Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men

A national survey of lower urinary tract symptoms in Jordan

Objective

To determine the prevalence of lower urinary tract symptoms (LUTS) and their severity population in Jordan.

Methods

This cross-sectional survey was conducted using a paper-based survey between August and September in 2019. The study was carried out in the health care centers or hospitals in three different regions of Jordan: North (Irbid and Jarash), Middle (Amman, Madaba, Salt, and Zarqa), and South (Karak and Aqaba).

Results

To estimate the prevalence of LUTS, two definitions were used, including the first definition (presence of any LUTS regardless of the degree of severity) and the second definition (presence of any LUTS that occurs half the time or more). According to the first definition, 1038 (89.9%) reported LUTS (male: 47.3%, female: 52.7%), while 763 (66.1%) reported LUTS according to the second definition (male: 45.6%, female: 54.4%). According to the International Prostate Symptom Score characterization, 73.9% had nocturia and 62.9% reported daytime increased frequency.

Conclusion

LUTS are highly prevalent among the Jordanian population, and more than half of them have nocturia or daytime increased frequency as most frequently reported symptoms.

Lower urinary tract symptom severity, urinary bother, and incident life-space mobility restriction among older men

BACKGROUND

Life-space mobility represents the distance, frequency, and independence of mobility, ranging from one's bedroom to beyond their town. Older men with lower urinary tract symptoms (LUTS) may limit their life-space to stay close to a bathroom. However, it's unknown whether LUTS severity or urinary bother are associated with risk of life-space mobility restriction.

METHODS

We analyzed data from 3025 community-dwelling men age ≥71 years without life-space mobility restriction at analytic baseline (Year 7) of the Osteoporotic Fractures in Men (MrOS) study. The American Urologic Association Symptom Index (AUASI) was assessed at baseline and includes one question assessing urinary bother ("If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?"; score 0-1,2,3,4-6) and seven items to classify LUTS severity as none/mild (score 0-7), moderate (8-19), or severe (20-35). The University of Alabama Life-space Assessment was used to define life-space mobility restriction (≤60) at baseline and follow-up (Year 9). We used log-binomial regression with robust variance estimators to model adjusted risk ratios (ARR) for LUTS severity and urinary bother with incident life-space mobility restriction, controlling for age, site, health-related factors, and comorbidities. We then mutually adjusted for urinary bother and LUTS severity.

RESULTS

Overall, the 2-year risk of life-space mobility restrictions was 9.9%. Compared to men without urinary bother (scores 0-1), the risk of life-space mobility restriction was significantly higher among men with bother scores of 4-6 (ARR = 2.20, 95% CI: 1.52, 3.19), independent of LUTS severity and confounders. Conversely, LUTS severity was not independently associated with the risk of life-space mobility restriction.

CONCLUSIONS

Urinary bother, but not LUTS severity, is independently associated with incident life-space mobility restriction among older men. To maintain life-space mobility in older men with LUTS, future studies should identify shared mechanisms and interventions that minimize urinary bother.

Influence of Prostate Artery Embolization on Different Qualities of Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction

BACKGROUND

Prostate artery embolization (PAE) is an increasingly used minimally invasive treatment for lower urinary tract symptoms secondary to benign prostatic obstruction (BPO) OBJECTIVE: To analyze the impact of PAE on voiding and storage symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Between July 2014 and May 2019, 351 consecutive men with BPO who underwent PAE were included in a single-center study.

INTERVENTION

PAE is an interventional radiological procedure embolizing the prostatic arteries with microspheres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint represented assessment of the International Prostatic Symptom Score (IPSS) at baseline and at 1, 3, 6, 12, and 24 mo after PAE. Secondary endpoints comprised assessment of IPSS quality of life (QoL), International Index of Erectile Function, peak urinary flow rate, postvoid residual volume, prostate volume, and prostate-specific antigen at the same time points. Data were analyzed using standard statistical methods, generalized estimating equations (symptom improvement over time as odds ratios), and McNemar-Bowker test (degree of improvement compared between symptoms).

RESULTS AND LIMITATIONS

Clinical success rates for PAE were 68%, 73%, and 66% at 1, 12, and 24 mo, respectively. The median IPSS improved significantly from 22 to 10 points after 2 yr (p < 0.001). Storage (-50%) and voiding (-58%) symptoms improved similarly (each p < 0.001), with nocturia decreasing least frequently but significantly (p < 0.001). After 1 and 2 yr, 35% (95% confidence interval [CI] 29-41%) and 30% (95% CI 21-40%) of patients reported alleviated storage, and 39% (95% CI 33-45%) and 38% (95% CI 29-49%) reported alleviated voiding symptoms, respectively. QoL improved from 5 to 2 points (p < 0.001). The main limitation is the number of patients lost during follow-up.

