Postvoid residual urine in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: pooled analysis of eleven controlled studies with alfuzosin

Can we define the optimal postvoid residual volume at which intermittent catheterization should be recommended, and are there other measures that could guide an intermittent catheterization protocol: ICI-RS 2023

AIMS

The postvoid residual (PVR) volume of urine in the bladder is widely used in clinical practice as a guide to initiate treatment, including clean-intermittent self-catheterization (CISC). It is often believed that an elevated PVR causes complications such as recurrent urinary tract infections (UTI) and renal failure. However, evidence for this is limited and identifying alternative measures to guide treatment decisions may optimize patient care. At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2023 a Think Tank addressed the question of whether we can define the optimal PVR at which CISC should be recommended, and whether there are other measures that could guide a CISC protocol.

METHODS

The Think Tank conducted a literature review and expert consensus meeting focusing on current limitations in defining and measuring PVR, and highlighting other measures that may optimize selection for, and persistence with, CISC.

RESULTS

There is no consensus on the threshold value of PVR that is considered "elevated" or "significant." There is a lack of standardization on terminology, and the normal range of PVR in different populations of different ages remains to be well-studied. The measurement of PVR is influenced by several factors, including intraindividual variation, timing and method of measurement. Furthermore, the evidence linking an elevated PVR with complications such as UTI and renal failure is mixed. Other measures, such as bladder voiding efficiency or urodynamic parameters, may be better at predicting such complications, and therefore may be more relevant at guiding a CISC protocol.

CONCLUSIONS

There is a lack of high quality evidence to support PVR as a predictor for complications of UTI or renal failure. Threshold values for normal PVR in different populations are unknow, and so threshold values for "elevated" or "significant" PVR cannot be determined. Other factors, such as urodynamic findings, may be better at predicting complications and therefore guiding management decisions, and this remains to be studied. Areas for further research are proposed.

Orthostatic Hypotension in Benign Prostatic Hyperplasia Patients and Its Association With Alpha-1 Antagonist Use: A Comprehensive Literature Review

Orthostatic hypotension (OH) is frequently observed in benign prostatic hyperplasia (BPH) patients undergoing alpha-1 adrenergic antagonist (A1AA) therapy. While previous studies have acknowledged the prevalence of OH in BPH patients on A1AAs, limited data exist on ranking the safety of different A1AAs. This comprehensive review explores the underlying mechanisms of OH, examines numerous factors influencing its development, and provides insights into effective treatment strategies such as hydration, gradual postural changes, leg exercises, compression stockings, and tilt-table training for BPH management. The review highlights the significance of individualized care, interdisciplinary collaboration, and further research to optimize A1AA treatment, improve patient outcomes, and enhance quality of life.

Biomaterials assisted reconstructive urology: The pursuit of an implantable bioengineered neo-urinary bladder

Urinary bladder is a dynamic organ performing complex physiological activities. Together with ureters and urethra, it forms the lower urinary tract that facilitates urine collection, low-pressure storage, and volitional voiding. However, pathological disorders are often liable to cause irreversible damage and compromise the normal functionality of the bladder, necessitating surgical intervention for a reconstructive procedure. Non-urinary autologous grafts, primarily derived from gastrointestinal tract, have long been the gold standard in clinics to augment or to replace the diseased bladder tissue. Unfortunately, such treatment strategy is commonly associated with several clinical complications. In absence of an optimal autologous therapy, a biomaterial based bioengineered platform is an attractive prospect revolutionizing the modern urology. Predictably, extensive investigative research has been carried out in pursuit of better urological biomaterials, that overcome the limitations of conventional gastrointestinal graft. Against the above backdrop, this review aims to provide a comprehensive and one-stop update on different biomaterial-based strategies that have been proposed and explored over the past 60 years to restore the dynamic function of the otherwise dysfunctional bladder tissue. Broadly, two unique perspectives of bladder tissue engineering and total alloplastic bladder replacement are critically discussed in terms of their status and progress. While the former is pivoted on scaffold mediated regenerative medicine; in contrast, the latter is directed towards the development of a biostable bladder prosthesis. Together, these routes share a common aspiration of designing and creating a functional equivalent of the bladder wall, albeit, using fundamentally different aspects of biocompatibility and clinical needs. Therefore, an attempt has been made to systematically analyze and summarize the evolution of various classes as well as generations of polymeric biomaterials in urology. Considerable emphasis has been laid on explaining the bioengineering methodologies, pre-clinical and clinical outcomes. Some of the unaddressed challenges, including vascularization, innervation, hollow 3D prototype fabrication and urinary encrustation, have been highlighted that currently delay the successful commercial translation. More importantly, the rapidly evolving and expanding concepts of bioelectronic medicine are discussed to inspire future research efforts towards the further advancement of the field. At the closure, crucial insights are provided to forge the biomaterial assisted reconstruction as a long-term therapeutic strategy in urological practice for patients' care.

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a common condition in aging men that is frequently associated with troublesome lower urinary tract symptoms (LUTS). The American Urologic Association Symptom Index is a validated, self-administered tool that is used to diagnose LUTS, guide initial treatment, and assess treatment response. Watchful waiting is an option for men with mild symptoms. Pharmacologic treatment includes alpha-adrenergic blockers and 5-alpha reductase inhibitors. There is no evidence to support the use of herbal supplements in the treatment of LUTS. Surgical therapy is effective and indicated for men with complications from BPH or who fail medical therapy.

