Alpha-adrenoceptor inhibitors in the treatment of benign prostatic hyperplasia

Review of exercise and the risk of benign prostatic hyperplasia

It has been long appreciated that a healthy lifestyle plays a critical role in cardiovascular health. It is now apparent that the same is true in the development of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). Since 1995, 14 studies have been identified that investigate the clinical relationship between exercise and BPH/LUTS. No randomized controlled trials have been performed, but useful prospective cohort data originating from recent publications on the medical treatment of BPH and prevention of prostate cancer are available. Most of the literature supports a clinically significant, independent, and strong inverse relationship between exercise and the development of BPH/LUTS. Several mechanisms for this relationship have been proposed, including decreased sympathetic tone, avoidance of metabolic syndrome, and reduced oxidative damage to the prostate.

Adenosine 5'-triphosphate (ATP) is an excitatory cotransmitter with noradrenaline to the smooth muscle of the rat prostate gland

1. This study investigated whether adenosine 5'-triphosphate (ATP) is involved in neurotransmission to the rat prostate gland. 2. Fluorescence immunohistochemistry carried out on formaldehyde-fixed and frozen sections of rat prostate showed immunoreactivity for the P2X(1)-receptor in the fibromuscular stroma surrounding the secretory acini but not in the glandular epithelium. P2X(2)-, P2X(3)-, P2X(4)- and P2X(7)-receptors were immunonegative in the rat prostate stroma. Double-staining procedures showed P2X(1)-receptor immunoreactivity to be colocalized with alpha-actin immunoreactivity. 3. Isolated organ bath studies investigated whether drugs, which modify purinergic mechanisms, are able to affect contractility of the rat prostate gland. Suramin (100 micro M) and alphabetamethylene ATP (10 micro M) inhibited contractile responses to trains of electrical-field stimulation (70 V, 0.5 ms, 0.1-2 Hz) in the absence and presence of prazosin (300 nM). Responses to 5-20 Hz were unaffected by suramin or alphabetamethylene ATP. 4. Exogenous application of ATP analogues to unstimulated isolated preparations of rat prostate produced concentration-dependent suramin (100 micro M) sensitive transient contractions with a relative order of potency: alphabetamethylene ATP>betagammamethylene ATP>ATP. 5. Adenosine and adenosine 5'-monophosphate (AMP) did not produce contractile responses. 6. These results suggest that P2X(1)-receptors for ATP, which mediate contractions are present in the fibromuscular stroma of the rat prostate. The relative order of potency of ATP analogues in producing contractions of the rat prostate is consistent with the activation of P2X(1)-receptors. Inhibition by suramin and alphabetamethylene ATP of electrically evoked nerve-mediated contractions of the rat prostate implies that ATP contributes to this contractile response and is therefore a cotransmitter with noradrenaline during low-frequency stimulation.

Species differences in the actions of sensory neuropeptides on contractility of the smooth muscle of the rat and guinea-pig prostate

1. The present review describes the actions of sensory neuropeptides on the contractility of the rat and guinea-pig prostate gland and discusses the differences in sensitivity of the smooth muscle of the prostates taken from these species to these neuropeptides. 2. Nerve fibres immunoreactive for the tachykinins substance P and neurokinin A, as well as for the sensory neuropeptide calcitonin gene-related peptide (CGRP), are sparsely distributed throughout the fibromuscular stroma of the prostate gland in both the rat and guinea-pig. 3. In functional experiments, tachykinin agonists potentiate electrical field stimulation-induced contractile responses of prostates taken from guinea-pigs, but have no effect on those taken from rats. This potentiation is through stimulation of tachykinin NK1-receptors. 4. Conversely, CGRP inhibits electrical field stimulation-induced contractile responses of prostates taken from rats, but has no effect on those taken from guinea-pigs. 5. It is concluded that although the sensory innervation to the prostate glands of the rat and guinea-pig appears similar, the nature and sensitivity of the contractile response of the prostatic smooth muscle to applied sensory neuropeptides is vastly different in the two species.

