Prostatic injection of botulinum toxin is not inferior to optimized medical therapy in the management of lower urinary tract symptoms due to benign prostatic hyperplasia: results of a randomized clinical trial

[Botulinum toxin in male lower urinary tract symptoms (LUTS): What can we expect?]

During the last two decades botulinum toxin has also conquered urology. Botulinum toxin reduces the contractility and sensitivity of the detrusor muscle and relieves pain. It is therefore a promising drug whose use in men also appears promising. The following article highlights the practical relevance of botulinum toxin for male lower urinary tract symptoms (LUTS). But first of all, a distinction must be made between use in male LUTS due to benign prostate syndrome (BPS) and use in cases of overactive bladder (OAB) alone. A differentiated diagnosis and treatment of male LUTS is therefore essential.

Early investigational agents for the treatment of benign prostatic hyperplasia'

INTRODUCTION

Benign prostatic hyperplasia (BPH), as a clinical entity that affects many people, has always been in the forefront of interest among researchers, pharmaceutical companies, and physicians. Patients with BPH exhibit a diverse range of symptoms, while current treatment options can occasionally cause adverse events. All the aforementioned have led to an increased demand for more effective treatment options.

AREAS COVERED

This review summarizes the outcomes of new medications used in a pre-clinical and clinical setting for the management of male lower urinary tract symptoms (LUTS)/BPH and provides information about ongoing trials and future directions in the management of this condition. More specifically, sheds light upon drug categories, such as reductase‑adrenoceptor antagonists, drugs interfering with the nitric oxide (NO)/cyclic guanosine monophosphate (GMP) signaling pathway, onabotulinumtoxinA, vitamin D3 (calcitriol) analogues, selective cannabinoid (CB) receptor agonists, talaporfin sodium, inhibitor of transforming growth factor beta 1 (TGF-β1), drugs targeting the hormonal control of the prostate, phytotherapy, and many more.

EXPERT OPINION

Clinical trials are being conducted on a number of new medications that may emerge as effective therapeutic alternatives in the coming years.

Effects of Tamsulosin Combined With Solifenacin on Lower Urinary Tract Symptoms: Evidence From a Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

This study is aimed to systematically evaluate the efficacy of tamsulosin combined with solifenacin and provide clinical evidence for treatment of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang data information service platform were searched to select randomized controlled trials (RCTs) of tamsulosin combined with solifenacin in the treatment of BPH with LUTS. After extraction of the data, the statistical information was calculated by means of STATA 12.0. The publication bias was calculated using Egger's test and Begg's funnel plot. A total of 17 articles contained 1,870 patients treated with tamsulosin in combination with solifenacin and 1,897 patients treated with tamsulosin only were included in this study. Results show that tamsulosin combined with solifenacin therapy was more effective in reducing the Total International Prostate Symptom Score (TIPSS), Storage International Prostate Symptom Score (SIPSS), Quality of life (QOL), and Overactive bladder symptom score (OABSS) in comparison with tamsulosin monotherapy treatment. However, it was found that the combination therapy may increase levels of prostate-specific antigen (PSA) and the maximal urinary flow rate (QMAX). Differences between the combination therapy and tamsulosin monotherapy were not statistically significant for urgency episodes per 24 h, micturitions per 24 h, Voiding International Prostate Symptom Score (VIPSS), and postvoid residual volume (PVR). Tamsulosin combined with solifenacin therapy is more effective than tamsulosin monotherapy for the treatment of BPH concurrent with LUTS and won't increase the risk of dysuria.

Lower Urinary Tract Symptoms: What's New in Medical Treatment?

CONTEXT

Pharmacological treatment is a cornerstone in the management of patients with lower urinary tract symptoms (LUTS).

OBJECTIVE

To review emerging evidence in the medical treatment of LUTS.

EVIDENCE ACQUISITION

An Embase/Pubmed-based literature search was conducted in December 2017, screening for randomized controlled trials (RCTs), prospective and retrospective series, animal model studies, and reviews on medical treatment of LUTS.

EVIDENCE SYNTHESIS

The main medical innovation in recent years in overactive bladder (OAB) has been the approval of the first β₃-adrenoceptor agonists (mirabegron) and intradetrusor onabotulinum toxin A, while several other drugs such as antiepileptics, phosphodiesterase inhibitors, or other β₃-agonists have brought promising results in phase 3 trials. Intraprostatic injections of various drugs for LUTS/benign prostatic hyperplasia have been investigated, but results of phase 3 trials are still pending, while combination therapies of phosphodiesterase type 5 inhibitors+α-blockers or finasteride have been proved as superior to single therapies in RCTs conducted in these patients. Two new formulations of desmopressin have been approved for nocturia in the USA (desmopressin nasal spray) and Europe/Canada/Australia (desmopressin orally disintegrated tablet). Fedovapagon, a vasopressin V₂ receptor agonist, has recently completed a large phase 3 trial in male patients with nocturia. Other phase 3 trials are ongoing in bladder pain syndrome (AQX 11-25, a SHIP-1 activator) and in neurogenic detrusor overactivity (mirabegron and abobotulinum toxin A).

CONCLUSIONS

Medical treatment of LUTS is a very active research field with recently approved drugs for nocturia (desmopressin acetate nasal spray/orally disintegrated tablet) and numerous emerging drugs currently investigated in OAB, LUTS/benign prostatic hyperplasia, nocturia, bladder pain syndrome, and neurogenic detrusor overactivity.

PATIENT SUMMARY

Medical treatment of lower urinary tract symptoms is a very active research field with recently approved drugs for nocturia (desmopressin acetate nasal spray/orally disintegrated tablet) and numerous emerging drugs in overactive bladder, nocturia, neurogenic detrusor overactivity, bladder pain syndrome, or benign prostatic hyperplasia.