Voided volume < 150 mL on initial uroflowmetry in men with storage symptoms: Is it an unreliable test result or a sign of severe storage symptoms?

Purpose

To assess the utility of voided volume on initial uroflowmetry in predicting symptom severity in men with storage symptoms. In addition, we assessed the probability that men would show a voided volume of ≥ 150 mL on uroflowmetry if the examination is repeated.

Methods

Between 2016 and 2017, 352 men with storage symptoms were enrolled in the study. The patients completed the frequency–volume chart and were divided into four groups based on the voided volume. A multivariate analysis was performed to determine the variables affecting voided volume.

Results

The VV was < 68.8 mL in 88 patients (25.0%), 68.9–150 in 89 (25.3%), 150–250 in 87 (24.7%), and ≥ 250 in 88 (25.0%) patients. Although the International Prostate Symptom Score did not differ among the groups, the storage subscore was significantly higher in patients with decreased voided volume (p = 0.010). The total number of voids was greater in patients with decreased voided volume (p < 0.001), as was the number of nocturnal voids (p = 0.007). The maximum voided volume (p < 0.001) and 24-h urine output (p = 0.003) decreased as voided volume decreased. The proportions of patients with a mean daytime urine output ≥ 150 mL were 30.1%, 43.0%, 64.7%, and 66.7% in each group, respectively (p < 0.001). Older age and decreased maximum voided volume significantly affected the voided volume on initial uroflowmetry.

Conclusions

A decreased voided volume on initial uroflowmetry may be a sign of severe storage symptoms in men. This finding is related to older age and decreased functional capacity. In these patients, it is better to perform a careful clinical assessment to diagnose and treat overactive bladder.

Expectant long-term follow-up of patients with chronic urinary retention

AIMS

To describe urologic complications in patients with chronically elevated post-void residual (PVR) volumes and to evaluate other related risk factors during a long-term follow-up in patients managed conservatively.

METHODS

Non-neurogenic patients who refused surgical intervention of the prostate and had PVR volumes >300 mL on two or more separate occasions at least 6 months apart were included. We followed this cohort over time, recorded complications and evaluated risk factors for complications.

RESULTS

Twenty-eight men with a mean age of 74 were followed for a median of 56 months (IQR: 26-101 months); 26 had benign prostatic hyperplasia with a median prostate size of 55 cc. Baseline median PVR was 468 cc (IQR: 395-828) and follow-up median PVR was 508 cc (IQR: 322-714). During follow-up, 13 patients (46%) had at least one complication with acute urinary retention being the most common occurring in 10 patients (36%) with 15 episodes. Other complications presented in less than 15%, and no patients developed permanent renal insufficiency. Patients with prostate size ≥ 100 cc had significantly higher total number of acute retention episodes (P-value: 0.01).

CONCLUSIONS

Although the presence of CUR could commonly predispose to episodes of acute retention, severe complications are infrequent although present. Additionally, prostate size may play a role in increasing some adverse outcomes. With proper counseling about different complications, patients with retention who denied surgical treatment can be safely followed for at least 5 years without renal deterioration.

Concise Review: Tissue Engineering of Urinary Bladder; We Still Have a Long Way to Go?

Regenerative medicine is a new branch of medicine based on tissue engineering technology. This rapidly developing field of science offers revolutionary treatment strategy aimed at urinary bladder regeneration. Despite many promising announcements of experimental urinary bladder reconstruction, there has been a lack in commercialization of therapies based on current investigations. This is due to numerous obstacles that are slowly being identified and precisely overcome. The goal of this review is to present the current status of research on urinary bladder regeneration and highlight further challenges that need to be gradually addressed. We put an emphasis on expectations of urologists that are awaiting tissue engineering based solutions in clinical practice. This review also presents a detailed characteristic of obstacles on the road to successful urinary bladder regeneration from urological clinician perspective. A defined interdisciplinary approach might help to accelerate planning transitional research tissue engineering focused on urinary tracts. Stem Cells Translational Medicine 2017;6:2033-2043.

Pathophysiology of clinical benign prostatic hyperplasia

A disease can be defined as an abnormal anatomy (pathology) and/or function (physiology) that may cause harm to the body. In clinical benign prostatic hyperplasis (BPH), the abnormal anatomy is prostate adenoma/adenomata, resulting in a varying degree of benign prostatic obstruction (BPO) that may cause harm to the bladder or kidneys. Thus clinical BPH can be defined as such and be differentiated from other less common causes of male lower urinary tract symptoms. Diagnosis of the prostate adenoma/adenomata (PA) can be made by measuring the intravesical prostatic protrusion (IPP) and prostate volume (PV) with non-invasive transabdominal ultrasound (TAUS) in the clinic. The PA can then be graded (phenotyped) according to IPP and PV. Multiple studies have shown a good correlation between IPP/PV and BPO, and therefore progression of the disease. The severity of the disease clinical BPH can be classified into stages from stage I to IV for further management. The classification is based on the effect of BPO on bladder functions, namely that of emptying, normal if post-void residual urine (PVRU) < 100 mL; and bladder storage, normal if maximum voided volume (MVV) > 100 mL. The effect of BPO on quality of life (QoL) can be assessed by the QoL index, with a score ≥3 considered bothersome. Patients with no significant obstruction and no bothersome symptoms would be stage I; those with no significant obstruction but has bothersome symptoms (QoL ≥ 3) would be stage II; those with significant obstruction (PVRU > 100 mL; or MVV < 100 mL), irrespective of symptoms would be stage III; those with complications of the disease clinical BPH such as retention of urine, bladder stones, recurrent bleeding or infections would be stage IV. After assessment, further management can then be individualised. A low grade and stage disease can generally be watched (active surveillance) while a high grade and stage disease would need more invasive management with an option for surgery. The final decision making would take into account the patient's age, co-morbidity, social economic background and his preferences/values. Proper understanding of pathophysiology of clinical BPH would lead to better selection of patients for individualised and personalised care and more cost effective management.

