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Pattanaik S, Mavuduru RS, Panda A, Mathew JL, Agarwal MM, Hwang EC, Lyon JA, Singh SK, Mandal AK. Phosphodiesterase inhibitors for lower urinary tract symptoms consistent with benign prostatic hyperplasia. Cochrane Database Syst Rev 2018; 11:CD010060. [PMID: 30480763 PMCID: PMC6517182 DOI: 10.1002/14651858.cd010060.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Benign prostatic hyperplasia (BPH) refers to non-malignant enlargement of the prostate gland that may cause bothersome lower urinary tract symptoms (LUTS). Alpha-blockers (ABs) and 5-alpha reductase inhibitors (5-ARIs) are the mainstay of medical treatment. Recently, phosphodiesterase inhibitors (PDEIs) that so far have been used mainly to treat erectile dysfunction were introduced to treat male LUTS. OBJECTIVES To assess the effects of PDEIs compared to placebo and other standard of care drugs (ABs and 5-ARIs) in men with LUTS consistent with BPH. SEARCH METHODS We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and clinical trials registries of the World Health Organization (WHO) and the National Institutes of Health (NIH) (updated 2 August 2018). We performed citation tracking and handsearching of abstracts and conference proceedings. We also contacted study authors to ask for additional information. SELECTION CRITERIA We considered for inclusion in this systematic review randomised controlled trials (RCTs) comparing PDEIs versus placebo, ABs, or 5-ARIs for at least four weeks in men with BPH-LUTS. DATA COLLECTION AND ANALYSIS Three review authors independently screened the literature and extracted data. Primary outcomes were effects on urinary symptoms as assessed by the International Prostate Symptom Score (IPSS-total; score ranging from 0 to 35, with higher values reflecting more symptoms), urinary bother as assessed by the Benign Prostatic Hyperplasia Impact Index (BPHII; score ranging from 0 to 13, with higher values reflecting more bother), and adverse events (AEs). We used GRADE to rate the quality of evidence. We considered short-term (up to 12 weeks) and long-term (12 weeks or longer) results separately. MAIN RESULTS We included a total of 16 randomised trials in this review. The results for primary outcomes are as follows.PDEI versus placebo: PDEIs may result in a small improvement in IPSS-total score (mean difference (MD) 1.89 lower, 95% confidence interval (CI) 2.27 lower to 1.50 lower; n = 4293; low-quality evidence) compared to placebo, and may reduce the BPHII score slightly (MD 0.52 lower, 95% CI 0.71 lower to 0.33 lower; n = 3646; low-quality evidence). Rates of AEs may be increased (risk ratio (RR) 1.42, 95% CI 1.21 to 1.67; n = 4386; low-quality evidence). This corresponds to 95 more AEs per 1000 participants (95% CI 47 more to 151 more per 1000). Study results were limited to a treatment duration of six to 12 weeks.PDEI versus AB: PDEIs and ABs probably provide similar improvement in IPSS-total score (MD 0.22 higher, 95% CI 0.49 lower to 0.93 higher; n = 933; moderate-quality evidence) and may have a similar effect on BPHII score (MD 0.03 higher, 95% CI 1.10 lower to 1.16 higher; n = 550; low-quality evidence) and AEs (RR 1.35, 95% CI 0.80 to 2.30; n = 936; low-quality evidence). This corresponds to 71 more AEs per 1000 participants (95% CI 41 fewer to 264 more per 1000). Study results were limited to a treatment duration of six to 12 weeks.PDEI and AB versus AB alone: the combination of PDEI and AB may provide a small improvement in IPSS-total score (MD 2.56 lower, 95% CI 3.92 lower to 1.19 lower; n = 193; low-quality evidence) compared to AB alone. We found no evidence for BPHII scores. AEs may be increased (RR 2.81, 95% CI 1.53 to 5.17; n = 194; moderate-quality evidence). This corresponds to 235 more AEs per 1000 participants (95% CI 69 more to 542 more per 1000). Study results were limited to treatment duration of four to 12 weeks.PDEI and AB versus PDEI alone: the combination of PDEI and AB may provide a small improvement in IPSS-total (MD 2.4 lower, 95% CI 6.47 lower to 1.67 higher; n = 40; low-quality evidence) compared to PDEI alone. We found no data on BPHII or AEs. Study results were limited to a treatment duration of four weeks.PDEI and 5-ARI versus 5-ARI alone: in the short term (up to 12 weeks), the combination of PDEI and 5-ARI probably results in a small improvement in IPSS-total score (MD 1.40 