CONCLUSIONS

PAE significantly improved voiding and storage symptoms to a similar extent. This study may aid in counseling patients about this minimally invasive BPO treatment.

PATIENT SUMMARY

Prostate artery embolization (PAE) is a minimally invasive treatment option for patients with voiding and storage symptoms from benign prostate enlargement. Our analysis shows that PAE improves relevant lower urinary tract symptoms.

A Novel Nomogram Based on Initial Features to Predict BPH Progression

Objectives: The aim of this study was to establish a tool to identify patients at risk for pharmaceutical and surgical interventions for benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) over a 10 year follow-up. Methods: The data of patients with mild to moderate male LUTS undergoing phytotherapy from January to December 2010 were reviewed. Patients were followed for 10 years through medical visits and telephone consultations. The outcomes were (1) treatment switch from phytotherapy or no therapy to alpha-blockers or 5α-reductase inhibitors (5-ARI), and (2) clinical progression (acute urinary retention or need for surgery). Two calibrated nomograms (one for each outcome) were constructed on significant predictors at multivariate analysis. Results: A total of 107 patients with a median age of 55 years at presentation were included; 47% stopped or continued phytotherapy, while 53% switched to alpha-blockers and/or 5-ARI after a median time of 24 months. One-third in the second group experienced clinical progression after a median time of 54 months. Age, symptom score, peak flow rate (Qmax), prostate-specific antigen (PSA), and post-void residual volume were significantly associated with the outcomes. According to our nomograms, patients switching therapy or progressing clinically had average scores of 75% and 40% in the dedicated nomograms, respectively, as compared to 25% and <5% in patients who did not reach any outcome. Conclusions: We developed a nomogram to predict the risk of pharmaceutical or surgical interventions for BPH-related LUTS at 10 years from presentation. On the basis of our models, thresholds of >75% and >40% for high risk and <25% and <5% for low risk of pharmaceutical or surgical interventions, respectively, can be proposed.

Effect of superselective prostatic artery embolization on benign prostatic hyperplasia

PURPOSE

To investigate the safety and effectiveness of superselective prostatic artery embolization (PAE) in patients with benign prostatic hyperplasia (BPH).

METHODS

Sixty-five patients diagnosed with BPH in Fujian Provincial Hospital between December 2014 and July 2019 were included. Patients with ineffective drug treatment after 6 months, who refused surgery, or who were unsuitable for surgery were included. We observed postoperative complications, followed up at 1, 3, and 6 months, compared clinical symptoms, and monitored changes in prostate-specific antigen (PSA) and prostatic volume (PV) before and after treatment.

RESULTS

Of the 65 patients, 58 (89.23%) successfully received PAE; 44 and 14 bilateral and unilateral embolization, respectively. Clinical efficacy was 94.83% (55/58) after the 6-month follow-up. Postoperative PV, International Prostate Symptom Score, quality of life, maximum flow rate, and post-void residual significantly improved after 6 months (P < 0.05). One month after PAE, the serum total PSA increased by 1.47 (10.84/7.37) times and dropped 3 months later to a level lower than that before surgery (P < 0.05). Six months after PAE, the degree of relief from obstructive symptoms was more apparent than that of irritative symptoms. No serious complications were observed after PAE.

CONCLUSION

PAE was safe and effective for the treatment of BPH. The efficacy of bilateral PAE was better than that of unilateral PAE.

Prostate Artery Embolization: State of the Evidence and Societal Guidelines

Medically refractory benign prostatic hyperplasia induced lower urinary tract symptoms is an extremely prevalent issue in older men. The current gold standard therapy transurethral resection of the prostate does produce urologic improvements but is also associated with higher than desired morbidity. This has led to the need to develop new minimally invasive means to treat this disease; prostate artery embolization (PAE) has emerged as one minimally invasive treatment option for these patients. The body of evidence which supports the use of PAE has grown quickly and substantially over the last decade. The goal of this review is to introduce and summarize the published urologic outcomes for PAE when utilized to treat benign prostatic hyperplasia induced lower urinary tract symptoms as well as document the established complication profile. Finally, the paper reviews current societal recommendations as they relate to PAE.

Biomarkers in the setting of benign prostatic hyperplasia-induced lower urinary tract symptoms: what an interventional radiologist needs to know

With increasing evidence to support prostate artery embolization (PAE) in the treatment of benign prostatic hyperplasia (BPH)-induced lower urinary tract symptoms (LUTS), Interventional Radiologists have begun to play an important role in the management of these patients. One area of knowledge needed when developing a PAE practice is knowledge of prostate-specific antigen (PSA) and other biomarkers utilized to detect prostate cancer in this population and what role they should play in the work up and follow-up of patients presenting with presumed BPH-induced LUTS. Furthermore, understanding how to evaluate presumed BPH-induced LUTS and stratify the risk of prostate cancer is an important skill to develop. The goal of this review is to provide Interventional Radiologists who have begun or aim to begin a PAE practice with the information they need to know regarding PSA levels and prostate cancer risk stratification for this patient population.