The autonomic and sensory innervation of the smooth muscle of the prostate gland: a review of pharmacological and histological studies

1. We review literature demonstrating (a) the presence and (b) the actions of substances that mediate or modify neuroeffector transmission to the smooth muscle of the prostrate stroma of a number of species including man. 2. In all species studied prostatic stroma, but not secretory acini, receives rich noradrenergic innervation. Stimulation of these nerves causes contractions of prostate smooth muscle that are inhibited by guanethidine and by alpha1-adrenoceptor antagonists that probably act at the alpha1L-adrenoceptor. Such actions underlie the clinical use of alpha1-adrenoceptor antagonists in benign prostatic hyperplasia (BPH). 3. Acetylcholinesterase-positive nerves innervate prostatic stroma as well as epithelium. Atropine reduces nerve-mediated contractions of stromal muscle in the rat, guinea-pig and rabbit. M1, M2 and M3 muscarinic receptors have been implicated in eliciting or facilitating contraction in the prostate from guinea-pig, dog and rat, respectively. 4. Adenine nucleotides and nucleosides, nitric oxide (NO), opioids, neuropeptide Y (NPY) and vasoactive intestinal peptide (VIP) may act as co-transmitters or modulators in autonomic effector nerves supplying prostate stroma. Adenosine inhibits neurotransmission to the rat prostate, and NO is inhibitory in prostate from human, rat, rabbit, pig and dog. The activity of peptides present in the relatively sparse sensory innervation of the prostate exhibits species variation, but, when effective, calcitonin gene-related peptide is inhibitory while tachykinins are stimulant. The roles of NPY and VIP in modulating stromal contractility remain unclear. 5. Taken together the current literature indicates that, in addition to noradrenaline, other neurotransmitters and neuromodulators may regulate the tone of prostatic smooth muscle. Whether drugs that mimic or modify their actions might be useful in providing symptomatic relief of the urinary symptoms associated with BPH remains to be established.

Calcitonin gene-related peptide (CGRP) inhibits contractions of the prostatic stroma of the rat but not the guinea-pig

This study investigated the presence and effects of calcitonin gene-related peptide (CGRP) within the rat and guinea-pig prostate glands. Immunohistochemical studies demonstrated that CGRP immunoreactive nerve fibres are sparsely distributed throughout the prostatic fibromuscular stroma in both species. These CGRP immunopositive nerve fibres shared a similar distribution profile but were not colocalized with tyrosine hydroxylase immunopositive nerve fibres which also innervate the prostatic stroma of these species. Nerve terminals within rat and guinea-pig prostatic tissues were electrically field stimulated (60 V, 0.5 ms, 10 Hz, 20 pulses every 60 s). In guinea-pig preparations, application of human alpha-CGRP, rat adrenomedullin or rat amylin (0.1 nM-1 microM) had no effect on responses to field stimulation. In contrast, both rat and human alpha-CGRP (10 pM-300 nM), rat adrenomedullin (0.3 nM-1 microM) and rat amylin (3 nM-1 microM) concentration-dependently inhibited electrically evoked contractile responses in the rat prostate. The relative order of potency was rat alpha-CGRP=human alpha-CGRP>rat adrenomedullin>rat amylin. The inhibition by rat alpha-CGRP of field stimulation-induced contractions in the rat prostate was competitively antagonized by human CGRP((8-37)) (1, 3 and 10 microM) with a pA(2) of 6.20+/-0.13. Rat alpha-CGRP (10 nM) attenuated contractile responses of the rat prostate to exogenously added noradrenaline (1-100 microM). Inhibitory concentration-response curves to rat alpha-CGRP in rat prostates were unaffected by preincubation in either glibenclamide (10-100 microM), N-nitro-L-arginine methyl ester (L-NAME) (10 microM), bestatin (10 microM), captopril (10 microM) or phosphoramidon (3 microM). Our results indicate that CGRP-induced inhibition of electrically evoked contractions in the rat prostate occurs through activation of postjunctional CGRP(2) receptors which act independently of a K(ATP) channel or nitrergic mechanisms. Degradation of rat alpha-CGRP via peptidases does not appear to occur in the rat prostate.

alpha(1L)-adrenoceptors mediate noradrenaline-induced contractions of the guinea-pig prostate stroma

