Sildenafil citrate in combination with tamsulosin versus tamsulosin monotherapy for management of male lower urinary tract symptoms due to benign prostatic hyperplasia: A randomised, double-blind, placebo-controlled trial

Medical Advancements in Benign Prostatic Hyperplasia Treatments

PURPOSE OF REVIEW

This review aims to identify and summarize the current literature on the most recent therapeutic agents and combination strategies for the medical management of lower urinary tract symptoms resulting from benign prostatic hyperplasia.

RECENT FINDINGS

The latest advancements in BPH therapy have been in combination strategies. Alpha blockers continue to be the mainstay of treatment, but research is exploring the synergistic benefits of combining them with 5-alpha reductase inhibitors (5-ARIs), phosphodiesterase-5 (PDE5) inhibitors, and beta-3 agonists. The alpha-blocker + 5-ARI combination remains ideal for enlarged, significantly reducing clinical progression risk compared to monotherapy. Alpha-blocker + PDE5 inhibitor combinations appear safe and potentially beneficial for men with concomitant erectile dysfunction; sildenafil might hold an edge over tadalafil based on limited data. Beta-3 agonists show synergistic effects with alpha blockers for residual storage symptoms, offering similar efficacy to anticholinergics but with a better side effect profile.

Validation of the Arabic linguistic version of the Danish Prostatic Symptom Score for benign prostatic hyperplasia associated with lower urinary tract symptoms

Objective: To validate an Arabic version of the Danish Prostatic Symptom Score (DAN-PSS), a self-administered quality-of-life questionnaire.

Patients and methods: The reliability of the Arabic DAN-PSS was assessed by determining the internal consistency (Cronbach’s α coefficient) and by assessing the test–retest reliability (Kappa [κ] test). Inter-domain associations were examined using Spearman’s correlation coefficient (r). The discrimination validity was evaluated using receiver operating characteristic (ROC) curves. The sensitivity to change of the questionnaire and its individual items was assessed before and after intervention using a paired t-test.

Results: In all, 106 men (55 patients with BPH and 51 without BPH symptoms) were included. A high level of internal consistency amongst the three domains of the answered Arabic DAN-PSS questionnaire was observed (Cronbach’s α > 0.70). Also, there was a good correlation between storage and voiding (r = 0.75; P < 0.001) and post-micturition symptoms domains (r = 0.51; P < 0.001). Voiding and post-micturition symptoms domains also had a good correlation (r = 0.51; P < 0.001). The agreement between the test and retest scores had a κ value of 0.83 (P < 0.001). The ROC curve had an area under the curve of 0.98. The sensitivity to change comparing patients with BPH who received medical or surgical intervention revealed Arabic DAN-PSS mean (SD) scores of 34.7 (17.7) and 17 (8.7) before and after the intervention, respectively (P < 0.001).

Conclusion: The Arabic DAN-PSS is a clear questionnaire, valid, reliable, and responsive that can be used for BPH associated with lower urinary tract symptoms assessment and follow-up in clinical practice and research in Arabic-speaking patients.

Abbreviations: AUC: area under the curve; BPH: benign prostatic hyperplasia; CI: confidence interval; DAN-PSS: Danish Prostatic Symptom Score; DRE: digital rectal examination; ICIQ-MLUTS: International Consultation on Incontinence Male LUTS Questionnaire; ICS: international continence society; IPSS: international Prostatic Symptom Score; IPSS-Arb: Arabic version of the IPSS; LUTS: lower urinary tract symptoms; PSA: prostatic specific antigen; PSS: prostatic symptom score; QoL: quality of life; ROC: receiver operating characteristic; UTI: urinary tract infection.

Efficacy and Safety of Combination Comprising Tamsulosin and PDE5-Is, Relative to Monotherapies, in Treating Lower Urinary Tract Symptoms and Erectile Dysfunction Associated With Benign Prostatic Hyperplasia: A Meta-Analysis

We report safety and efficacy of a combination therapy, comprising tamsulosin and phosphodiesterase type 5 inhibitors (PDE5-Is), relative to monotherapy, to ascertain its potential in treating lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) secondary to benign prostatic hyperplasia (BPH) after 3 months’ treatment. We screened MEDLINE, EMBASE, and the Cochrane Controlled Trials Register databases, for randomized controlled trials, and obtained eight articles comprising 1144 participants. Results showed that the combination group had superior outcomes with regard to International Prostate Symptom Score (IPSS) and Qmax, compared to the other two groups. The combination group also had superior efficacy with regard to International Index of Erectile Function (IIEF) than the tamsulosin group, but not over the PDE5-Is group. Further, the combination group showed better efficacy in IPSS voiding and quality of life (QoL) compared to the PDE5-Is group. An analysis of safety outcomes revealed extremely high adverse events (AEs) and pain in the combination group. However, therapy discontinuation due to pain and AEs did not increase with increase in AEs. Overall, our findings indicate that a combination of tamsulosin and PDE5-Is is superior to individual tamsulosin and PDE5-Is monotherapy, with regard to improving LUTS and ED secondary to BPH.