Relation of baseline prostate volume to improvement of lower urinary tract symptoms due to tamsulosin monotherapy in benign prostatic hyperplasia: An exploratory, multicenter, prospective study

Aims:

The aim of the study was to investigate the relation between baseline prostate volume (PV) and the improvement of lower urinary tract symptoms (LUTS) induced by tamsulosin monotherapy after 2-year follow-up in Egyptian benign prostatic hyperplasia (BPH) patients.

Settings and Design:

This was a prospective comparative multicenter study.

Subjects and Methods:

Three hundred and eighty-one BPH patients were included in the study from January 2014 to January 2017. The patients were divided according to their PV into two groups. Group A included patients with small-sized prostate (≤40 ml) and Group B included those with PV larger than 40 ml. Full evaluation was done at presentation. The patients are followed up at 6, 12, and 24 months of continued medical treatment with tamsulosin 0.4 mg once daily.

Statistical Analysis Used:

Data were coded and entered using the Statistical Package for the Social Sciences version 24. Data were summarized using mean and standard deviation in quantitative data. Comparisons between quantitative variables were done using unpaired t-test or the nonparametric Mann–Whitney test. A comparison between paired measurements in the same person was done using paired t-test (Chan, 2003). P < 0.05 was considered as statistically significant.

Results:

The mean age was 60.1 ± 7.2 years. The mean value of the International Prostate Symptom Score (IPSS) was recorded for the 381 patients at presentation. In Group A, the mean value of IPSS was 20.44 ± 3.18, whereas in Group B, the mean value of IPSS was 21.23 ± 3.5. There was a significant improvement in symptoms (Q_max-IPSS) in both groups, but we found that this improvement was significantly better in Group A (P = 0.017).

Conclusions:

PV is an important prognostic factor affecting the improvement of the LUTS by α1-blocker monotherapy. Tamsulosin monotherapy may not be enough for large prostate (>40 mg) to maintain adequate symptom relief, and it is better to start with other medical options such as combined therapy or early nonmedical therapy. Starting α1-blocker monotherapy in smaller prostates may be of benefit in symptomatic patients without considering watchful waiting.

Prostate Artery Embolization for Lower Urinary Tract Symptoms in Men Unfit for Surgery

Nearly one in three men develop lower urinary tract symptoms (LUTS) and 10% clinically progress despite medication. Transurethral resection of the prostate (TURP) is the reference standard for symptoms refractory to medical treatment. However, some patients cannot tolerate TURP for medical (e.g., comorbidity) or technical (e.g., large prostate) reasons. This study estimated the safety and effect of prostate artery embolization (PAE) in men unfit for surgery. A prospective, single-centre trial including men with LUTS or urinary retention secondary to benign prostatic hyperplasia (BPH) who were unfit for surgery. The primary objective was to treat urinary retention and LUTS. Outcome measures included International Prostate Symptom Score (IPSS), quality of life (IPSS-QoL), International Index of Erectile Function (IIEF-5), prostate volume (PV), prostate-specific antigen (PSA), peak void flow (Qmax), post-void residual (PVR), and complications. A p-value < 0.05 was considered statistically significant. Eleven consecutive patients with a mean age of 75.2 (SD ± 8.2) underwent PAE. Catheter removal was successful in 60%. IPSS-QoL improved 4.5 points (95% CI: -5.6; -3.4), and PV was reduced by 26.2 cm³ (95% CI: -50.9; -2.3). None of the remaining outcomes changed. No major complications occurred. PAE was effective and safe for LUTS and urinary retention associated with BPH in men unfit for surgery.

Prostate embolization: patient selection, clinical management and results

Background

Prostate artery embolization is an emerging technique, that with the continued publication of promising data, is slowly moving from the research to the everyday clinical setting.

Main body

This paper reviews the patient selection, clinical management and expected results of prostate artery embolization. Patient selection is paramount in delivering the desired results for any procedure. Likewise, the ability to clinically manage patients in the pre-operative and post-operative setting is an important skill to acquire when implementing new techniques. This paper introduces important urologic measurements/tests, patient selection paradigms, and clinical management concepts for interventional radiologists. It also reviews the outcomes patients can expect following prostate artery embolization as well as the complication profile.

Conclusion

Prostate artery embolization is a promising technique for the treatment of benign prostatic hyperplasia induced lower urinary tract symptoms.