lower, 95% CI 2.24 lower to 0.56 lower; n = 695; moderate-quality evidence) compared to 5-ARI alone. We found no evidence on BPHII scores or AEs. In the long term (13 to 26 weeks), the combination of PDEI and 5-ARI likely results in a small reduction in IPSS-total score (MD 1.00 less, 95% CI 1.83 lower to 0.17 lower; n = 695; moderate-quality evidence). We found no evidence about effects on BPHII scores. There may be no difference in rates of AEs (RR 1.07, 95% CI 0.84 to 1.36; n = 695; low-quality evidence). This corresponds to 19 more AEs per 1000 participants (95% CI 43 fewer to 98 more per 1000).We found no trials comparing other combinations of treatments or comparing different PDEI agents. AUTHORS' CONCLUSIONS Compared to placebo, PDEI likely leads to a small reduction in IPSS-total and BPHII sores, with a possible increase in AEs. There may be no differences between PDEI and AB with regards to improvement in IPSS-total, BPHII, and incidence of AEs. There appears to be no added benefit of PDEI combined with AB compared to PDEI or AB alone or PDEI combined with 5-ARI compared to ARI alone with regards to urinary symptoms. Most evidence was limited to short-term treatment up to 12 weeks and of moderate or low certainty.
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Affiliation(s)
- Smita Pattanaik
- Post Graduate Institute of Medical Education and ResearchDepartment of PharmacologyChandigarhIndia160012
| | - Ravimohan S Mavuduru
- Post Graduate Institute of Medical Education and ResearchDepartment of UrologyChandigarhIndia
| | - Arabind Panda
- Christian Medical CollegeDepartment of UrologyVelloreIndia
| | - Joseph L Mathew
- Post Graduate Institute of Medical Education and ResearchDepartment of PediatricsChandigarhIndia160012
| | - Mayank M Agarwal
- Post Graduate Institute of Medical Education and ResearchDepartment of UrologyChandigarhIndia
| | - Eu Chang Hwang
- Chonnam National University Medical School, Chonnam National University Hwasun HospitalDepartment of UrologyHwasunKorea, South
| | - Jennifer A Lyon
- Children's Mercy HospitalLibrary Services2401 Gillham RoadKansas CityMissouriUSA64118
| | - Shrawan K Singh
- Post Graduate Institute of Medical Education and ResearchDepartment of UrologyChandigarhIndia
| | - Arup K Mandal
- Post Graduate Institute of Medical Education and ResearchDepartment of UrologyChandigarhIndia
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Zhao C, Kwan Park J. Phosphodiesterase Type 5 Inhibitor and Erectile Dysfunction in Lower Urinary Tract Symptoms. Low Urin Tract Symptoms 2015; 4 Suppl 1:75-80. [PMID: 26676704 DOI: 10.1111/j.1757-5672.2011.00121.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Benign prostatic hyperplasia (BPH) is one of the most common diseases in older men and mostly induces lower urinary tract symptoms (LUTS). Multiple studies have shown that BPH inducing LUTS are intensely correlated with erectile dysfunction (ED) and that severity of LUTS was proportional to ED severity. Although a direct causal relationship has not been clarified, a tentative pathophysiology has been suggested to interpret the relationship between two disorders. Androgen plays an important role in the maintenance of the functional and structural integrity of the lower urinary tract and penis. Low testosterone, especially free testosterone, worsened detrusor overactivity and replacement of testosterone improved LUTS in the hypogonadal BPH patients. Nitric oxide synthase and nitric oxide are decreased in the transition zone of the hyperplastic prostate but phosphodiesterase types 4, 5, 11 are prominent in transition zone of hyperplastic prostate. Phosphodiesterase type 5 (PDE5) inhibitor with a long half-life could obtain the desired effect; therefore, tadalafil and undenafil frequently have been used to evaluate the effects in the two disorders. In clinical trials, tadalafil showed improvement of BPH-induced LUTS, but few of the studies showed a significant improvement on uroflowmetry. PDE5 inhibitors increase the concentration of cyclic guanosine monophosphate (cGMP) in plasma and smooth muscle, promoting erection of the penis, as well as relaxation of the bladder neck and prostate, leading to natural voiding. Sexual function and LUTS should be assessed and discussed with the patient when choosing the appropriate strategy and the patient's response to treatment should also be evaluated at the same time.