The Value of Urodynamic Study for Diagnosing the Causes of Lower Urinary Tract Symptoms in Male Patients: A Study From Iran

Background

Most disorders of the lower urinary tract are functional, so diagnoses are typically based on urodynamic findings. Treatment is likely to fail if the pathology is not correctly diagnosed.

Objectives

There are various diagnostic tests for lower urinary tract symptoms (LUTS). In this study, we evaluated the value of urodynamic testing to diagnose the causes of lower urinary symptoms in male patients.

Patients and Methods

Urodynamic tests were performed in 407 patients referred to the urology clinic in Baqiyatallah in 2014 with complaints of LUTS, and the diagnosis was based on the findings of the tests.

Results

The mean age of patients in this study was 50.88 years, and most patients were in their third decade (20 - 30 years of age). Urinary frequency (28.8%), enuresis (22.22%), and incontinence (16.12%) were the most common complaints. The most prevalent disorder was bladder sensation disorder.

Conclusions

Patients made various complaints, and several pathologies were diagnosed, which emphasizes the importance of using urodynamic tests for subsequent medical approaches as a non-invasive, accessible, and inexpensive tool.

Therapy of calcium oxalate urolithiasis in a rhesus macaque (Macaca mulatta)

A rhesus macaque (Macaca mulatta) was presented for anuria. Examination revealed calcium oxalate concrements in the bladder. A cystotomy was performed, and a therapy with alfuzosin was conducted. Over 1 year after the treatment, the rhesus macaque had not shown any more signs of stranguria. This is the first case reporting the successful treatment of urolithiasis in a rhesus macaque.

Lower Urinary Tract Symptoms and Risk of Bladder Cancer in Men: Results From the Health Professionals Follow-up Study

OBJECTIVE

To understand the association between lower urinary tract symptoms (LUTS) and risk of bladder cancer in a large cohort of men.

METHODS

Using data from the Health Professionals Follow-up Study, we examined risk of bladder cancer in relation to severity of LUTS among 30,183 men. During the follow-up period from 1996 until 2010, 476 newly diagnosed cases of bladder cancer occurred. The Cox proportional hazards regression was used to adjust for potential confounders.

RESULTS

Among men with severe LUTS, risk of bladder cancer was 64% higher (relative risk [RR], 1.64; 95% confidence interval [CI], 0.87-3.08) compared with men who reported no LUTS. Subjects with both voiding and storage dysfunction had a significantly higher risk of bladder cancer (RR, 1.60; 95% CI, 1.00-2.56). Among individual urinary symptoms, urinary hesitancy was strongly associated with bladder cancer; those who experienced urinary hesitancy at least 50% of the time had more than twice the risk of bladder cancer (RR, 2.21; 95% CI, 1.29-3.78).

CONCLUSION

Our findings suggest that LUTS, especially urinary hesitancy, are associated with the development of bladder cancer in men.

The cutoff value of bladder voiding efficiency for predicting surgical outcomes after GreenLight HPS™ laser photoselective vaporization of the prostate

PURPOSE

A large postvoid residual (PVR) has been considered to be an indicator for the need to further management. However, the threshold level of PVR has been not defined. We determined the PVR volume by using bladder voiding efficiency (BVE) that would predict surgical outcomes after GreenLight HPS™ laser photoselective vaporization of the prostate (HPS-PVP).

METHODS

A total of 193 patients who underwent HPS-PVP were divided into two groups based on BVE: >75% (group A) and ≤75% (group B). BVE was calculated by dividing voided volume by voided volume plus PVR. Surgical outcomes were assessed from the ratio of the IPSS, the difference in Qmax, and the difference in the quality of life IPSS subscore (QoL) before surgery and at 3, 12, and 36 months postoperatively.

RESULTS

There were significant improvements in all outcome measures after 3, 12, and 36 months; the improvement in Qmax was greater in group A than group B at each time point. The IPSS ratio was significantly greater in group A than group B at 3 months. There was no difference in QoL between the groups. The multivariate logistic regression analysis showed that BVE correlated significantly with short-term surgical success, but not with prostate volume or age. In the area under curve of ROC analysis, the BVE cutoff value of 75% showed the highest sensitivity and specificity for predicting the short-term success of surgical outcomes.

CONCLUSIONS

Our results suggest that a large PVR may predict relatively slight improvements in short-term surgical outcomes after HPS-PVP. The cutoff value of PVR in predicting surgical success is 25% or more of residual fraction.