Prevalence estimates for lower urinary tract symptom severity among men in Uganda and sub-Saharan Africa based on regional prevalence data

INTRODUCTION

In the absence of specific regional data, the prevalence of urinary symptoms in the developing world is currently estimated. Regional prevalence data and estimates based on them have relevance for accurate planning/provision of future healthcare. We sought to extrapolate prevalence estimates for lower urinary tract symptom (LUTS) severity and associated sexual dysfunction for Uganda as a whole and sub-Saharan Africa (SSA) using newly available regional data from a community-based cohort of men in Uganda.

METHODS

Global Burden of Disease Study (GBDS) population statistics were applied to a regional dataset to provide prevalence estimates for Uganda and SSA; 415 men >55 years from five rural Ugandan communities had completed the International Prostate Symptom Scale (IPSS) and Epstein inventory to grade their LUTS severity and satisfaction with sexual function.

RESULTS

Prevalence rates for moderate and severe LUTS were 40.5% and 20%, respectively, in men >55 in the Ugandan regional data; associated scores for all four Epstein sexual satisfaction measures were low. GBDS population figures (2016) for men >55 years are 942 115 (Uganda) and 33.9 million (SSA); hence, scaling up from regional prevalence data suggests 381 557 and 188 423 men >55 years in Uganda, and 13 729 500 and 6 780 000 in SSA have moderate and severe LUTS, respectively, and the majority will have compromise of elements of their sexual function.

CONCLUSIONS

Extrapolation from a small regional dataset (for which we have no guarantee of national or SSA representability) provides the first prevalence estimates for LUTS severity based on African data, and suggests a large proportion of men >55 years are troubled with LUTS and associated sexual dysfunction.

Genetic variants in 5p13.2 and 7q21.1 are associated with treatment for benign prostatic hyperplasia with the α-adrenergic receptor antagonist

BACKGROUND

The etiology of benign prostatic hyperplasia (BPH) has not been well established. The preferred medical treatment for many men with symptomatic benign prostatic hyperplasia is either an α-adrenergic receptor antagonist (α-blocker), or a 5α-reductase inhibitor. Single nucleotide polymorphism (SNP) is a powerful tool for successful implementation of individualized treatment.

METHODS

Eighteen SNPs associated with drug efficacy in a Chinese population were genotyped in 790 BPH cases (330 aggressive and 460 non-aggressive BPH cases) and 1008 controls. All BPH patients were treated with α-adrenergic blockers for at least 9 months. We tested the associations between tagging single nucleotide polymorphism and BPH risk/aggressiveness, clinical characteristics at baseline, including the International Prostate Symptom Score (IPSS) and total prostate volume, and changes in clinical characteristics after treatment.

RESULTS

There were nine SNPs associated with BPH risk, clinical progression and therapeutic effect. (1) There were nine tSNPs been chosen in CYP3A4, CYP3A5 and RANBP3L genes. (2) The SNP, rs16902947 in RANBP3L at 5p13.2 (p = .01), was significantly associated with BPH. (3) We found two SNPs, rs16902947 in RANBP3L at 5p13.2 (p = .0388) and rs4646437 in CYP3A4 at 7q21.1 (p = .0325), associated with drug effect. (4) Allele "G" for rs16902947 was found to be risk alleles for BPH risk (OR= 2.357, 95%CI 1.01-1.48). The "A" allele of rs4646437 was associated with lower IPSS at baseline (β= -0.4232, p= .03255).

CONCLUSIONS

rs16902947, rs16902947 and rs4646437 single nucleotide polymorphisms are significantly associated with the clinical characteristics of benign prostatic hyperplasia and the efficacy of benign prostatic hyperplasia treatment.

Lower Urinary Tract Symptoms and Risk of Nonspine Fractures among Older Community Dwelling U.S. Men

PURPOSE

Among older men, moderate and severe lower urinary tract symptoms are associated with increased fall risk compared to mild lower urinary tract symptoms. Falls are a major risk factor for fractures. Therefore, we assessed associations of lower urinary tract symptoms with fracture risk in community dwelling U.S. men age 65 years or older.

MATERIALS AND METHODS

We conducted a prospective study in the MrOS (Osteoporotic Fractures in Men Study) cohort. Men were enrolled at 6 U.S. sites. The AUA-SI, lower urinary tract symptoms medication use, fracture risk factors and potential confounders were recorded at baseline and every 2 years thereafter for 4 assessments. Lower urinary tract symptom severity was categorized from the AUA-SI as mild (0 to 7 points), moderate (8 to 19 points) or severe (20 or more points). Associations of lower urinary tract symptom severity with fracture rate were estimated with HRs and 95% CIs from extended proportional hazards regression.

