is currently used in daily clinical practice is the 5-alpha reductase inhibitor. In this article, we review the current evidence on the use of the 5-alpha reductase inhibitors finasteride and dutasteride. We also discuss new emerging hormonal manipulation strategies for patients with LUTS secondary to BPO.

Inhibitory effect of rape pollen supercritical CO2 fluid extract against testosterone-induced benign prostatic hyperplasia in rats

Benign prostatic hyperplasia (BPH) can lead to lower urinary tract symptoms. Rape pollen is an apicultural product that is composed of nutritionally valuable and biologically active substances. The aim of the present study was to investigate the protective effect of rape pollen supercritical CO₂ fluid extract (SFE-CO₂) in BPH development using a testosterone-induced BPH rat model. BPH was induced in the experimental groups by daily subcutaneous injections of testosterone for a period of 30 days. Rape pollen SFE-CO₂ was administered daily by oral gavage concurrently with the testosterone injections. Animals were sacrificed at the scheduled termination and the prostates were weighed and subjected to histopathological examination. Testosterone, dihydrotestosterone (DHT), 5α-reductase and cyclooxygenase-2 (COX-2) levels were also measured. BPH-induced animals exhibited an increase in prostate weight with increased testosterone, DHT, 5α-reductase and COX-2 expression levels. However, rape pollen SFE-CO₂ treatment resulted in significant reductions in the prostate index and testosterone, DHT, 5α-reductase and COX-2 levels compared with those in BPH-induced animals. Histopathological examination also demonstrated that rape pollen SFE-CO₂ treatment suppressed testosterone-induced BPH. These observations indicate that rape pollen SFE-CO₂ inhibits the development of BPH in rats and these effects are closely associated with reductions in DHT, 5α-reductase and COX-2 levels. Therefore, the results of the present study clearly indicate that rape pollen SFE-CO₂ extract may be a useful agent in BPH treatment.

Androgens and prostate disease

A growing body of literature has established the anabolic benefi ts of testosterone (T) therapy in hypogonadal men. However, there remains a paucity of data regarding the risks of exogenous androgen use in older men and the potential for adverse effects on the prostate gland. Whether T therapy in older, hypogonadal men might worsen lower urinary tract symptoms or exacerbate, unmask, or even incite prostate cancer development has tempered enthusiasm for T therapy, while known prostatic disease has served as a relative contraindication to T therapy. Androgens are necessary for the development and maintenance of the prostate gland. However, epidemiologic studies do not consistently fi nd a positive relationship between endogenous serum androgen concentrations and the risk of prostate disease. Recent data demonstrate that 5α-reductase inhibitors decrease the risk of low-grade prostate cancer, suggesting that modifying androgen metabolism may have beneficial effects on prostate health, yet similar reductions in high-grade disease have not been observed, thereby questioning the true clinical benefits of these agents for chemoprevention. Knowing how to best investigate the relationship between androgens and the development of prostate disease given the lack of large, randomized trials is difficult. Accumulating data challenges the assumption that alterations in serum androgens have parallel effects within the prostate hormonal environment or change androgen-regulated processes within the gland. Long-term intervention studies are needed to truly ascertain the effects of androgen manipulation on prostate tissue and disease risk. However, available data do not support the notion that restoring serum androgens to normal physiologic ranges drives prostate disease.

Personalized medicine for the management of benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia affects more than 50% of men by age 60 years, and is the cause of millions of dollars in health care expenditure for the treatment of lower urinary tract symptoms and urinary obstruction. Despite the widespread use of medical therapy, there is no universal therapy that treats all men with symptomatic benign prostatic hyperplasia. At least 30% of patients do not respond to medical management and a subset require surgery. Significant advances have been made in understanding the natural history and development of the prostate, such as elucidating the role of the enzyme 5α-reductase type 2, and advances in genomics and biomarker discovery offer the potential for a more targeted approach to therapy. We review the current understanding of benign prostatic hyperplasia progression as well as the key genes and signaling pathways implicated in the process such as 5α-reductase. We also explore the potential of biomarker screening and gene specific therapies as tools to risk stratify patients with benign prostatic hyperplasia and identify those with symptomatic or medically resistant forms.