Pelvic ultrasound evaluation for benign prostatic hyperplasia: prediction of obstruction

Global improvements in water quality, management of infectious diseases, and other medical therapeutics have resulted in a growing population of healthy aging men. One obligate anatomic consequence of aging for these men is the development of benign prostatic hyperplasia (BPH) with secondary bladder outlet obstruction. Although the voiding symptoms associated with the change in bladder health over time predominantly impact the quality of a man's daily experience, there are also significant medical consequences of BPH that require intervention. It is a challenge to distinguish men who are at risk for these medical consequences from the much larger population of older men with voiding symptoms (lower urinary tract symptoms, LUTS). A variety of national guidelines have been developed to establish a diagnostic paradigm for meeting this challenge, but all suffer from inadequate sensitivity for the early identification of men at risk for permanent bladder injury. It is likely that the application of a thorough pelvic ultrasound designed to identify the pertinent anatomic aspects of both the bladder and prostate will improve the sensitivity of these diagnostic paradigms, with subsequent improvement in the outcomes for men with BPH/LUTS.

Cystometric parameters and the activity of signaling proteins in association with the compensation or decompensation of bladder function in an animal experimental model of partial bladder outlet obstruction

We conducted this study to determine whether the degree of detrusor contractility is associated with the compensation or decompensation of bladder function depending on the residual volume (RV) during the first two weeks after the onset of partial bladder outlet obstruction (BOO). Moreover, we also examined whether the degree of the phosphorylation and expression of signaling proteins [AMP-activated kinase (AMPK), extracellular signal‑regulated protein kinases 1 and 2 (ERK1/2) and protein kinase C (PKC)] is associated with the prevalence of compensation or decompensation of bladder function. Twenty-seven female Sprague-Dawley (SD) rats were randomly assigned to either the sham-operated group (n=7) or the group with partial bladder outlet obstruction (BOO) (n=20). We then measured cystometric parameters from three reproducible micturition cycles and averaged the results for a comparison between the two groups. Based on a cut-off value of a mean RV% of 25%, we subdivided our experimental animals into two subgroups: the subgroup with bladder compensation (mean RV%, <25%) and the subgroup with bladder decompensation (mean RV%, >25%). Our results indicated that the degree of detrusor overactivity (DO) was associated with the compensation or decompensation of bladder function depending on the RV during the first two weeks after the onset of BOO in an animal experimental model of partial BOO. Moreover, we also demonstrate that AMPK and ERK1/2 are involved in the compensation or decompensation of bladder function. Furthermore, our results suggest that PKC is not involved in two-phase bladder contraction. Alterations in the activities of signaling proteins, such as AMPK and ERK1/2 may prove to be helpful in the treatment of patients with voiding difficulty.

How do urodynamics findings influence the treatment of the typical patient with overactive bladder?

Overactive bladder (OAB) is a clinical symptom complex whose hallmark is the symptom of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence. Historically, urodynamics (UDS) evaluation has not been recommended in the initial evaluation of OAB, since it is defined primarily by clinical symptoms. As the pathophysiology of the OAB complex has become more clearly elucidated from recent studies, the role of UDS has again become a topic of discussion as a tool that can provide objective data to reflect these new findings. The utility of UDS in the diagnosis and treatment of OAB is still evolving, but in certain clinical scenarios, especially when empiric treatment has failed, it can provide definitive information that can identify associated pathologies and/or alter the treatment course. Herein, we will discuss the current literature regarding use of UDS in OAB patients and offer our own opinions as to its use.

Decision making in the management of benign prostatic enlargement and the role of transabdominal ultrasound

Benign prostate enlargement (BPE) is a common disease affecting elderly men. It can present clinically in many ways including, but not exclusively, lower urinary tract symptoms (LUTS) and acute urinary retention (AUR). Therefore, in managing men with BPE, a correct diagnosis in the outpatient setting is important. Diagnosis of BPE in the clinic can be aided by simple, non-invasive, transabdominal ultrasound (TAUS). In our practice, a normal prostate is generally defined as less than 20 mL, and shows no intravesical prostatic protrusion (IPP) to distort the normal funneling bladder neck on TAUS, with a maximum flow rate of more than 15 mL/s. The degree of IPP can be measured non-invasively in the midsagittal plane, and can be graded accordingly. Studies have shown that the grade of IPP correlates well with the degree of bladder outlet obstruction (BOO). In addition, TAUS can also be used to measure prostate volume (PV) and post-void residual urine (PVR). There is a good correlation between IPP and PV, but IPP is a better predictor for BOO. Patients with low-grade IPP, no significant PVR (<100 mL) and no bothersome symptoms (low stage) can generally be watched; whereas those with high-grade IPP, significant PVR (>100 mL) and bothersome symptoms (higher stage) will need more aggressive management. The final decision for management can then be tailored and individualized to achieve cost-effectiveness.

