What are the factors contributing to failure in improvement of subjective symptoms following silodosin administration in patients with benign prostatic hyperplasia? Investigation using a pressure-flow study

Prospective comparison of tadalafil 5 mg alone, silodosin 8 mg alone, and the combination of both in treatment of lower urinary tract symptoms related to benign prostatic hyperplasia

BACKGROUND

Men with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH), will have deterioration in the quality of life. Likewise, BPH can be complicated by damage to bladder function, bladder stones formation, hematuria, and impaired kidney function. The goal of treatment is to avoid all those effects caused by BPH.

OBJECTIVE

To evaluate the efficacy of tadalafil alone, silodosin alone, and the combination of both in the treatment of LUTS associated with BPH.

PATIENTS AND METHODS

Patients in our department with BPH who had LUTS were assigned randomly to three groups: A (101 patients) received tadalafil, 5 mg; B (102 patients) received silodosin, 8 mg; and group C (105 patients) received the combination of tadalafil, 5 mg, and silodosin, 8 mg. For all participants, we asses changes in the maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) score, Post-voiding urine (PVR) and all results were recorded and analyzed with the (SPSS) and Microsoft Excel 2010.

RESULTS

Qmax, IPSS, PVR and IIEF score improved significantly more with the combination of tadalafil and silodosin than with either drug alone (p < 0.001). Three months after treatment, the mean Qmax values were 14.4 ml/sec in group A, 15.2 ml/sec in group B, and 15.8 ml/sec in group C; and the mean IPSSs were 17.6 in group A, 16.7 in group B, and 15.6 in group C (p < 0.001).

CONCLUSION

Tadalafil and silodosin are effective treatment options in men with BPH who have LUTS, but the combination of both is more effective and feasible in treating LUTS of BPH.

[Most recent findings of curative drugs for lower urinary tract symptoms in clinical practice]

As Japan enters into an aging society, aged patients with chief complaint of lower urinary tract symptoms (LUTS) have increased. The most common cause of LUTS in men older than 50 years is benign prostatic hyperplasia (BPH). In particular, LUTS associated with overactive bladder (OAB) symptoms was reported to have a significant negative impact on patient quality of life (QOL). In clinical practice, monotherapy with α1-blockers or PDE5 inhibitors is widely employed for the initial management of BPH accompanied by OAB (BPH/OAB). However, storage symptoms may persist in some patients. In patients with residual OAB symptoms despite α1-blocker or PDE5 inhibitor monotherapy, the addition of an anticholinergic agent or a β3-adrenergic receptor (β3-AR) agonist is recommended by the BPH guidelines. Although both agents have been shown to effectively improve OAB symptoms and bladder storage functions, it remains unclear which type of add-on therapy, anticholinergic agents or β3-AR agonists, is most effective for alleviating OAB symptoms and storage functions. Recently, detrusor underactivity (DU) is also considered to be a common cause of non-neurogenic LUTS in men. DU has been reported to be present in 9%-48% of men undergoing urodynamic evaluation for non-neurogenic LUTS. DU can lead to adverse health effects, in addition to significant burden and decreased QOL. Thus, development of a safe and effective treatment for patients with LUTS induced by DU is an urgent issue at present. In this paper, we will introduce most recent findings of curative drugs for LUTS, especially BPH/OAB and DU in clinical practice.

Comparison of Silodosin Monotherapy vs Silodosin With Tadalafil Add-on Therapy in Patients With Benign Prostatic Hyperplasia

OBJECTIVE

To evaluate the efficacy and safety of add-on therapy with the phosphodiesterase type 5 inhibitor tadalafil for patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH) treated with the α₁-adrenoceptor blocker silodosin.

MATERIALS AND METHODS

We analyzed 103 patients with LUTS/BPH with an International Prostate Symptom Score (IPSS) of >8 after ≥4 weeks of silodosin treatment from April 2016 through December 2016 at Kori Hospital. The patients subsequently received silodosin 4.0 mg twice daily (monotherapy group) or silodosin 4.0 mg twice daily plus tadalafil 5.0 mg once daily (add-on therapy group) for 8 weeks. We assessed adverse events and evaluated the mean change from baseline to 8 weeks in the IPSS, Overactive Bladder Symptom Score (OABSS), maximum urine flow rate (Q_max), and post-void residual urine volume.

RESULTS

Of 103 patients, 101 (98.1%) could continue medical treatment. The IPSS, OABSS, and Q_max showed significantly greater improvement in the add-on therapy than in the monotherapy group (-3.92 vs -1.24, -1.18 vs 0.10, and 1.09 vs -1.04, respectively; all P <.05). Although 4 patients experienced adverse events (add-on therapy: n = 3, 5.7%; monotherapy: n = 1, 2.0%), no significant differences were observed (P = .62). Among patients with overactive bladder (n = 55), the IPSS storage symptom subscore, IPSS urgency subscore, and OABSS urgency subscore showed significantly greater improvement in the add-on therapy than in the monotherapy group (-2.23 vs 0.17, -0.88 vs 0.28, and -1.5 vs -0.48, respectively; all P <.05).

CONCLUSION

Add-on therapy with tadalafil may be effective for patients with LUTS/BPH resistant to silodosin monotherapy.

Intravesical prostatic protrusion can predict therapeutic response to silodosin in male patients with lower urinary tract symptoms

OBJECTIVES

To investigate the predicting factors of therapeutic response to α1-blockers in patients with lower urinary tract symptoms associated with benign prostate enlargement based on a urodynamic study.