RESULTS

Among 5,989 men with baseline AUA-SI score and hip bone mineral density measures, 745 incident nonspine fractures occurred during 43,807 person-years of followup. In a multivariable model adjusted for age, enrollment site, baseline hip bone mineral density, falls in the last year and prevalent fracture before baseline, there were no significant associations of moderate (HR 0.9, 95% CI 0.8-1.1) or severe (HR 1.0, 95% CI 0.8-1.3) lower urinary tract symptoms with fracture risk. None of the individual lower urinary tract symptoms assessed on the AUA-SI, including nocturia and urgency, was associated with increased fracture risk.

CONCLUSIONS

In this cohort of older U.S. men, lower urinary tract symptoms were not independently associated with fracture risk.

Quantification of Nighttime Micturition With an Ambulatory Sensor-Based System

Among elderly males, benign prostate syndrome (BPS) is the most common urinary disorder. Nocturia is one of the major symptoms of BPS and has a considerable influence on the quality of life. For assessment of BPS (including nocturia), the International Prostate Symptom Score is widely used, but questionnaires are prone to bias. To date, there is no objective measurement system available for nocturia. In this study, we present an unobtrusive and nonstigmatizing device for objective measurement of nighttime micturition. In a preliminary study of six males diagnosed with BPS and nighttime micturition ≥ 2×, we showed that the device is accurate, with an average misdetection rate of 0.32 events and a mean absolute deviation of 3.8% when comparing the average number of nighttime micturition occurrences. In this extended study, an additional nine males were recorded and data from an occupancy sensor were also included. The results of the preliminary study were confirmed with an average misdetection rate of 0.33 events and a mean absolute deviation of 9.1%. The system can, therefore, be used to objectively measure nighttime micturition and, thereby, provide the basis for treatment, e.g., medication efficacy assessment.

Association between self-perception period of lower urinary tract symptoms and International Prostate Symptom Score: a propensity score matching study

Background

Most studies focusing on progression of BPH have been limited to the relationship between age and BPH progression, and only few studies have focused on the time duration to start treatment. This study aimed to investigate the association between self-perception period (S-PP) of lower urinary tract symptoms (LUTS) and International Prostate Symptom Score (IPSS).

Methods

This study used data from two large-population surveys: a community-based survey and a university hospital outpatient-based interview survey. Both surveys were conducted in male subjects aged 40 years or older who gave consent to the survey questionnaire and voluntarily expressed their intention to participate. Propensity score matching (PSM) was used to organize the population in both surveys into randomized groups to reduce selection bias. After excluding those who had missing values, 483 subjects were assigned to each group by PSM.

Results

The S-PP of LUTS became significantly longer as the severity of LUTS increased. The S-PP was 4.15 years in the mild group, 4.36 years in the moderate group, and 6.23 years in the severe group. These differences were statistically significant. The correlation between S-PP of LUTS and IPSS was measured by partial correlation while controlling for age (correlation coefficient = 0.20, p <0.001). Multiple regression analysis after controlling for age revealed that one-year increase in the S-PP of LUTS significantly (p <0.001) increased IPSS by 0.322 points.

Conclusions

This study clarified the association between S-PP of LUTS and IPSS in a large-scale population. These findings suggest that, from the perspective of public health, S-PP is an important risk factor for LUTS progression.

Progression and treatment of incident lower urinary tract symptoms (LUTS) among men in the California Men's Health Study

OBJECTIVES

To characterise the progression and treatment of lower urinary tract symptoms (LUTS) among men aged 45-69 years in the California Men's Health Study.

PATIENTS AND METHODS

A total of 39,222 men, aged 45-69 years, enrolled in the Southern California Kaiser Permanente Health Plan were surveyed in 2002-2003 and again in 2006-2007. Those men who completed both surveys who did not have a diagnosis of benign prostatic hyperplasia (BPH) and were not on medication for LUTS at baseline were included in the study (N = 19,505). Among the men with no or mild symptoms at baseline, the incidence of moderate/severe LUTS (American Urological Association Symptom Index [AUASI] score ≥8) and odds of progression to severe LUTS (AUASI score ≥20) was estimated during 4 years of follow-up.

RESULTS

Of the 9640 men who reported no/mild LUTS at baseline, 3993 (41%) reported moderate/severe symptoms at follow-up and experienced a 4-point change in AUASI score on average. Of these men, 351 (8.8%) had received a pharmacological treatment, eight (0.2%) had undergone a minimally invasive or surgical procedure and 3634 (91.0%) had no treatment recorded. Men who progressed to severe symptoms (AUASI score ≥20; n = 165) were more likely to be on medication for BPH (odds ratio [OR] 8.09, 95% confidence interval [CI] 5.77-11.35), have a BPH diagnosis (OR 4.74, 95% CI 3.40-6.61) or have seen a urologist (OR 2.49, 95% CI 1.81-3.43) when compared with men who did not progress to severe symptoms (AUASI score <20).