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Affiliation(s)
- Chen Zhao
- Department of Urology, Medical School, and Institute for Medical Sciences, and Research Institute of Chonbuk National University, Chonbuk National University Hospital, Jeonbuk, Korea
| | - Jong Kwan Park
- Department of Urology, Medical School, and Institute for Medical Sciences, and Research Institute of Chonbuk National University, Chonbuk National University Hospital, Jeonbuk, Korea
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Zhang LT, Park JK. Are phosphodiesterase type 5 inhibitors effective for the management of lower urinary symptoms suggestive of benign prostatic hyperplasia? World J Nephrol 2015; 4:138-147. [PMID: 25664256 PMCID: PMC4317624 DOI: 10.5527/wjn.v4.i1.138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 07/22/2014] [Accepted: 10/10/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To review the efficacy of phosphodiesterase type 5 inhibitors (PDE5-Is) in lower urinary tract symptoms (LUTS) suggestive of benign prostate hyperplasia (LUTS/BPH).
METHODS: A comprehensive research was conducted to identify all publications relating to benign prostate hyperplasia and treatment with sildenafil, vardenafil and tadalafil. To assess the efficacy, the changes in total international prostate symptom score (IPSS), IPSS subscore including voiding, storage and quality of life (QoL), Benign prostatic hyperplasia Impact Index (BII), maximum urinary flow rate (Qmax) and the International Index of Erectile Function (IIEF) were extracted. A meta-analytical technique was used for the analysis of integrated data from the included studies to evaluate the mean difference in the results.
RESULTS: Total IPSS score, IIEF and BII showed a significant improvement in trials in which LUTS/BPH with or without erectile dysfunction (ED) were compared with the placebo. For LUTS/BPH, the mean differences of total IPSS score, IIEF and BII are -2.17, 4.88 and -0.43, P < 0.00001, respectively. For LUTS/BPH with comorbid ED, the mean difference are -1.97, 4.54 and -0.52, P < 0.00001, respectively. PDE5-Is appear to improve IPSS storage, voiding and QoL subscore (mean difference = -0.71, -1.23 and -0.33, P < 0.00001, respectively). Although four doses of tadalafil (2.5, 5, 10 and 20 mg) failed to reach significance in Qmax (mean difference = 0.22, P = 0.10), the 5 mg dose of tadalafil significantly improved the Qmax (mean difference = 0.33, P = 0.03).
CONCLUSION: PED5-Is demonstrated efficacy for improving LUTS in BPH patients with or without ED and could be considered to be the first line treatment for LUTS/BPH.
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New Medical and Injectable Treatments for LUTS/BPH – Anticholinergics, PDE-5, and Botox. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0227-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kim SE, Ko IG, Hwang L, Choi IY, Shin MS, Kim CJ, Kim KH. An animal study to compare the degree of the suppressive effects on the afferent pathways of micturition between tamsulosin and sildenafil. J Biomed Sci 2013; 20:81. [PMID: 24160992 PMCID: PMC3871018 DOI: 10.1186/1423-0127-20-81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/21/2013] [Indexed: 01/18/2023] Open
Abstract
Background Tamsulosin, an α1-adrenoceptor antagonist, and sildenafil, a phosphodiesterase (PDE) inhibitor, are reported to improve lower urinary tract symptoms including overactive bladder (OAB). This study is aimed at investing the effects of tamsulosin and sildenafil and comparing the degree of the suppressive effects on the afferent pathways of micturition between them using an animal model of OAB, the spontaneously hypertensive rat (SHR). Results The cystometric parameters, the basal pressure and duration of bladder contraction, were significantly increased in the SHR group as compared with the Wistar-Kyoto (WKY) group. The intercontraction interval also significantly decreased in the SHR group. In the SHR-Tam 0.01 mg/kg group and the SHR-Sil 1 mg/kg group, however, the basal pressure and duration were significantly reduced and the intercontraction interval was significantly prolonged. Moreover, the degree of the expression of c-Fos and NGF was significantly higher in the SHR group as compared with the WKY group. But it was significantly reduced in the SHR-Tam 0.01 mg/kg group and the SHR-Sil 1 mg/kg group. Furthermore, tamsulosin had a higher degree of effect as compared with sildenafil. Conclusions In conclusion, α1-adrenergic receptor antagonists and PDE-5 inhibitors may have an effect in improving the voiding functions through an inhibition of the neuronal activity in the afferent pathways of micturition.