Staging of Benign Prostate Hyperplasia is Helpful in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostate Hyperplasia

Introduction: We prospectively evaluated the staging of benign prostate hyperplasia (BPH) to decide transurethral resection of prostate (TURP) therapeutic modality and the final outcomes in patients with lower urinary tract symptoms (LUTS) suggestive of BPH. Materials and Methods: Male patients above 50 years old presented with LUTS suggestive of BPH were included in this study. The initial assessment included the International Prostatic Symptoms Score (IPSS) and the Quality of Life (QOL) index, digital rectal examination (DRE). Transabdominal ultrasound was done to measure the prostate volume, intravesical prostatic protrusion (IPP) and the post void residual (PVR) urine. BPH was classified according to the degree of IPP using grades 1 to 3. The staging of BPH was performed according to the presence or absence of bothersome symptoms (QOL ≥3) and significant obstruction (PVR >100ml). Patients with stage I BPH with no bothersome symptoms and no significant obstruction were generally observed. Those with stage II BPH, bothersome symptoms but no significant obstruction, received pharmacotherapy in the first instance, and were offered TURP if symptoms persisted or worsened. Patients with significant obstruction, persistent PVR >100ml, irrespective of symptoms would be classified as stage III, and were advised to undergo TURP as an option. Lastly, those with stage IV (complications of BPH) were strongly recommended to undergo TURP. Results: A total of 408 patients were recruited in this study and after a mean follow-up of 30 months (range, 6 to 84), 96 (24%) eventually had TURP. Sixteen (13%), 50(21%), 28(64%) and 2(100%) patients who underwent TURP were initially diagnosed as stage I, II, III and IV, respectively. Eighty-seven (91%) of the 96 patients significantly improved to stage I BPH post TURP. Conclusions: These results showed that the staging of BPH can assist in the tailoring of treatment for patients with LUTS suggestive of BPH, with good outcome in 91% post TURP. Key words: Intravesical prostatic protrusion, Post void residual urine, Quality of life, Symptoms score

Long-term outcome of patients with a successful trial without catheter, after treatment with an alpha-adrenergic receptor blocker for acute urinary retention caused by benign prostatic hyperplasia

OBJECTIVE

To perform a retrospective review of long-term outcome for patients with a first episode of acute urinary retention (AUR) who could void successfully after the initial trial without catheter (TWOC) after treatment with an alpha-adrenergic receptor blocker (AR blocker).

METHODS

The records of 248 patients who presented with a first episode of AUR secondary to benign prostatic hyperplasia (BPH) and who could void successfully after the initial TWOC following treatment with an AR blocker were reviewed during the period January 1998 to December 2001. The characteristics of the patients and the subsequent outcomes were recorded. The primary outcome assessed was failed medical treatment within the five-year follow-up period. Factors correlated with the primary outcome were also assessed.

RESULTS

For these 248 patients, the median follow-up time was 33.0 months (range 0-96 months). The percentage of patients with failed medical treatment at 6, 12, 24, and 60 months was 11.6, 14.3, 28.4, and 50.5%, respectively. Multivariate analysis indicated that only a prostate size >50 ml and serum prostate specific antigen (PSA) level during AUR >10 ng/dl were significant predictors of subsequent requirement for surgical intervention after a successful TWOC.

CONCLUSIONS

Although AR blockers increased the success rate of TWOC, approximately half of the patients in this study still required additional intervention within five years. By using appropriate selection criteria, such as a large prostate size (>50 ml) or high serum PSA level during AUR (>10 microg/l), patients who are at greater risk of TWOC failure can be identified, and earlier surgical intervention can be offered to them.

Should an antimuscarinic agent be used for persistent LUTS after treatment with an alpha(1)-blocker?

This Practice Point discusses the study by MacDiarmid and colleagues, which is the latest to support a beneficial effect of adding antimuscarinic agents to alpha(1)-blockers in men with persistent lower urinary tract symptoms. Such studies have also alleviated concerns about the adverse effects of antimuscarinic agents, particularly the risk of developing urinary retention. In practice, however, some issues regarding the use of antimuscarinic agents in this patient population remain. First, persistent storage symptoms are suggestive of other pathologies, and this possibility must be carefully evaluated before combined treatment is initiated. Second, postvoid residual urine volume should be repeatedly monitored during antimuscarinic therapy to avoid sequelae of residual urine or urinary retention. Third, the effect of adding an antimuscarinic agent is statistically significant, but might not be clinically significant for the majority of men. Better evaluation of storage symptoms might facilitate the more-appropriate use of combined treatment in this setting.

[Prevalence of ejaculatory dysfunction secondary to alpha-blocker therapy in patients with benign prostatic hyperplasia]

INTRODUCTION

Benign prostatic hyperplasia (BPH) is characterized by lower urinary tract symptoms (LUTS) that may cause ejaculatory disorders, although they could be also a consequence of alpha-blocker treatment.

OBJECTIVES

To determine the prevalence of ejaculatory dysfunction in patients with HBP undergoing alpha-blocker therapy. Secondary objectives were to evaluate the effect of different drugs on normal ejaculation and the relationship of dysfunction degree to prognostic factors and BPH severity.

MATERIALS AND METHODS

Epidemiologic, transversal, uncontrolled and open-label study in 1.177 patients older than 40, who had been diagnosed of BPH/LUTS with more than 6 months of evolution and treated with the same alpha-blocker for at least the last 3 months. Severity of ejaculatory dysfunction was determined by the domain on ejaculation of the Male Sexual Health Questionnaire (MSHQ). Results were stratified by age and BPH severity, determined by the International Prostate Symptoms Score (IPSS).