CONCLUSION

These data show that the majority of men who experienced progression did not have pharmacological or surgical therapy for their symptoms and, therefore, may prove to be good candidates for a self-management plan.

Epidemiology of lower urinary tract symptoms: emphasis on the status in Korea

A comprehensive and correct understanding of epidemiologic finding about lower urinary tract symptoms (LUTS) is important for several reasons. First, LUTS are highly prevalent in both genders all around the world and are expected to be a major concern to physicians in the near future because of the rapid rise in the elderly population. Second, it is crucial to observe trends in prevalence when national health care policy is established. By using a Medline search with various terms related to LUTS and prevalence, a review of epidemiologic studies was undertaken with an emphasis on the status in Korea. Despite the suggestions made by the International Continence Society, the lack of uniform definitions and the lack of a unified threshold of symptoms are the biggest obstacles in epidemiologic study with regard to LUTS. Most Korean epidemiologic studies on LUTS have been reported since 2000 and reveal that the prevalences of specific clinical conditions, such as LUTS, benign prostatic hyperplasia, overactive bladder, and detrusor underactivity, are in line with prevalences in Western counties. However, the prevalence of nocturia is somewhat different from that in Western countries. Many epidemiologic studies of LUTS have provided us with valuable information and a better understanding of the clinical conditions. Given that the impact of these clinical conditions on quality of life and health care cost will be emphasized more in the near future, more studies on optimal management approaches to LUTS are needed on the basis of this knowledge.

Initial treatment of men with newly diagnosed lower urinary tract dysfunction in the Veterans Health Administration

OBJECTIVE

To examine initial treatments given to men with newly diagnosed lower urinary tract dysfunction (LUTD) within a large integrated health care system in the United States.

METHODS

We used data from 2003 to 2009 from the Veteran's Health Administration to identify newly diagnosed cases of LUTD using established ICD-9CM codes. Our primary outcome was initial LUTD treatment (3 months), categorized as watchful waiting (WW), medical therapy (MT), or surgical therapy (ST); our secondary outcome was pharmacotherapy class received. We used logistic regression models to examine patient, provider, and health system factors associated with receiving MT or ST when compared with WW.

RESULTS

There were 393,901 incident cases of LUTD, of which 58.0% initially received WW, 41.8% MT, and 0.2% ST. Of the MT men, 79.8% received an alpha-blocker, 7.7% a 5-alpha reductase inhibitor, 3.3% an anticholinergic, and 7.3% combined therapy (alpha-blocker and 5-alpha reductase inhibitor). In our regression models, we found that age (higher), race (white/black), income (low), region (northeast/south), comorbidities (greater), prostate-specific antigen (lower), and provider (nonurologist) were associated with an increased odds of receiving MT. We found that age (higher), race (white), income (low), region (northeast/south), initial provider (urologist), and prostate-specific antigen (higher) increased the odds of receiving ST.

CONCLUSION

Most men with newly diagnosed LUTD in the Veteran's Health Administration receive WW, and initial surgical treatment is rare. A large number of men receiving MT were treated with monotherapy, despite evidence that combination therapy is potentially more effective in the long-term, suggesting opportunities for improvement in initial LUTD management within this population.

Rapid ambulatory pathway laser prostatectomy is safe: results within the global period

What's known on the subject? and What does the study add? Laser prostatectomy is a commonly performed procedure for BOO, and has been shown to have short- and medium-term results equivalent to the gold standard procedure (i.e. TURP) in various studies. It also has an advantage over TURP in that it can be performed on patients who are taking anticoagulant medication. However, patients in most studies are admitted to the hospital overnight on continuous bladder irrigation and are discharged home the next day. The present study shows that it is safe and feasible to perform laser prostatectomy in an ambulatory fashion with discharge of patients within hours of their surgery. The discharge pathway is associated with minimal morbidity or the need for admission after surgery, and the reported short-term results are in accordance with the available literature on laser prostatectomy.

OBJECTIVE

To investigate the feasibility and safety of a rapid ambulatory discharge pathway after holmium laser ablation of the prostate (HoLAP) for the treatment of benign prostatic hyperplasia.

PATIENTS AND METHODS

The study group comprised a cohort of 65 consecutive patients undergoing HoLAP scheduled as a day surgical case by a single surgeon between January 2007 and December 2009. Patients were discharged from day surgery with a catheter in place, and returned for a voiding trial on postoperative day 3. Preoperative, intra-operative and postoperative parameters were reviewed with follow-up data for the 90-day global postoperative period. Statistical analysis employed Student's t-test with P < 0.05 (two-tailed) being considered statistically significant.