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Affiliation(s)
| | | | | | | | | | | | - Khae-Hawn Kim
- Department of Urology, Gil Medical Center, Gachon University, #1198 Guwol-dong, Namdong-gu, Incheon 405-760, Republic of Korea.
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[Medicinal therapy of benign prostate syndrome with phosphodiesterase-5 inhibitors]. Urologe A 2013; 52:204-11. [PMID: 23417046 DOI: 10.1007/s00120-012-3084-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Phosphodiesterase-5 (PDE5) inhibitors, such as sildenafil, tadalafil and vardenafil are first line treatment for erectile dysfunction (ED). These PDE5 inhibitors are known to increase cyclic guanosine monophosphate (cGMP) concentrations in the smooth muscle cells of the corpora cavernosa penis by inhibiting PDE5, leading to smooth muscle relaxation. This mode of action is also believed to result in prostatic smooth muscle relaxation and to improve lower urinary tract symptoms (LUTS). Randomized controlled trials have shown beneficial effects on LUTS and on objective parameters such as maximum urinary flow rate (tadalafil). Based on these data tadalafil was recently approved for treatment of patients with male LUTS; however, the mechanisms leading to improvement of symptoms are still under debate.
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Rahnama'i MS, Ückert S, Hohnen R, van Koeveringe GA. The role of phosphodiesterases in bladder pathophysiology. Nat Rev Urol 2013; 10:414-24. [DOI: 10.1038/nrurol.2013.101] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Giuliano F, Rouprêt M, Doridot G, de la Taille A. Effets des inhibiteurs de la phosphodiestérase de type 5 sur les symptômes du bas appareil urinaire associés à une hypertrophie bénigne de la prostate. Prog Urol 2013; 23:283-95. [DOI: 10.1016/j.purol.2012.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/24/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
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9
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Rahnama'i MS, van Koeveringe GA, Hohnen R, Ona S, van Kerrebroeck PE, de Wachter SG. Distribution of phosphodiesterase type 5 (PDE5) in the lateral wall of the guinea pig urinary bladder. BJU Int 2013; 112:246-57. [DOI: 10.1111/bju.12031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Ramona Hohnen
- European Graduate School of Neuroscience; Department of Psychiatry and Neuropsychology; Maastricht University; Maastricht; The Netherlands
| | - Samsya Ona
- Lehman College of The City University of New York; New York; NY; USA
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Scranton RE, Goldstein I, Stecher VJ. Erectile Dysfunction Diagnosis and Treatment as a Means to Improve Medication Adherence and Optimize Comorbidity Management. J Sex Med 2013; 10:551-61. [DOI: 10.1111/j.1743-6109.2012.02998.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ventura S, Oliver VL, White CW, Xie JH, Haynes JM, Exintaris B. Novel drug targets for the pharmacotherapy of benign prostatic hyperplasia (BPH). Br J Pharmacol 2011; 163:891-907. [PMID: 21410684 DOI: 10.1111/j.1476-5381.2011.01332.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Benign prostatic hyperplasia (BPH) is the major cause of lower urinary tract symptoms in men aged 50 or older. Symptoms are not normally life threatening, but often drastically affect the quality of life. The number of men seeking treatment for BPH is expected to grow in the next few years as a result of the ageing male population. Estimates of annual pharmaceutical sales of BPH therapies range from $US 3 to 10 billion, yet this market is dominated by two drug classes. Current drugs are only effective in treating mild to moderate symptoms, yet despite this, no emerging contenders appear to be on the horizon. This is remarkable given the increasing number of patients with severe symptoms who are required to undergo invasive and unpleasant surgery. This review provides a brief background on prostate function and the pathophysiology of BPH, followed by a brief description of BPH epidemiology, the burden it places on society, and the current surgical and pharmaceutical therapies. The recent literature on emerging contenders to current therapies and novel drug targets is then reviewed, focusing on drug targets which are able to relax prostatic smooth muscle in a similar way to the α(1) -adrenoceptor antagonists, as this appears to be the most effective mechanism of action. Other mechanisms which may be of benefit are also discussed. It is concluded that recent basic research has revealed a number of novel drug targets such as muscarinic receptor or P2X-purinoceptor antagonists, which have the potential to produce more effective and safer drug treatments.