The alpha(1)-adrenoceptor subtype mediating noradrenaline-induced contractions of the guinea-pig isolated prostatic smooth muscle was investigated. Noradrenaline produced concentration-dependent contractions of the tissue with a mean pD(2) value of 5.26+/-0.03 (n=20). These contractions were antagonised by prazosin, 2-(2, 6-dimethoxyphenoxyethyl)aminomethyl-1,4-benzodioxane hydrochloride (WB-4101), N-[2-(2-cyclopropylmethoxyphenoxy)ethyl]-5-chloro-alpha, alpha-dimethyl-1H-indole-3-ethanamine hydrochloride (RS-17053) and (R)-5-[2-[[2-(2-ethoxyphenoxy)ethyl]amino]-2-methylethyl]-2- methoxybenzensulfonamide methanesulphonate hydrate (tamsulosin). Mean pA(2) or apparent pK(B) estimates for the antagonism of noradrenaline were 8.15+/-0.05 for prazosin; 8.83+/-0.11 for WB-4101, 7.18+/-0.14 for RS-17053 and 10.11+/-0.12 for tamsulosin. The relatively low estimates of the apparent dissociation constant for all antagonists except tamsulosin indicate that an alpha(1L)-adrenoceptor mediates noradrenaline-induced prostatic smooth muscle contraction in the guinea-pig prostate gland.

Binding and functional characterization of alpha1-adrenoceptor subtypes in the rat prostate

The alpha1-adrenoceptor subtypes of rat prostate were characterized in binding and functional experiments. In binding experiments, [3H]tamsulosin bound to a single class of binding sites with an affinity (pKD) of 10.79+/-0.04 and Bmax of 87+/-2 fmol mg(-1) protein. This binding was inhibited by prazosin, 2-(2,6-dimethoxy-phenoxyethyl)-aminomethyl-1,4-benzodioxane hydrochloride (WB4101), 5-methylurapidil, alpha-ethyl-3,4,5,-trimethoxy-alpha-(3-((2-(2-methoxyphenoxy)ethyl)-amin o)-propyl)benzeneacetonitrile fumarate (HV723) and oxymetazoline with high efficacy, resulting in a good correlation with the binding characteristics of cloned alpha1a but not alpha1b and alpha1d-adrenoceptor subtypes. In functional studies, noradrenaline and oxymetazoline produced concentration-dependent contractions. These contractions were antagonized by tamsulosin, prazosin, WB4101 and 5-methylurapidil with an efficacy lower than that exhibited by these agents for inhibition of [3H]tamsulosin binding. The relationship between receptor occupancy and contractile amplitude revealed the presence of receptor reserve for noradrenaline, but the contraction induced by oxymetazoline was not in parallel with receptor occupation and developed after predicted receptor saturation. From these results, it is suggested that alpha1A-adrenoceptors are the dominant subtype in the rat prostate which can be detected with [3H]tamsulosin, but that the functional subtype mediating adrenergic contractions has the characteristics of the alpha1L-adrenoceptor subtype, having a lower affinity for prazosin and some other drugs than the alpha1A-adrenoceptor subtype.

A placebo controlled double blind study using perioperative prazosin in the prevention of urinary retention following inguinal hernia repair

Acute urinary retention is a frequent complication following inguinal hernia repair. The smooth muscle of the bladder neck and the prostate have been demonstrated to be rich in alpha-1 adrenergic receptors. It has been postulated that the aetiology of acute urinary retention postoperatively is at least partially due to adrenergic stimulation; blocking these receptors may reduce the incidence of acute urinary retention. We have used prazosin in a double blind, placebo controlled study to establish its efficacy in the prevention of acute urinary retention in patients undergoing elective inguinal hernia repair. A total of 70 male patients were enrolled; 36 patients had been allocated active drug and 34 patients had been allocated placebo. Only two patients developed acute urinary retention. Both patients had been allocated prazosin and had received a general anaesthetic for their hernia surgery. In either arm of the study, a higher number of patients developing urinary retention would have been expected but this may be explained by the greater vigilance on urinary output by nursing staff aware that the trial was being conducted. On the basis of our findings, we do not recommend the routine use of perioperative prazosin with inguinal hernia repair. Further studies in high risk groups would be necessary to assess more fully the efficacy of prazosin in this situation.