Efficacy and tolerability of combination therapy with alpha-blockers and phosphodiesterase-5 inhibitors compared with monotherapy for lower urinary tract symptoms: Protocol for a systematic review and network meta-analysis

PURPOSE

This study aimed to compare the efficacy and safety of combination therapy consisting of α-blockers and different phosphodiesterase type 5 inhibitors for lower urinary tract symptoms (LUTS) by performing a network meta-analysis.

METHOD

Relevant articles were retrieved from the Cochrane Library, PubMed, and EMBASE databases. Bayesian network meta-analyses were performed with a random-effect model to compare the efficacy and safety of combination therapy with α-blockers and phosphodiesterase-5 inhibitors for LUTS. The odds ratio (OR), mean difference (MD) and surface under the cumulative ranking curve (SUCRA) were calculated with the GeMTC R package.

RESULTS

Twenty randomized trials with 4131 patients were included in this network meta-analysis. Based on the SUCRA values, vardenafil (10 mg) combined with α-blockers ranked first, first and sixth; sildenafil (25 mg) combined with α-blockers ranked second, third and first; and tadalafil (20 mg) combined with α-blockers ranked third, second and fourth in IPSS, post void residual, and maximum flow rate, respectively.

CONCLUSIONS

Combination therapy with α-blockers and phosphodiesterase-5 inhibitors was effective and well tolerated for LUTS. For men who prioritize high efficacy, vardenafil (10 mg) combined with α-blockers seems to be the treatment of choice. For men wishing to optimize minimally invasive treatment, sildenafil (25 mg) and tadalafil (20 mg) combined with α-blockers appears to have a possible advantage in terms of avoiding adverse effects.

Defining the Efficacy and Safety of Phosphodiesterase Type 5 Inhibitors with Tamsulosin for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia with or without Erectile Dysfunction: A Network Meta-Analysis

Purpose

The purpose of this study was to compare the relative safety and efficacy of different types of phosphodiesterase type 5 inhibitors (PDE5-Is) with tamsulosin for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH) (BPH-LUTS) with or without erectile dysfunction (ED).

Methods

We use the Stata version 13.0 to conduct the network meta-analysis (NMA) with a random effects model of the Bayesian framework. The International Prostate Symptom Score (IPSS), Maximum Urinary Flow Fate (Q_max), International Index of Erectile Function (IIEF), and their credible intervals (CI) were used to compare the efficacy and safety of every medical intervention, including sildenafil plus tamsulosin, tadalafil plus tamsulosin, and vardenafil plus tamsulosin.

Results

Seven RCTs including 531 participants with seven interventions were analyzed. The results of NMA SUCRA showed that compared with different doses or types of PDE5-Is combined with tamsulosin (0.4 mg qd), the sildenafil (25 mg qd) combined with tamsulosin (0.4 mg qd) group had the greatest probabilities of being the best in the achievement of improving IIEF. The sildenafil (25 mg 4 days per week) combined with tamsulosin (0.4 mg qd) group had the greatest probabilities of being the best in the achievement of improving Q_max, whereas sildenafil (25 mg qd) combined with tamsulosin (0.4 mg qd) ranked the best for the safety outcomes.

Conclusions

This meta-analysis indicates that sildenafil combined with tamsulosin is the best effective and tolerated treatment option for BPH-LUTS with or without ED. Further RCTs are strongly required to provide more direct evidence.

Placebo Responses Among Men With Erectile Dysfunction Enrolled in Phosphodiesterase 5 Inhibitor Trials: A Systematic Review and Meta-analysis

IMPORTANCE

Placebo responses in the treatment of erectile dysfunction (ED) are poorly described in the literature to date.

OBJECTIVE

To quantify the association of placebo with ED outcomes among men enrolled in placebo-controlled, phosphodiesterase 5 inhibitor (PDE5I) trials.

DATA SOURCES

For this systematic review and meta-analysis, a database search was conducted to identify double-blind, placebo-controlled studies using PDE5Is for the treatment of ED published from January 1, 1998, to December 31, 2018, within MEDLINE, Embase, Cochrane Library, and Web of Science. Only articles published in the English language were included.