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Affiliation(s)
- S Ventura
- Medicinal Chemistry and Drug Action, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
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Corona G, Mondaini N, Ungar A, Razzoli E, Rossi A, Fusco F. Phosphodiesterase type 5 (PDE5) inhibitors in erectile dysfunction: the proper drug for the proper patient. J Sex Med 2011; 8:3418-32. [PMID: 21995676 DOI: 10.1111/j.1743-6109.2011.02473.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Erectile dysfunction (ED) is a very common multidimensional disorder affecting men worldwide. Physical illness, reaction to life stresses, or an unhappy couple relationship influence clinical outcome. Phosphodiesterase type 5 (PDE5) inhibitors are recognized as efficacious and well tolerated, and are the first-line treatment for ED. Sildenafil, tadalafil, and vardenafil are the most widely used and studied PDE5 inhibitors. Data acquired during a routine diagnostic workup for ED should be taken into account when choosing the best PDE5 inhibitor for the individual patient, creating an individualized treatment plan, and going beyond "experience-based" subjective opinion and unfounded ideas and prejudice regarding currently available drugs. AIM As the process of matching a given patient's profile to any selected PDE5 inhibitor often relies more on physician's personal convictions than on solid evidence, the aim of this review is to identify the main clinical, demographic, and relational factors influencing the choice of the PDE5 inhibitor to be used for the treatment of ED. METHODS A systematic literature search and current treatment guidelines were evaluated in a systematic manner. MAIN OUTCOME MEASURES The main clinical, cultural, and demographical factors to be considered for the treatment of ED have been identified. RESULTS Main factors influencing the choice of the treatment for ED have been described. A short list of items that may help in choosing the right PDE5 inhibitor for the treatment of different patients in daily clinical practice has been prepared. CONCLUSIONS The simple algorithms prepared should be a useful tool to be used in daily practice, which may help in choosing the right treatment for each subject affected by ED.
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Affiliation(s)
- Giovanni Corona
- Andrology and Sexual Medicine Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy
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Morelli A, Sarchielli E, Comeglio P, Filippi S, Mancina R, Gacci M, Vignozzi L, Carini M, Vannelli GB, Maggi M. Phosphodiesterase Type 5 Expression in Human and Rat Lower Urinary Tract Tissues and the Effect of Tadalafil on Prostate Gland Oxygenation in Spontaneously Hypertensive Rats. J Sex Med 2011; 8:2746-60. [DOI: 10.1111/j.1743-6109.2011.02416.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kloner RA, Comstock G, Levine LA, Tiger S, Stecher VJ. Investigational noncardiovascular uses of phosphodiesterase-5 inhibitors. Expert Opin Pharmacother 2011; 12:2297-313. [DOI: 10.1517/14656566.2011.600306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Martínez-Salamanca JI, Carballido J, Eardley I, Giuliano F, Gratzke C, Rosen R, Salonia A, Stief C. Phosphodiesterase type 5 inhibitors in the management of non-neurogenic male lower urinary tract symptoms: critical analysis of current evidence. Eur Urol 2011; 60:527-35. [PMID: 21684677 DOI: 10.1016/j.eururo.2011.05.054] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 05/30/2011] [Indexed: 11/15/2022]
Abstract
CONTEXT A large body of epidemiologic data suggests a causal relationship between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). Recently reported studies on phosphodiesterase type 5 inhibitors (PDE5-Is) and LUTS have further contributed to the understanding of mechanisms involved in this relationship and of potential treatment options. OBJECTIVE A nonsystematic descriptive review was performed to summarize the literature concerning the role of PDE5-Is in men with LUTS, particularly looking at data derived from clinical trials in relation to the different PDE5-Is or their association with α-blockers. EVIDENCE ACQUISITION A comprehensive electronic search was conducted in October 2010 using the Medline database to identify all publications relating to ED and BPH and treatment with sildenafil, vardenafil, tadalafil, udenafil, UK-369003, and combination therapy with alfuzosin and tamsulosin. EVIDENCE SYNTHESIS In studies in which either ED or LUTS was the entry criterion, sildenafil appears to improve both erectile function and LUTS in subjects with ED. Placebo-controlled trials of tadalafil and vardenafil showed improvement of LUTS secondary to benign prostatic hyperplasia (BPH), but none of the studies showed a significant effect on urodynamic measures. Exploratory studies with UK-369003 showed improvements in LUTS and ED. Sildenafil or tadalafil associated with alfuzosin or tamsulosin showed greater benefits for the combination therapy for both LUTS and ED. The coadministration of udenafil and an α-blocker in patients with BPH and ED also appeared to improve both LUTS and ED severity. CONCLUSIONS Consistent evidence of improvements in LUTS has been shown with PDE5-Is, either alone or in combination with α-blockers. However, effects on urodynamics or objective measures of urinary flow are lacking. Further areas of research include investigation of mechanism of PDE5-Is, urodynamic studies, identification of new efficacy end points, head-to-head comparison with standard of care, potential benefit of add-on treatment, and long-term outcomes.
