Reasons for Prescription Change of α1-Blockers in Patients With Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia

[Interest of a systematic assessment of the treatment of the lower urinary tract symptoms in the management of benign prostatic hypertrophy in general practice (1380 patients) - Study EVALURO]

OBJECTIVE

To evaluate the efficacy of a modification or initiation of treatment by a α-blocker in patients already medically treated for BPH-related LUTS, with persistent urinary symptoms.

METHODS

This is a prospective observational study among general practitioners in France. Included patients were over 60 years of age with BPH-related LUTS who had been medically treated for at least 6 months. A treatment by an α-blocker was initiated or modified if the PGI-I (Patient Global Impression of Improvement) did not objective any improvement under treatment and the IPSS (International Prostate Symptom Score) was≥8. Patients were followed up between 1 and 3 months after inclusion. The primary endpoint was the frequency of unsatisfactory progression of patients, assessed by persistence of urinary symptoms under treatment (IPSS≥8 and PGI-I unchanged or worsened). Progress of LUTS (IPSS and PGI-I) following modification of treatment with α-blocker was also assessed at the follow-up visit.

RESULTS

Three hundred and fifty-three physicians included 1449 patients between February 2, 2016 and March 9, 2017 (1380 patients were analyzed): the average age was 70.0±6.9 years ; the duration of the LUTS was 4.1±4.2 years; at inclusion, they received mainly plants (n=744; 53.9%) and α-blockers (n=463; 33.6%); the mean IPSS score was 16.4±6.7, it was not correlated with duration of SBAU; the mean PGi-I was 2.6±1.2. In total, 48.8% (612/1255) of patients had a non-satisfactory evaluation of the LUTS; 42.8% (591/1380) of patients had a modification of treatment according to the protocol: 385 (65.6%) had an initiation of a α-blocker, 202 (34.4%) had a modification of treatment by α-blocker (4 missing data). The α-blocker was monotherapy for 484 (81.9%) patients. At the follow-up visit (1 to 3 months), the average IPSS score was 7.7±4.8, significantly lower (18.7±6.1 at inclusion); the average PGI-I of 1.2±0.7 was significantly lower (3.5±0.8 at inclusion); the quality of life (Q8-IPSS) was significantly improved. For the 345 patients under plant extracts having changed for one α-blocker, as well as for the 67 patients under α-blocker having changed for another α-blocker, the 3 scores had decreased significantly.

CONCLUSION

A systematic evaluation of medical treatment for BPH showed that 48.8% of patients medically treated for at least 6 months were not improved. A modification of treatment by an α-blocker (initiation or modification) can then significantly improve the LUTS.

Non-Adrenergic, Tamsulosin-Insensitive Smooth Muscle Contraction is Sufficient to Replace α1 -Adrenergic Tension in the Human Prostate

BACKGROUND

Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia may be caused by prostate smooth muscle contraction. Although α₁ -blockers may improve symptoms by prostate smooth muscle relaxation, their efficacy is limited. This may be explained by non-adrenergic mediators causing contraction in parallel to α₁ -adrenoceptors. However, little is known about the relevance and cooperative actions of non-adrenergic mediators in the prostate.

METHODS

Prostate tissues were obtained from radical prostatectomy (n = 127 patients). Contractile responses were studied in an organ bath.

RESULTS

Endothelin-1 and noradrenaline induced contractions of similar magnitude (116 ± 23 and 117 ± 18% of KCl-induced contractions). Endothelin-2- and -3-induced maximum contractions of 63 ± 8.6 and 71 ± 19% of KCl, while contractions by the thromboxane analog U46619 amounted up to 63 ± 9.4%. Dopamine-induced contractions averaged to 22 ± 4.5% of KCl, while maximum contractions by serotonin, histamine, and carbachol stayed below 10% of KCl-induced. While noradrenaline-induced contractions were inhibited by tamsulosin (300 nM), endothelin-1-, -2-, or -3-induced contraction were not. No additive effects were observed if endothelins and noradrenaline were applied consecutively to the same samples. If endothelin-1 was applied after U46619, resulting tension (172 ± 43% of KCl) significantly exceeded noradrenaline-induced contraction. Tensions following combined application of endothelin-2 or -3 with U46619 stayed below noradrenaline-induced contractions. Tension following combined application of all three endothelins with U46619 resembled maximum noradrenaline-induced tone.

CONCLUSIONS

Contractions following concomitant confrontation of human prostate tissue with noradrenaline and endothelin-1 are not additive. Endothelin-1 is sufficient to induce a smooth muscle tone resembling that of noradrenaline. This may replace lacking α₁ -adrenergic tone under therapy with α₁ -blockers, explaining the limited efficacy of α₁ -blockers in LUTS treatment. Contractions by thromboxane and endothelin-1 may be additive, and may exceed α₁ -adrenergic tone. Prostate 77:697-707, 2017. © 2017 Wiley Periodicals, Inc.

Incidence of benign prostate hypertrophy in Danish men with and without HIV infection

BACKGROUND

Information on risk of benign prostate hypertrophy (BPH) in HIV-infected men is sparse. We aimed to estimate the incidence of being diagnosed with BPH among HIV-infected men compared with an age and sex-matched comparison cohort from the background population. To exclude that family-associated risk factors influence risk of BPH diagnoses in families of HIV-infected individuals, we estimated risk of BPH in fathers of HIV-infected men and fathers of the comparison cohort.

METHODS

In a nationwide, population-based, matched cohort study, we calculated incidence rates and used Poisson regression models to calculate incidence rate ratios (IRRs) of being diagnosed with BPH, defined as the earliest of date of the second redeemed prescription of a drug used to treat BPH, the first registration of a BPH diagnosis in the Danish National Hospital Registry (DNHR) or the first registration of a surgical procedure for BPH in DNHR.

RESULTS

We identified 4633 HIV-infected men, 46 330 comparison cohort individuals, 1585 fathers of HIV-infected men and 20 449 fathers of the comparison cohort. Incidence rate of being diagnosed with BPH was 37.0 [95% confidence interval (95% CI) 31.5-43.1] per 10 000 person-years of follow-up among HIV-infected men and was not increased compared with the comparison cohort (IRR 1.04, 95% CI 0.88-1.22). Risk was not increased for fathers of HIV-infected men vs. fathers of the comparison cohort (IRR 0.99, 95% CI 0.87-1.12). Stratified analyses did not change the above results markedly.

CONCLUSION

HIV-infected individuals do not have an increased risk of being diagnosed with BPH.