MATERIALS AND METHODS

A PubMed® literature search of current and past peer reviewed literature on prostate development, lower urinary tract symptoms, benign prostatic hyperplasia pathogenesis, targeted therapy, biomarkers, epigenetics, 5α-reductase type 2 and personalized medicine was performed. An additional Google Scholar™ search was conducted to broaden the scope of the review. Relevant reviews and original research articles were examined, as were their cited references, and a synopsis of original data was generated with the goal of informing the practicing urologist of these advances and their implications.

RESULTS

Benign prostatic hyperplasia is associated with a state of hyperplasia of the stromal and epithelial compartments, with 5α-reductase type 2 and androgen signaling having key roles in the development and maintenance of the prostate. Chronic inflammation, multiple growth factor and hormonal signaling pathways, and medical comorbidities have complex roles in prostate tissue homeostasis as well as its evolution into the clinical state of benign prostatic hyperplasia. Resistance to medical therapy with finasteride may occur through silencing of the 5α-reductase type 2 gene by DNA methylation, leading to a state in which 30% of adult prostates do not express 5α-reductase type 2. Novel biomarkers such as single nucleotide polymorphisms may be used to risk stratify patients with symptomatic benign prostatic hyperplasia and identify those at risk for progression or failure of medical therapy. Several inhibitors of the androgen receptor and other signaling pathways have recently been identified which appear to attenuate benign prostatic hyperplasia progression and may offer alternative targets for medical therapy.

CONCLUSIONS

Progressive worsening of lower urinary tract symptoms and bladder outlet obstruction secondary to benign prostatic hyperplasia is the result of multiple pathways including androgen receptor signaling, proinflammatory cytokines and growth factor signals. New techniques in genomics, proteomics and epigenetics have led to the discovery of aberrant signaling pathways, novel biomarkers, DNA methylation signatures and potential gene specific targets. As personalized medicine continues to develop, the ability to risk stratify patients with symptomatic benign prostatic hyperplasia, identify those at higher risk for progression, and seek alternative therapies for those in whom conventional options are likely to fail will become the standard of targeted therapy.

Comparison of outpatient versus inpatient transurethral prostate resection for benign prostatic hyperplasia: Comparative, prospective bi-centre study

INTRODUCTION

We compare the symptomatic relief with urodynamic parameter change and operative safety of the outpatient transurethral resection in saline (TURIS-V) technique with inpatient transurethral resection of the prostate (TURP) for the management of benign prostatic hyperplasia (BPH).

METHODS

This prospective cohort comparison study enrolled patients who needed BPH surgery. Between January 2010 and June 2011, outpatient TURIS-V was performed at 1 centre and the results of the treatment were compared with inpatient TURP performed at a separate hospital. Preoperative characteristics, including prostate volume, were similar in both groups. Perioperative data and any treatment complications were recorded. The analysis compared postoperative outcomes, including a 6-month postoperative International Prostate Symptom Score (IPSS), a quality of life (QoL) evaluation and a record of any changes in uroflowmetry findings, between the 2 groups.

RESULTS

In the TURIS-V patient group, 75 patients agreed to be in the study. Of these, 69 ultimately complete the study. In the TURP group, 76 patients agreed and 71 of these completed the study. Both study groups were well-matched for age, IPSS, QoL and uroflowmetry findings. The TURIS-V group experienced both shorter operation times (54.6 vs. 74.8 minutes) and shorter catheterization times (2.2 vs. 4.2 days) when compared to the TURP group. There were comparable improvements in the 6-month postoperative IPSS, QoL, and uroflowmetry findings between the 2 groups. There were also equally low incidence rates of procedural complications.

CONCLUSIONS

Both TURIS-V and TURP relieve lower urinary tract symptoms in a similar way, with great efficacy and safety. Overall, TURIS-V had shorter operative and catheterization times compared to TURP. Notwithstanding the paper's limitations (non- randomized cohort comparison with possible selection or surgeon bias and small heterogeneous sample size), TURIS-V can be performed safely even in an outpatient setting.