RESULTS

The mean (range) patient age was 64 (41-87) years; mean (range) American Society of Anesthesiologists score was 2.2 (1-4); mean (sd) operation duration was 44 (17) min; and mean (sd) time after surgery until discharge was 149 (51) min. Postoperative complications included catheter occlusion (1.5%) and admission for haematuria (1.5%). There were no re-admissions after discharge from the hospital. Within the 90-day global period, 13 patients described lower urinary tract symptoms (20%), five patients had postoperative urinary retention (7.7%) and one patient had a urinary tract infection (1.5%). After surgery, mean American Urological Association Symptom Score decreased from 21.3 to 7.6 (P < 0.001); mean quality of life score decreased from 4.04 to 1.38 (P < 0.001); and mean post-void residual decreased from 190.2 to 46.4 mL (P < 0.001).

CONCLUSION

In appropriately selected patients, HoLAP can be safely performed as an ambulatory case with a rapid discharge pathway and minimal morbidity during the 90-day global period.

Changes in surgical strategy for patients with benign prostatic hyperplasia: 12-year single-center experience

Purpose

The purpose of this study was to evaluate the annual changes in prostate variables and style of surgical treatment of patients with benign prostatic hyperplasia (BPH) over the past 12 years.

Materials and Methods

The subjects were 918 patients (January 1999-November 2010) who were treated by either open prostatectomy or transurethral resection of prostate (TURP). Every year, the performance ratio between open prostatectomy and TURP was evaluated. Before surgery, total and transitional zone volumes of the prostate were measured by transrectal ultrasonography (TRUS). After surgery, resection weight and residual volume of the prostate were measured by TRUS.

Results

From 2001 through 2010, the performance ratio of TURP increased greatly from 89% to 97%. During 1999 to 2010, the total volume of the prostate increased from 40.0 cc to 55.0 cc in the TURP group and from 74.1 cc to 116.7 cc in the open prostatectomy group. During 1999 to 2010, the mean resection volume of the TURP group increased from 2.3 cc to 20.1 cc. Also, the mean resection volume of the open prostatectomy group increased from 59.3 cc to 114.3 cc. During 1999 to 2003, the resection time of the TURP group decreased from 72.9 minutes to 43.2 minutes.

Conclusions

During 1999 through 2010, the performance ratio between open prostatectomy vs TURP was high for TURP. The total volume and resection volume of the prostate increased annually, and the resection time decreased annually.

Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH)

Male lower urinary tract symptoms, benign prostatic hyperplasia, enlargement of the prostate, and bladder outlet obstruction are common among aging men and will increase in socioeconomic and medical importance at a time of increased life expectancy and aging of the baby boomer generation. This article reviews the epidemiology, management, and therapeutic options for these conditions. In patients bothered by moderate to severe symptoms, providers can make educated and differential choices between several classes of drugs, alone or in combination, to treat effectively and improve the symptoms in most men. Despite the efficacy of medical therapy, there will be patients who require referral to a urologist either early, to rule out prostate cancer and other conditions, or later, after initial medical therapy and lifestyle management has failed. Perhaps as many as 30% of patients fail to achieve sufficient symptom improvement with medication, lifestyle adjustment, and fluid management, and may require more invasive or surgical treatment options.

Effects of tadalafil on lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with or without erectile dysfunction

OBJECTIVES

To compare the safety and efficacy of the daily erectogenic therapy, tadalafil, on lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) in men with or without comorbid erectile dysfunction (ED).

METHODS

Following a 4-week placebo run-in period, men with moderate-to-severe BPH-LUTS were randomized to placebo or tadalafil 2.5, 5, 10, or 20 mg once daily for 12 weeks. International Prostate Symptom Scores (IPSS), IPSS quality of life, and BPH Impact Index were measured every 4 weeks. Safety was mainly assessed via spontaneous reports of adverse events. Data from men with (n=716) or without (n=340) ED at baseline were compared in posthoc analyses.

RESULTS

Men with ED were older and had more frequent hypertension, hyperlipidemia, coronary artery disease, and diabetes at baseline compared with men without ED. After 12 weeks, changes in IPSS in men with ED (least squares mean change from baseline, placebo: -2.4; tadalafil 2.5, 5, 10, 20 mg: -4.3, -4.8, -5.3, -5.6) and without ED (-2.4, -3.2, -5.3, -5.1, -4.5) were not significantly different (subgroup/interaction P values: .352/.644). Similar effects were observed for IPSS quality of life (with ED: -0.6, -0.9, -0.9, -1.0, -1.1; without ED: -0.6, -0.7, -0.9, -0.8, -0.8; 0.090/0.773) and BPH Impact Index (with ED: -0.7, -0.9, -1.3, -1.3, -1.4; without ED: -1.0, -0.7, -1.3, -1.3, -1.2; 0.753/0.852). Tadalafil was generally well tolerated, and men with or without ED had similar tolerability profiles.