STUDY SELECTION

Double-blind, placebo-controlled randomized clinical trials of PDE5Is for ED were included. Studies were excluded if they did not provide distribution measures for statistical analysis. Study selection review assessments were conducted by 2 independent investigators. A total of 2215 studies were identified from the database search, and after review, 63 studies that included 12 564 men were analyzed.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in abstracting data and assessing validity. Data were extracted from published reports by 2 independent reviewers. Quality assessment was performed using the Jadad scale. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The main outcome was improvement in the erectile function domain of the International Index of Erectile Function questionnaire in the placebo arm of the included studies. Effect size was reported as bias-corrected standardized mean difference (Hedges g). The hypothesis was formulated before data extraction.

RESULTS

A total of 63 studies that included 12 564 men (mean [SD] age, 55 [7] years; age range, 36-68 years) were included. Erectile function was significantly improved among participants in the placebo arm, with a small to moderate effect size (Hedges g [SE], 0.35 [0.03]; P < .001). Placebo effect size was larger among participants with ED associated with posttraumatic stress disorder (Hedges g [SE], 0.78 [0.32]; P = .02) compared with the overall analysis. No significant difference was found between placebo and PDE5Is for ED after prostate surgery or radiotherapy (Hedges g [SE], 0.30 [0.17]; P = .08).

CONCLUSIONS AND RELEVANCE

In this study, placebo was associated with improvement of ED, especially among men with ED-related posttraumatic stress disorder. No difference was found between placebo and PDE5I among men treated for ED after prostate surgery.

Emerging drugs to target lower urinary tract symptomatology (LUTS)/benign prostatic hyperplasia (BPH): focus on the prostate

OBJECTIVES

The benign prostatic syndrome, comprising lower urinary tract symptomatology secondary to benign prostatic hyperplasia/enlargement, represents a major health care issue in westernized countries. The pharmacological management involves alpha-adrenoceptor antagonists, intervention into the hormonal control of prostate growth using inhibitors of the enzyme 5-alpha-reductase, and stimulation of the nitric oxide/cyclic GMP pathway by tadalafil, an inhibitor of the phosphodiesterase type 5.

METHODS

This review summarizes the achievements which have been made in the development of drug candidates assumed to offer opportunities as beneficial treatment options in the management of the benign prostatic syndrome.

RESULTS

A review of the literature has revealed that the line of development is focusing on drugs interfering with peripheral neuromuscular/neuronal mechanisms (nitric oxide donor drugs, agonists/antagonists of endogenous peptides, botulinum toxin, NX-1207), the steroidal axis (cetrorelix) or the metabolic turn-over (lonidamine), as well as the combination of drugs already established in the treatment of lower urinary tract symptomatology/benign prostatic hyperplasia (phosphodiesterase 5 inhibitor plus alpha-adrenoceptor antagonist).

CONCLUSION

Many research efforts have provided the basis for the development of new therapeutic modalities for the management of lower urinary tract dysfunctions, some of which might be offered to the patients in the near future.

Study of phosphodiesterase 5 inhibitors and α-adrenoceptor antagonists used alone or in combination for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia

INTRODUCTION

This study sought to compare the improvement in lower urinary tract symptoms (LUTS) and complications of phosphodiesterase type 5 inhibitors (PDE5i) and alpha-blockers (Abs) in combination or alone among males with benign prostatic hyperplasia (BPH).

EVIDENCE ACQUISITION

We searched the PubMed, Embase, and Cochrane Library databases to identify all studied variables, including lower urinary tract symptoms (LUTS), BPH, Abs, and PDE5i and performed comparisons between combination treatment and single treatments as primary endpoints. Efficacy analysis including the International Prostate Symptom Score (IPSS), quality of life (QOL), maximum urinary flow rate (Qmax), postvoiding residual volume (PVR), and International Index of Erectile Function erectile function domain (IIEF-EF) score. Complications were also recorded. In addition, the secondary endpoint was a comparison of the efficacy and complications between the two single treatments.

EVIDENCE SYNTHESIS

Nineteen studies involving 2,426 patients met the inclusion criteria. The data synthesized from these studies indicated that the combination treatment is better in efficiency than PDE5i or Abs alone in including IPSS (P<0.00001 in PDE5i; P=0.01 in Abs), QOL (P<0.00001 in PDE5i; P<0.00001 in Abs), Qmax (P<0.00001 in PDE5i; P<0.00001 in Abs), PVR (P=0.04 in PDE5i; P<0.00001 in Abs), and IIEF-EF (P<0.00001 in PDE5i; P<0.00001 in Abs). Regarding complications, only headache (P<0.00001), dyspepsia (P=0.01), and flushing (P=0.04) were more frequent in individuals undergoing the combination treatment.

CONCLUSIONS

Combination treatment is more effective than PDE5i or Abs alone, though the side effects are not significantly different.