RESULTS

The prevalence of ejaculatory dysfunction has been estimated to be 82.6% in patients with BPH/LUTS treated with alpha-blockers. Although usually mild, the dysfunction is considered as bothersome by a high percentage of those who suffer it. Advanced age is the most influential factor in the severity of both ejaculatory abnormalities and prostate symptoms. Moreover, a solid correlation between these two parameters has been established. Finally, among the analyzed alpha-blockers, alfuzosin has been associated with the best sexual function.

CONCLUSIONS

More than 80% of patients with BPH suffer ejaculatory abnormalities, which are closely related to the severity of prostate symptoms and increased age. When initiating alpha-blocker treatment, we should consider that alfuzosin is the one with less negative impact on ejaculatory function.

A practical guide to the evaluation and treatment of male lower urinary tract symptoms in the primary care setting

AIMS

Lower urinary tract symptoms (LUTS) are common in both men and women, and are among the most prevalent patient complaints heard by primary care physicians (PCPs). This article aims to provide PCPs with a logical algorithm for the assessment and initiation of treatment for LUTS in the male patient.

RESULTS

Management of LUTS involves a focused history and physical, as well as the assessment of bother. In patients for whom treatment is warranted, a series of decisions regarding therapy should be considered. Male patients commonly suffer from storage and/or voiding symptoms. Treatment of male LUTS is commonly begun with agents that are aimed at remedying the outlet symptoms of benign prostatic hyperplasia (BPH). When this intervention is ineffective or when refractory symptoms persist, consideration should be given to treating the storage symptoms characteristic of overactive bladder (OAB).

DISCUSSION

This article is intended to provide the PCP with a logical guide to the treatment of male LUTS. Benign prostatic hyperplasia and OAB predominate among the causes of these symptoms, and the PCP should be comfortable treating each. Recent data detailing the safety of the use of these treatments in the male patient are reviewed and incorporated into the algorithm.

CONCLUSION

Primary care physicians are in a unique position to successfully identify and treat male patients with LUTS. With this paper, they now have a tool to approach treatment logically and practically.

Acute urinary retention: medical management and the identification of risk factors for prevention

Male lower urinary tract symptoms associated with benign prostatic hyperplasia can be progressive in some patients and lead to adverse consequences such as acute urinary retention (AUR), which might require prostate surgery. This Review identifies baseline and dynamic variables that have been recognized as risk factors that might predispose men to AUR. Evidence for the use of medical therapy to reduce the risk of benign prostatic hyperplasia progression, which might prevent AUR, has been critically evaluated. The literature describing the pharmacological management of men with AUR, and in those who have successfully voided after removal of a catheter, has been critically appraised in this article.

Chronic prostatitis/chronic pelvic pain syndrome: role of alpha blocker therapy

INTRODUCTION

This article reviews the rationale and data supporting alpha blocker therapy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), the most common and difficult prostatitis syndrome.

METHODS

Systematic review identified ten clinical trials evaluating alpha blocker therapy for patients with CP/CPPS, including five open-label or small prospective studies and five double-blinded and placebo-controlled clinical trials.

RESULTS

Encouraging results in uncontrolled and small clinical trials led to the development of reasonably powered, double-blinded, placebo-controlled, randomized clinical trials evaluating terazosin, doxazosin, tamsulosin, and alfuzosin.

CONCLUSIONS

Current data suggest that treatment-naïve and/or newly diagnosed patients appear more likely to respond than long-term, chronic refractory patients. Longer courses of treatment (12 weeks to 6 months) appear superior to shorter courses, and less selective agents appear superior to more selective alpha1 blockers. These observations outline important questions that must be answered to define optimal treatment strategies for patients with CP/CPPS.

Managing enlarged prostate in primary care

Assessment and treatment of benign prostatic hyperplasia, or enlarged prostate, has evolved considerably in recent years; clear evidence has accumulated for the progression of disease over time, the association between disease progression and negative outcomes, and the potential for medical management of this condition. Commensurate with the long-term preventive role of primary care, efforts can and should be made to treat the underlying condition of enlarged prostate as well as to manage the symptoms short-term. This review outlines evaluation of men presenting with lower urinary tract symptoms, examines the challenges for medical treatment and suggests how treatment choice can address these challenges.

Acute urinary retention: who is at risk and how best to manage it?

In recent years, we have begun to understand the progressive nature of benign prostatic hyperplasia. By careful analysis of population studies and clinical trials, we can determine the factors most likely to predict progression to one of its most distressing complications, acute urinary retention. Acute urinary retention is a common urologic emergency and causes significant suffering, although rarely has it any serious consequences. Using our knowledge regarding the progression of benign prostatic hyperplasia, new treatment modalities are being assessed for their effectiveness at halting progression and ultimately preventing this distressing condition.

Post-Void Residual Urine Volume is Not a Good Predictor of the Need for Invasive Therapy Among Patients With Benign Prostatic Hyperplasia

PURPOSE

We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW.

MATERIALS AND METHODS

The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses.

RESULTS

PVR has weak (-0.2<R <0.2) correlations with other baseline parameters. With increasing PVR cutoff levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45% to 64% and from 15% to 21% in the alpha1-blockers and WW group, respectively. Large PVR yields a significant 2-fold up to a 4-fold increased risk of invasive therapy compared to small PVR in both treatment groups. In multivariate models these significant risk differences largely disappear, although a statistically not significant higher risk remains for the large PVR (greater than 300 ml) patients.