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Affiliation(s)
- Juan I Martínez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain.
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Aktas BK, Gokkaya CS, Bulut S, Dinek M, Ozden C, Memis A. Impact of metabolic syndrome on erectile dysfunction and lower urinary tract symptoms in benign prostatic hyperplasia patients. Aging Male 2011; 14:48-52. [PMID: 21087172 DOI: 10.3109/13685538.2010.529197] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The aim of this study was to investigate the relationship among metabolic syndrome (MetS), erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH). METHODS Our study included 106 patients with BPH, 33 (31.1%) of whom had MetS. Blood pressures, waist circumferences, serum levels of fasting blood glucose, high density lipoprotein and triglyceride of patients were recorded. Erectile functions of the patients were evaluated by International Index of Erectile Function (IIEF). Patients were divided into two groups according to IIEF scores, namely 'mild/no ED' and 'moderate/severe ED'. IIEF scores of ED groups were between 17 and 30 and 6-16 in turn. LUTS severities were assessed by International Prostate Symptom Score (IPSS) and classified as mild (IPSS 0-7), moderate (IPSS 8-19) and severe (IPSS 20-35). RESULTS There was a significant difference between ED groups concerning MetS presence (p=0.032). MetS presence was not found to be associated with the severity of LUTS (p=0.144). There was no correlation between ED groups regarding LUTS severity (p=0.303). CONCLUSION Results of the present study showed a correlation between MetS presence and ED. In the light of our results, MetS seems to play an important role in the etiopathogenesis of ED in patients with BPH.
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Affiliation(s)
- Binhan Kagan Aktas
- Ankara Numune Education and Research Hospital, 1st Urology Clinic, Ulku Mah., Ankara, 06100, Turkey.
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Liu L, Zheng S, Han P, Wei Q. Phosphodiesterase-5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review and meta-analysis. Urology 2011; 77:123-9. [PMID: 21195830 DOI: 10.1016/j.urology.2010.07.508] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 06/14/2010] [Accepted: 07/02/2010] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of phosphodiesterase-5 (PDE-5) inhibitors for treating lower urinary tract symptoms secondary to benign prostatic hyperplasia. METHODS Randomized controlled trials were identified and extracted from MEDLINE, Embase, Cochrane Central, and relevant reference lists. The database search, quality assessment, and data extraction were independently performed by 2 reviewers. Heterogeneity was analyzed using the chi-square test and I(2) test. If lacking of heterogeneity, fixed-effects models were used for the meta-analysis, otherwise random-effects models were used. RESULTS A total of 5 studies (11 randomized controlled trials) were identified from the search strategy. Compared with placebo, short-term trials (≤12 weeks) indicated that PDE-5 inhibitors significantly improved the International Prostate Symptom Score (mean difference -2.60, 95% confidence interval [CI] -3.12 to -2.07; P < .00001), and statistical significance was observed in the International Prostate Symptom Score irritative and obstructive subscore, International Prostate Symptom Score quality of life and erectile function. However, no statistically significant difference was detected in maximal urinary flow rate (mean difference 0.21, 95% CI -0.21-0.64; P = .32) and postvoid residual urine volume (mean difference 0.09, 95% CI -4.71-4.89; P = .80). No statistically significant difference was found between the 2 groups in the incidence of serious adverse events (relative risk 0.52, 95% CI 0.25-1.07; P = .07), despite that adverse event with a greater incidence was detected in the PDE-5 group (relative risk 1.87, 95% CI 1.31-2.68; P = .0005). CONCLUSIONS As the first-line treatment of erectile dysfunction, the PDE-5 inhibitor is also effective and safe for lower urinary tract symptoms secondary to benign prostatic hyperplasia. It could be considered as the first-line treatment in the future for the treatment of patients with comorbid benign prostatic hyperplasia and erectile dysfunction.