Combination Therapy with Alpha-blocker and Phosphodiesterase-5 Inhibitor for Improving Lower Urinary Tract Symptoms and Erectile Dysfunction in Comparison with Monotherapy: A Systematic Review and Meta-analysis

CONTEXT

The effects of combination therapy consisted of an α-blocker and a phosphodiesterase-5 inhibitor (PDE5I) for the treatment of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED).

OBJECTIVE

To systematically investigate the efficacy and safety of combination therapy in comparison with monotherapy.

EVIDENCE ACQUISITION

The study complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and the recommendations of the European Association of Urology Guidelines office. The study was registered in the PROSPERO database with ID CRD42018086619. Only comparative prospective studies, randomized or quasirandomized, with at least one control group with monotherapy were selected for the meta-analysis. The primary endpoint was the quality of life related to LUTS and ED, measured with the International Prostate System Score (IPSS), maximum flow rate (Qmax), postvoid residual (PVR), and International Index of Erectile Function (IIEF). Secondary endpoints included the adverse events rate. In the subgroup analysis of the influence of adding a PDE5I to the treatment of LUTS, the use of different PDE5Is was considered.

EVIDENCE SYNTHESIS

After the screening of 6687 publications, 25 randomized controlled trials were considered eligible to be included in the meta-analysis. In the combination group, IPSS was lower and Qmax was higher than in the α-blocker group, with mean differences (MDs) of 1.41 (95% confidence interval [CI]: 0.42, 2.41; I² = 71%, p =  0.005) and -1.01 ml/s (95% CI: -1.58, -0.43; I² = 58%, p =  0.0006), respectively. The mean change of the IPSS was bigger in the combination group, with an MD of -1.72 (95% CI: -2.55, -0.89; I² = 37%, p <  0.0001). The mean change of Qmax was insignificant, with an MD of -0.61 (95% CI: -1.57, 0.34; I² = 63%, p =  0.21), as well as PVR and the mean change of PVR, with MDs of 0.65 (95% CI: -5.37, 6.66; I² = 76%, p =  0.83) and -20.79 (95% CI: -48.94, 7.37; I² = 75%, p =  0.15), respectively. The IIEF and the mean change of the IIEF had no difference between the combination group and the PDE5I-monotherapy group, with MDs of 1.82 (95% CI: -0.91, 4.54; I² = 40%, p =  0.19) and 0.25 (95% CI: -1.11, 1.62; I² = 47%, p =  0.72), respectively. Regarding the adverse events, the meta-analysis was in favor of monotherapy. None of the studies reported any serious or severe adverse event.

CONCLUSIONS

Treatment with combination therapy is more effective for the improvement of the IPSS. Less significant improvement was shown in Qmax. The beneficial effect of combination therapy regarding ED remains equivocal. The combination therapy seemed to be safe and well tolerated.

PATIENT SUMMARY

In this study, we review the effects of the combination therapy consisting of an α-blocker and a phosphodiesterase-5 inhibitor for the treatment of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). We found strong evidence to suggest the combination therapy for the improvement of LUTS. Benefits regarding the treatment of ED are less clear.

Alpha-blockers with or without phosphodiesterase type 5 inhibitor for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review and meta-analysis

PURPOSE

Recently, several randomized controlled trials (RCTs) explored the effects of α-blockers with or without phosphodiesterase type 5 inhibitors (PDE5-Is) for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). However, the results were inconsistent. We performed this meta-analysis to evaluate the role of combination therapy (α-blockers and PDE5-Is) in patients with LUTS/BPH.

MATERIALS AND METHODS

Databases including PubMed, Cochrane library, Web of Science, and Embase were searched for qualified RCTs. Pooled mean differences (MDs) and odds ratios (ORs) were calculated to measure the effects and adverse events in combination therapy. Moreover, subgroup analyses of ethnicity, dosage of PDE5-Is, treatment duration, and severity of LUTS/BPH were performed. In addition, trial sequential analyses (TSAs) were used to assess whether the evidence for the results was sufficient.

RESULTS

Overall, this study identified 11 eligible RCTs, including 855 LUTS/BPH patients. Patients receiving combination therapy had better improvement in international prostate symptom score (IPSS: MD: 1.66, 95% CI - 3.03 to - 0.29), maximum urinary flow rate (Q_max: MD: 0.94, 95% CI 0.24-1.64), and international index of erectile function (IIEF: MD: 4.73, 95% CI 2.95-6.51), comparing those without PDE5-Is. Besides, subgroup analyses indicated that the effects of combination treatment were associated with ethnicity, treatment duration, and severity of LUTS/BPH. By TSA, the findings in the current study were based on sufficient evidence.

CONCLUSIONS

Our results indicated that combination therapy can significantly improve IPSS, Q_max, and IIEF in patients with LUTS/BPH. Combination therapy might be more suitable for these patients.