CONCLUSIONS

In general, baseline PVR has little prognostic value for the risk of BPH related invasive therapy in patients on alpha1-blocker and WW. Only patients with large PVR have a 2-fold increased risk of invasive therapy compared to patients with smaller PVR.

Overactive bladder in the male patient: epidemiology, etiology, evaluation, and treatment

The urologist's approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with "prostatism," an all-encompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.

Acute urinary retention in men: the risks and outcomes with medical therapy

This paper is restricted to the discussion of the relatively modern disorder of sudden painful inability to urinate in older men. It was not a common medical problem until the 19th century when, in developed countries, male life expectancy increased to beyond 60 years; it remains an uncommon problem in those developing countries where male life expectancy remains low, particularly in some sub-Saharan African countries where male life expectancy is only 44.8 years.

Unreliable residual volume measurement after increased water load diuresis

BACKGROUND

The aim of the present study was to examine whether increased water load intake prior to ultrasound examination of the lower urinary tract, affects the measurement of postvoid residual urine volume.

PATIENTS AND METHODS

Ninety four male patients with postvoid residual volumes after increased water load diuresis of more than 100 mL (PVR1) were included in the present study. All patients underwent a second PVR measurement by an urologist with a portable transabdominal bladder ultrasound scan without having received an increased water load (PVR2). A comparison of the measurements was performed and the PVR values were also correlated with other parameters, such as age, International Prostate Symptom Score, prostate volume and serum prostate-specific antigen (PSA) values.

RESULTS

Postvoid residual urine volume after increased water load diuresis (PVR1) differed from that recorded after normal bladder filling and voiding at first desire (PVR2), with the former being larger than the later in every patient (P < 0.001). The PVR values, PVR1 and PVR2, were independent to patient age, symptom score prostate volume and PSA value.

CONCLUSIONS

Measurement of postvoid residual volume in a relaxed patient, who voids at first desire, represents everyday life and should be the correct method of testing.

The Role of Alpha-Blockers in the Management of Acute Urinary Retention Caused by Benign Prostatic Obstruction

OBJECTIVES

To consider theories concerning the etiology of acute urinary retention (AUR), which may influence the outcome of a trial without catheter (TWOC), and to discuss evidence regarding the use of medical therapy in the management and secondary prevention of AUR.

METHODS AND MATERIALS

A search of the literature discussing measurable parameters that may identify patients at risk for AUR and who require further intervention after initial treatment was undertaken. Studies of the effect of medical interventions for benign prostatic hyperplasia (BPH) and AUR were also identified.

RESULTS

The etiology of acute urinary retention remains unknown in many cases, which are often described as spontaneous, but catheterization remains standard management followed by a TWOC and bladder outlet surgery in those who do not void satisfactorily. Alpha-blockers (alpha(1)-adrenoreceptor antagonists) effectively reduce the symptoms associated with BPH and improve the urodynamic parameters of obstruction, without the sexual adverse events associated with the 5alpha-reductase inhibitors. They may diminish the incidence of AUR and the need for surgical intervention in symptomatic men. There is now good evidence that alfuzosin, in particular, improves the success rate of a TWOC, although other uroselective alpha-blockers have also been shown to improve the success rates of TWOC.

CONCLUSIONS

The proven effects of alpha-blockers support the hypothesis that they will increase the chances of a successful TWOC following AUR, which has now been proven in several well-designed and conducted studies. However, it is not yet clear whether these or other medical therapies have a role to play in the secondary prevention of further AUR or the need for further surgery. It is clear that certain measurable parameters may be used to identify patients at highest risk of a further episode of AUR following a successful TWOC; these patients may then be offered urgent surgical intervention.

Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized, controlled study

PURPOSE

We evaluate the effect of tolterodine combined with tamsulosin on quality of life in patients with bladder outlet obstruction and concomitant detrusor instability.

MATERIALS AND METHODS

The study included 50 consecutive patients with urodynamically proven mild or moderate bladder outlet obstruction and concomitant detrusor instability. All patients were initially treated with 0.4 mg. tamsulosin orally once a day. A week later the patients were randomly allocated into group 1-25 who continued treatment with tamsulosin only and, group 2-25 who also received 2 mg. tolterodine orally twice daily. Reevaluation with a quality of life questionnaire and urodynamic study was performed after 3 months.

RESULTS

Two patients from group 2 stopped tolterodine while 1 patient from each group stopped tamsulosin because of hypotension. Analysis revealed statistically significant improvement in quality of life scores only in group 2 patients (mean score 525.0 and 628.4 before and after treatment, respectively, 2-sided t test p = 0.0003). A significant difference was noted in both groups after treatment for maximum flow rate and volume at first contraction. Additionally, in group 2, a statistically significant difference was observed for maximum detrusor pressure and maximum unstable contraction pressure after treatment.

CONCLUSIONS

Combination treatment with an alpha-blocker (tamsulosin) plus an anticholinergic (tolterodine) improves quality of life in patients with bladder outlet obstruction and concomitant detrusor instability. Interestingly, no acute urinary retention was observed and tolterodine did not affect the quality of urine flow or residual urine volume. The proposed combination appears to be an effective and relatively safe treatment option in patients with bladder outlet obstruction and detrusor instability.