Identification of alpha 1-adrenoceptor subtypes in the rabbit prostate

1. The alpha 1-adrenoceptor subtypes of rabbit prostate were characterized in binding and functional experiments. 2. In saturation experiments, [3H]-prazosin bound to two distinct affinity sites in the rabbit prostate (pKD = 11.20 +/- 0.22 and 8.39 +/- 0.11, Bmax = 15.3 and 736 fmol mg protein-1). 3. In the displacement experiments, the binding was inhibited with shallow displacement curves by unlabelled prazosin, WB4101, and 5-methylurapidil, suggesting the presence of two distinct affinity sites for prazosin, WB4101, or 5-methylurapidil. On the other hand, HV723 displaced the [3H]-prazosin binding monophasically with a low affinity. From the results, the presence of two distinct alpha 1-adrenoceptor subtypes was suggested; presumably one is the classical alpha 1A (cloned alpha 1C) subtype with high affinity for prazosin, WB4101 and 5-methylurapidil but not for HV723 and the other corresponds to the alpha 1L subtype, which shows low affinity for the four antagonists. 4. In the functional experiments, prazosin, WB4101, HV723 and 5-methylurapidil competitively antagonized the contractile response to noradrenaline with low affinities close to those for the alpha 1L subtype determined in binding experiments. These results suggest that contractile response to noradrenaline in the rabbit prostate is predominantly mediated through the alpha 1L subtype.

The alpha 1C-adrenoceptor in human prostate: cloning, functional expression, and localization to specific prostatic cell types

1. Benign prostatic hyperplasia (BPH) causes urinary obstruction in aging men that frequently requires surgery to relieve the symptoms of urinary retention, nocturia, and micturition. Smooth muscle tone which contributes to the urethral constriction in the enlarged gland appears to be mediated by the alpha 1-adrenoceptors. In this paper, molecular and pharmacological approaches are used to establish the role played by the alpha 1C-adrenoceptor subtype in the prostate. 2. The alpha 1-adrenoceptor subtype(s) expressed in human prostate were investigated by use of polymerase chain reaction (PCR), Northern blot, and in situ hybridization. The alpha 1C subtype was found in both prostate stromal and glandular cells while alpha 1B and alpha 1D subtypes were expressed in glandular cells. High expression levels for alpha 1C were observed in prostate cancer tissues in both stroma and glandular cells. 3. Full length alpha 1C-adrenoceptor cDNA was cloned from human prostate. Stable mammalian cell lines expressing human alpha 1B-, alpha 1C-, and alpha 1D-adrenoceptors were made. Membranes prepared from these cell lines and human prostate were used to evaluate the pharmacological profiles of human alpha 1B-, alpha 1C- and alpha 1D-adrenoceptors in comparison to human prostate. Leverage plot analysis of compound affinities determined by competition for [125I]-I-HEAT binding demonstrated that the alpha 1C subtype is the predominant alpha 1-adrenoceptor in human prostate. 4. The alpha 1-adrenoceptors cause smooth muscle constriction by coupling to IP3 turnover and intracellular Ca2+ release. Using stable cell lines to measure IP3 production in response to noradrenaline, alpha 1C stimulated IP3 production most efficiently, with alpha 1B at an intermediate level, while little IP3 above background could be detected with alpha 1D. These results supported a functional role of the alpha 1C-adrenoceptor on prostate smooth muscle constriction by noradrenaline stimulation.

Hypertension: are beta-blockers and diuretics appropriate first-line therapies?

OBJECTIVE

To review the existing data on the use of diuretics or beta-blockers as first-line therapy for the treatment of mild to moderate hypertension, and to examine the issues surrounding the impact of these classes as well as the angiotensin-converting enzyme (ACE) inhibitors, calcium-channel blockers (CCBs), alpha-blockers, and alpha-beta-blockers on cardiovascular risk factors and cardiovascular morbidity and mortality.

DATA SOURCES

A MEDLINE search of applicable articles on antihypertensive therapies and their impact on morbidity and mortality. In addition, a MEDLINE search of relevant articles regarding cardiovascular risk factors and the influence of the various antihypertensive therapies on these parameters.