METHODS

This was a prospective study involving 125 outpatients with lower urinary tract symptoms associated with benign prostate enlargement. They received 8 mg of silodosin for 12 months. International Prostate Symptom Score, Overactive Bladder Symptom Score, International Prostate Symptom Score quality of life assessment, and urodynamic study were used to assess subjective and objective symptoms. Patient age, prostate-specific antigen level, prostate volume, International Prostate Symptom Score, Overactive Bladder Symptom Score, maximum flow rate and post-void residual urine volume, and intravesical prostatic protrusion were investigated as potential parameters to predict the therapeutic response. Baseline parameters that influenced the improvement of International Prostate Symptom Score and bladder outlet obstruction were statistically analyzed.

RESULTS

A total of 103 patients with mean age of 69.2 years and mean prostate volume of 46.8 mL were included in the analysis. A total of 39 patients (37.9%) showed insignificant improvement in International Prostate Symptom Score (<25%), whereas 36 patients (35.0%) showed insufficient improvement in bladder outlet obstruction index (less than 25%). Prostate volume, maximum flow rate and intravesical prostatic protrusion were independent predictors of ineffective treatment. On multivariate logistic regression analysis, intravesical prostatic protrusion was found to be the only factor related to improvement of both the International Prostate Symptom Score and bladder outlet obstruction. Additionally, multiple linear regression analysis showed that intravesical prostatic protrusion was the only significant factor for predicting improvement of the International Prostate Symptom Score (r = -0.56, P < 0.001) and bladder outlet obstruction (r = -0.59, P < 0.001).

CONCLUSIONS

Intravesical prostatic protrusion can be considered a useful predictor of therapeutic response to silodosin for subjective symptoms and bladder outlet obstruction in male patients with lower urinary tract symptoms associated with benign prostate enlargement.

Efficacy and Safety of Initial Combination Treatment of an Alpha Blocker with an Anticholinergic Medication in Benign Prostatic Hyperplasia Patients with Lower Urinary Tract Symptoms: Updated Meta-Analysis

BACKGROUND

There is still controversy as to whether initial combination treatment is superior to serial addition of anticholinergics after maintenance or induction of alpha blockers in benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS).

OBJECTIVE

The objective of this study was to determine the benefits and safety of initial combination treatment of an alpha blocker with anticholinergic medication in BPH/LUTS through a systematic review and meta-analysis.

METHODS

We conducted a meta-analysis of improvement in LUTS using International Prostate Symptom Score (IPSS), maximal urinary flow rate (Qmax), post-voided residual volume (PVR), and quality of life (QoL).

RESULTS

In total, 16 studies were included in our analysis, with a total sample size of 3,548 subjects (2,195 experimental subjects and 1,353 controls). The mean change in total IPSS improvement from baseline in the combination group versus the alpha blocker monotherapy group was -0.03 (95% CI: -0.14-0.08). The pooled overall SMD change of storage IPSS improvement from baseline was -0.28 (95% CI: -0.40 - -0.17). The pooled overall SMD changes of QoL, Qmax, and PVR were -0.29 (95% CI: -0.50 - -0.07), 0.00 (95% CI: -0.08-0.08), and 0.56 (95% CI: 0.23-0.89), respectively. There was no significant difference in the number of acute urinary retention (AUR) events or PVR.

CONCLUSIONS

Initial combination treatment of an alpha blocker with anticholinergic medication is efficacious for in BPH/ LUTS with improved measures such as storage symptoms and QoL without causing significant deterioration of voiding function.

An observational study of the use of beclomethasone dipropionate suppositories in the treatment of lower urinary tract inflammation in men

Background

Nonbacterial prostatitis, together with chronic pelvic pain syndrome, accounts for 90–95 % of prostatitis cases. Anti-inflammatory medications are commonly used to reduce storage/inflammatory symptoms that can deteriorate quality of life. The purpose of this study was to observe the efficacy and safety of beclomethasone dipropionate rectal suppositories (Topster®) in inflammations of the lower urinary tract in men.

Methods

Patients underwent diagnostic and therapeutic protocols according to current evidence-based practice. Efficacy assessments: voiding parameters, perineal pain, International Prostate Symptom Score (IPSS), digital rectal examination (DRE). Adverse events and patient compliance were recorded throughout the study.

Results

One hundred eighty patients were enrolled, mean age 52 ± 14.97. Most frequent diagnosis: nonbacterial prostatitis (85 %). All patients completed visits 1 and 2. All patients were treated with beclomethasone dipropionate (BDP) suppositories, 136/180 also with Serenoa repens (SR) extract. Antibiotics were rarely required.

162/180 patients presented clinically significant improvements and terminated treatment.

Mean change vs. baseline in voiding frequency: −3.55 ± 2.70 n/day in patients taking only BDP and −3.68 ± 2.81 n/day in those taking both BDP and SR (P<.0001 in both groups). Uroflowmetry improved significantly; change from baseline 3.26 ± 5.35 ml/s in BDP only group and 5.61 ± 7.32 ml/s in BDP + SR group (P = 0.0002 for BDP, P<.0001 for BDP + SR). Urine stream normal in 35 % of patients at visit 1 and 57.22 % of patients at visit 2. Mean change in perineal pain, on 0–10 VAS, −0.66 ± 2.24 for BDP only group (P = 0.0699) and −1.37 ± 2.40 for BDP + SR group (P<.0001). IPSS increased at visit 2. No adverse events were reported.

For all parameters, none of the comparisons between groups was found to be statistically significant.

Conclusion

This study confirmed the drug’s good safety profile. We also observed an improvement in the main storage symptoms and clinical findings associated with lower urinary tract inflammation in patients treated with beclomethasone dipropionate suppositories.