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Affiliation(s)
- Liangren Liu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Laydner HK, Oliveira P, Oliveira CRA, Makarawo TP, Andrade WS, Tannus M, Araújo JLR. Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review. BJU Int 2010; 107:1104-9. [PMID: 20883484 DOI: 10.1111/j.1464-410x.2010.09698.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE • To review the evidence in support of the effectiveness of phosphodiesterase 5 inhibitors in lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). METHODS • Relevant studies were identified by performing a literature search using MEDLINE® and The Cochrane Library®. The criteria used during the search included randomized, placebo-controlled trials of treatment for LUTS secondary to BPH using the International Prostate Symptom Score as an outcome measure. RESULTS • Four trials that included a total of 1928 patients met the inclusion criteria. All four studies showed a statistically significant difference in the International Prostate Symptom Score, quality of life and erectile function in favour of phosphodiesterase 5 inhibitors. • No study showed a statistically significant improvement of the maximum urinary flow. • Meta-analysis of the results was not possible because of heterogeneity across the studies. CONCLUSIONS • Phosphodiesterase 5 inhibitors used in the clinical setting can significantly improve LUTS secondary to BPH, erectile function and quality of life. Maximum urinary flow improvement is not statistically significant. • Future research should focus on pathophysiological principles and cost analysis.
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Morelli A, Filippi S, Comeglio P, Sarchielli E, Chavalmane AK, Vignozzi L, Fibbi B, Silvestrini E, Sandner P, Gacci M, Carini M, Vannelli GB, Maggi M. Acute Vardenafil Administration Improves Bladder Oxygenation in Spontaneously Hypertensive Rats. J Sex Med 2010; 7:107-20. [DOI: 10.1111/j.1743-6109.2009.01558.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Fibbi B, Morelli A, Vignozzi L, Filippi S, Chavalmane A, De Vita G, Marini M, Gacci M, Vannelli GB, Sandner P, Maggi M. Characterization of phosphodiesterase type 5 expression and functional activity in the human male lower urinary tract. J Sex Med 2009; 7:59-69. [PMID: 19796053 DOI: 10.1111/j.1743-6109.2009.01511.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Phosphodiesterase type 5 (PDE5) inhibitors ameliorate low urinary tract (LUT) symptoms in men with ED and symptomatic benign prostatic hyperplasia (BPH). PDE5 is highly expressed in rat and human bladder, where it regulates cyclic guanosine monophosphate (cGMP) degradation, muscle tone, and proliferation. AIM To investigate PDE5 tissue distribution and activity in human LUT tissues (urethra, prostate, and bladder). MAIN OUTCOME MEASURES PDE5 expression and activity were analyzed and compared within the same BPH patient in LUT tissues and in smooth muscle cells (SMCs) cultured from urethra, prostate, and bladder. METHODS In LUT tissues, PDE5 was localized by immunohistochemistry and mRNA expression by quantitative real-time polymerase chain reaction. Proliferation assay was used as readout of PDE5 activity, evaluated as ability of vardenafil to increase the antiproliferative effect of different nitric oxide (NO)/cGMP pathway activators [the PDE5-resistant cGMP analog Sp-8-Br-PET-cGMPS, the NO donor sodium nitroprusside (SNP), and the soluble guanylate cyclase (sGC) stimulator BAY 41-8543]. RESULTS In all the LUT tissues, PDE5 was immunolocalized in blood vessels and in muscular fibres, but not in epithelium. PDE5 mRNA expression was higher in urethra and bladder than in prostate SMC. The antiproliferative effect of Sp-8-Br-PET-cGMPS was similar in all LUT SMC. In prostatic SMC, SNP and BAY 41-8543 show a dose-dependent antiproliferative effect that resulted marginally enhanced by vardenafil. Conversely, in urethra and bladder SMC the antiproliferative effect of SNP and BAY 41-8543 was lower than in prostatic SMC, but it was significantly enhanced by vardenafil. In urethral and bladder cells vardenafil half-maximal response inhibiting concentration was in the subnanomolar range, whereas in prostate cells it resulted significantly higher. CONCLUSIONS The highest expression and biological activity of PDE5 was found in bladder. However, a consistent PDE5 expression and activity was also found in prostatic urethra. In contrast, the prostate gland showed the lowest PDE5 abundance and cultures derived from this tissue were less sensitive to vardenafil.