DATA SYNTHESIS

The literature was evaluated with regard to outcome. Trials examining the impact of antihypertensive pharmacotherapy, primarily with diuretics and beta-blockers, have shown them to decrease the incidence of stroke by 33-50 percent. However, their effect on coronary heart disease has been disappointing, showing only a 14 +/- 5 (mean +/- SD) percent decrease. Examination of numerous clinical trials assessing the impact of the various antihypertensive therapies on cardiovascular risk factors, including blood pressure, plasma lipids, diabetic control/insulin sensitivity, and left ventricular hypertrophy was done. The classes included beta-blockers, diuretics, alpha-blockers, ACE inhibitors, and CCBs; the results show a diversity of effect. Diuretics and beta-blockers tend to worsen cardiovascular risk status, whereas the alpha-blockers, ACE inhibitors, and CCBs all show a beneficial effect.

CONCLUSIONS

Diuretics and beta-blockers can effectively reduce cerebrovascular morbidity and mortality, but have a limited effect on reducing cardiovascular disease, especially myocardial infarction. This may be explained, at least in part, by the negative, or lack of positive, effect on individual patients' overall cardiovascular risk status.

Characterization of alpha 1-adrenoceptor subtypes in prostate and prostatic urethra of rat, rabbit, dog and man

The alpha 1-adrenoceptor subtypes present in the smooth muscle of urethra and prostate of different animal species, including man, were characterized by using receptor binding techniques. In prostatic urethra and prostate membranes, [3H]prazosin labelled a single population of alpha 1-adrenoceptors (Hill coefficient not different from unity) with a high affinity in the range 0.21-0.51 nM. The number of specific [3H]prazosin binding sites was partially affected by chloroethylclonidine only in human and rat prostate membranes, whereas this agent proved practically devoid of activity in rabbit and dog prostate membranes as well as in the prostatic urethra membranes of all the animal species examined. These findings indicate that in prostatic and urethral membranes the alpha 1-adrenoceptors mainly belong to the alpha 1A subtype. The binding results were confirmed by in vitro functional studies on noradrenaline-induced contractions of rabbit and dog urethral preparations. The agonist-induced contractions were practically unaffected by preincubation of both tissues with chloroethylclonidine, but were sensitive to nifedipine. We found, moreover, a good correlation between the potency of different selective and non-selective alpha 1-adrenoceptor antagonists (WB-4101, 5-methylurapidil, phentolamine, spiperone, prazosin and urapidil) tested against the noradrenaline-induced contractions of rabbit urethra and their affinity for the alpha 1A-adrenoceptor subtype, no correlation with the affinity for the alpha 1B subtype, and a lower correlation with the affinity for the alpha 1C-adrenoceptor subtype.

Structure and function of alpha-adrenergic receptors

Alpha 1- and alpha 2-adrenergic receptors are the initial recognition sites on a wide variety of catecholamine-responsive target cells. This article addresses several major questions related to subtypes, structure, signal transduction mechanisms, and regulation of alpha 1- and alpha 2-adrenergic receptors. The application of biochemical and cell and molecular biologic techniques has provided many new insights regarding alpha-adrenergic receptors. Two (and perhaps three) distinct alpha 2-adrenergic receptor subtypes have been identified, and subtypes may exist for alpha 1-adrenergic receptors as well. These multiple subtypes imply much greater diversity among alpha-adrenergic receptors than among beta-adrenergic receptors. Alpha-adrenergic receptors are membrane glycoproteins with several common structural features (including seven membrane-spanning domains with extracellular amino terminus and intracellular carboxyl terminus) that are shared with other types of membrane receptors linked to guanine nucleotide-binding regulatory (G) proteins. These G proteins appear to link alpha-adrenergic receptors to multiple effector systems, including enzymes such as adenylate cyclase and phospholipases, and ion channels. The receptors themselves are dynamic entities, the number of which is regulated as a consequence of a poorly understood life cycle. Although unproven, it seems likely that several important clinical disorders represent alterations in alpha-adrenergic receptors themselves or in the G proteins or effector systems to which these receptors couple. New tools for studying receptor structure and function should help clarify the numerous, inadequately understood issues regarding alpha-adrenergic receptors and their possible alteration in disease states.