Finasteride in the treatment of clinical benign prostatic hyperplasia: a systematic review of randomised trials

BACKGROUND

Benign prostatic hyperplasia affects older men. This systematic review determined efficacy and adverse effects of finasteride.

REVIEW METHODS

PubMed, the Cochrane Library, reference lists of reports, and reviews were searched for randomised, double-blind trials of finasteride in benign prostatic hyperplasia. Outcomes included symptom score, urinary flow rate, prostate volume, discontinuation, and adverse effects. Relative risk and NNT or NNH were calculated for dichotomous data. Sensitivity analyses assessed influences of baseline symptom severity, initial prostate volume, a dominating trial, and previous interventions.

RESULTS

Three trials had active controls and 19 had placebo. In placebo-controlled trials, 8820 patients received finasteride 5 mg and 5909 placebo over 3-48 months. Over 48 months finasteride produced greater improvements in total symptom score, maximum urinary flow rate, and prostate volume. Significantly more sexual dysfunction, impotence, ejaculation disorder and decreased libido occurred with finasteride at 12 months; the NNH for any sexual dysfunction at 12 months was 14. Significantly fewer men treated with finasteride experienced acute retention or had surgery at 24 or 48 months than with placebo; at 12 months the NNT was 49 (31 to 112) to avoid one acute urinary retention and 31 (21 to 61) to avoid one surgery. Sensitivity analyses showed benefit with finasteride 5 mg to be constant irrespective of the initial prostate volume.

CONCLUSIONS

Information from many patients in studies of high quality showed beneficial effects of finasteride in terms of symptoms, flow rate and prostate volume. More utility would result if patient centred outcomes were reported in dichotomous form.

Alfuzosin: a review of the therapeutic use of the prolonged-release formulation given once daily in the management of benign prostatic hyperplasia

Alfuzosin, a quinazoline derivative, is a selective and competitive alpha(1)-adrenoceptor antagonist. It distributes preferentially in the prostate, compared with plasma, and decreases the sympathetically controlled tone of prostatic smooth muscle. As a result lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) are improved. The once-daily formulation of alfuzosin contains inactive barrier layers which have been added to the planar surfaces of compressed tablets. Drug release is sustained over 20 hours with a near constant dissolution rate between 2 and 12 hours. Mean values for area under the plasma concentration-time curve over 24 hours (AUC(24)) were similar after administration of prolonged-release alfuzosin 10mg once daily and immediate-release alfuzosin 2.5mg three times daily. Likewise, similar AUC(24) values were reported when prolonged-release alfuzosin 10mg once daily and sustained-release alfuzosin 5mg twice daily were compared. These data suggest that these alfuzosin regimens provide similar average systemic exposure. Data from short- (3 months) and long-term (up to 12 months) clinical trials show that the prolonged-release formulation of alfuzosin controls the symptoms associated with BPH as effectively as immediate-release alfuzosin 2.5mg three times daily and clinical improvement is maintained for up to 1 year. Improvements in International Prostate Symptom Score, maximum urinary flow rate and quality-of-life index were improved to a similar extent in patients treated with immediate- or prolonged-release alfuzosin and improvements were statistically significant compared with placebo. Prolonged-release alfuzosin 10mg is well tolerated and the overall incidence of adverse events is similar to that seen with placebo. The once-daily formulation of alfuzosin 10mg caused fewer vasodilatory adverse events than immediate-release alfuzosin 2.5mg three times daily and caused only slight decreases in systolic and diastolic blood pressure which were not clinically significant and did not differ significantly from those with placebo. No dosage titration is required. The incidence of ejaculatory disorders was <1%.

CONCLUSION

Prolonged-release alfuzosin 10mg once daily controls symptoms associated with BPH throughout a 24-hour dosage interval as effectively as immediate-release alfuzosin 2.5mg three times daily but with fewer vasodilatory adverse events. A nonblind extension study showed that clinical benefits were maintained for up to 1 year and the once-daily 10mg formulation continued to be well tolerated, particularly in terms of cardiovascular effects and sexual function. Thus, for the medical management of men with BPH, prolonged-release alfuzosin 10mg is an effective, well tolerated and convenient treatment option.

Alfuzosin: overview of pharmacokinetics, safety, and efficacy of a clinically uroselective alpha-blocker

Efficacy and safety of alfuzosin administered as 3-times-daily and 2-times-daily formulations have been previously demonstrated in placebo-controlled studies, and these formulations have been commercially available in many countries. A once-daily formulation of alfuzosin administered through a novel prolonged-release system has been recently developed to improve the convenience of dosing and to provide optimal pharmacokinetic coverage over 24 hours. The results of 2 double-blind, placebo-controlled phase 3 studies in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia suggests that 10 mg of alfuzosin administered once daily without dose titration is superior to placebo in terms of symptom and urinary flow rate improvement. Orthostatic hypotension and first-dose phenomenon related to the alpha-blocking property were rare. The incidences of asthenia and fatigue were comparable to those seen with placebo. Ejaculatory disorders were very rare. The most frequently reported adverse event potentially related to alpha blockade was dizziness, which occurred in 5.0% of patients treated with 10 mg alfuzosin compared with 2.1% of patients given placebo.