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Affiliation(s)
- Benedetta Fibbi
- Andrology and Sexual Medicine Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy.
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Imai A, Yamamoto H, Hatakeyama S, Iwabuchi I, Yoneyama T, Hashimoto Y, Koie T, Kamimura N, Danjyo K, Ohyama C. Risk factors for erectile dysfunction in healthy Japanese men. ACTA ACUST UNITED AC 2009; 33:569-73. [DOI: 10.1111/j.1365-2605.2009.00974.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Esquirol-Caussa J, Herrero-Vila E, Sánchez-Aldeguer J. Sexualidad en la edad geriátrica: disfunción eréctil, sintomatología urinaria del tracto inferior y posibilidades de tratamiento. Rev Int Androl 2009. [DOI: 10.1016/s1698-031x(09)71615-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Morelli A, Filippi S, Sandner P, Fibbi B, Chavalmane AK, Silvestrini E, Sarchielli E, Vignozzi L, Gacci M, Carini M, Vannelli GB, Maggi M. Vardenafil modulates bladder contractility through cGMP-mediated inhibition of RhoA/Rho kinase signaling pathway in spontaneously hypertensive rats. J Sex Med 2009; 6:1594-1608. [PMID: 19473460 DOI: 10.1111/j.1743-6109.2009.01249.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Phosphodiesterase type 5 inhibitors (PDE5i), the most widely used drugs for erectile dysfunction, could also improve lower urinary tract symptoms, essentially due to overactive bladder (OAB), a condition hypothesized to be a result of an increased RhoA/Rho-kinase (ROCK) signaling. Phosphorylation/inactivation of RhoA by cyclic guanosine monophosphate (cGMP)-dependent protein kinase (PKG) activity has been described in vascular smooth muscle. AIM The aim of this paper was to investigate whether vardenafil-induced cGMP accumulation reduces RhoA/ROCK signaling in bladder. METHODS Spontaneously hypertensive rats (SHRs), a strain genetically prone to develop OAB, were treated with vardenafil (10 mg/kg/day) for 2 weeks. Wistar-Kyoto rats (WKY) were used as control. In vitro experiments were performed in human bladder smooth muscle cells (hBCs). MAIN OUTCOME MEASURES Urodynamic parameters were registered in vivo in anesthetized WKY and SHRs. RhoA/ROCK activity in bladder was evaluated by molecular and functional studies in tissues and cells. RESULTS The intercontraction interval and bladder capacity, and were decreased in SHRs and restored by vardenafil. The in vitro relaxant effect of the ROCK inhibitor Y-27632 was higher in bladder strips from SHR than from WKY and reduced by vardenafil. Nomega-nitro-L-arginine-methyl-ester (a NO-synthase inhibitor, 40 mg/kg/day during the last week of the 2-week treatment with vardenafil) partially antagonized vardenafil effect on Y-27632 responsiveness. Vardenafil prevented RhoA membrane translocation/activation, decreased ROCK activity, and increased cGMP levels in vivo (rat) and in vitro (hBCs). Exposing hBCs to vardenafil increased Ser(188) RhoA phosphorylation, to the same extent as the PDE5-insensitive PKG agonist Sp-8-Br-PET-cGMP. Moreover, vardenafil inhibited several RhoA-dependent functions in hBCs, including smooth muscle gene transcription and endothelin-1-induced migration. These effects were reverted by the PKG inhibitor KT 5823, further suggesting a cGMP/PKG-dependency. In hBCs, vardenafil was active in the low nanomolar range. CONCLUSIONS This is the first study demonstrating that the effect of vardenafil on OAB could be partially determined by a cGMP-dependent RhoA/ROCK signaling inhibition.
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Affiliation(s)
- Annamaria Morelli
- Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | - Sandra Filippi
- Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | | | - Benedetta Fibbi
- Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | | | - Enrico Silvestrini
- Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | - Erica Sarchielli
- Department of Anatomy, Histology and Forensic Medicine, University of Florence, Florence, Italy
| | - Linda Vignozzi
- Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | - Mauro Gacci
- Department of Urology, University of Florence, Florence, Italy
| | - Marco Carini
- Department of Urology, University of Florence, Florence, Italy
| | - Gabriella B Vannelli
- Department of Anatomy, Histology and Forensic Medicine, University of Florence, Florence, Italy
| | - Mario Maggi
- Department of Clinical Physiopathology, University of Florence, Florence, Italy;.
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