CONCLUSIONS

Changes in BPH-LUTS after 12 weeks of treatment with placebo or various doses of once daily tadalafil were similar in men with or without comorbid ED.

Pathology of benign prostatic hyperplasia

The epidemiology of benign prostatic hyperplasia (BPH) is complex and not fully understood. The androgenic hormones testosterones and dihydrotestosterone play at least a permissive and important role. Growth factors and other hormones including estrogens may also play a role. BPH is a truely hyperplastic process resulting in growth of glandular-epithelial and stromal/muscle tissue in the prostate, leading to often measurable growth taking on different shapes and configurations which may impact symptoms and secondary outcomes. It is important to recognize that BPH is a histological conditions, which is one but not the only cause of lower urinary tract symptoms, and may or may not be associated with prostate enlargement and bladder outlet obstruction. Recognizing the different entities and determining their presence in individual patients may help with therapeutic decision making.

Medical therapy options for aging men with benign prostatic hyperplasia: focus on alfuzosin 10 mg once daily

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) are common in aging men and can significantly affect quality of life. Men with bothersome LUTS/BPH often present with various other age-related conditions, including sexual dysfunction, heart disease, hypertension, diabetes, and the metabolic syndrome, which can complicate management decisions. Therefore, healthcare providers should be familiar with first-line treatment options for LUTS/BPH and their differing safety profiles, particularly with respect to cardiovascular and sexual function side effects. This article presents a review of first-line medical therapy options for managing aging men with LUTS/BPH and patient considerations when evaluating and selecting these therapies, with a focus on the clinical efficacy and cardiovascular and sexual function safety profiles of the uroselective alpha1-adrenergic receptor antagonist alfuzosin 10 mg once daily. Alfuzosin improves LUTS, peak urinary flow rates, and disease-specific quality of life, reduces the long-term risk of overall BPH progression, and is well tolerated in aging men, with minimal vasodilatory and sexual function side effects, even in those with comorbidities. Alfuzosin is well tolerated when used in combination with antihypertensive medications and phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction. The long-term clinical efficacy and good cardiovascular and sexual function safety profile of alfuzosin can contribute to an improved quality of life for aging men with LUTS/BPH.

[Validation of the Spanish version of the Benign Prostatic Hyperplasia Impact Index Questionnaire. "Validart Study"]

INTRODUCTION

Benign Prostatic Hyperplasia is a chronic disease that affects Health related quality of life (HRQL). In Spain there are no specific questionnaires to assess HRQL in patients suffering from BPH. The objective of this study was to validate the Spanish version of the Benign Prostatic Hyperplasia Impact Index (BII) questionnaire.

MATERIAL AND METHODS

Study participants were men over 49 with confirmed BPH diagnosis and evaluated in three visits. Psychometric properties of the questionnaire were analyzed in terms of validity, reliability and sensitivity to change.

RESULTS

A total of 1,719 men with mean (SD) age 68.36 were evaluated and classified according to the BPH severity. Both longitudinal and construct validity (r>0.6) of the BII questionnaire were moderate-high. Internal consistency (alpha=0.91), test-retest reliability (CCI=0.8) and sensitivity to change (effect size=0.6) showed good results. The HRQL improved significantly during the monitoring period (p<0.01).

DISCUSSION

There were no available specific HRQL questionnaires for Spanish population with BPH until now. The Spanish version of the BII questionnaire fulfils with the psychometric properties that are necessary to evaluate HRQL in patients with BPH; furthermore, it has been confirm the considerable impact of this disease in the quality of life of this patients.

Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients

PURPOSE

Transurethral resection of the prostate has for decades been the standard surgical therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia, the most common benign neoplasm in men. To generate a contemporary reference for evolving medical and minimally invasive therapies we analyzed complications and immediate outcomes of transurethral prostate resection in a statewide multicenter study.

MATERIALS AND METHODS

We prospectively evaluated 10,654 patients undergoing transurethral prostate resection in the state of Bavaria, Germany from January 1, 2002 until December 31, 2003. Case records containing 54 items concerning preoperative status, operation details, complications and immediate outcome, were recorded for each patient.

RESULTS

The mortality rate for transurethral prostate resection was 0.10%. The cumulative short-term morbidity rate was 11.1%. The most relevant complications were failure to void (5.8%), surgical revision (5.6%), significant urinary tract infection (3.6%), bleeding requiring transfusions (2.9%) and transurethral resection syndrome (1.4%). The resected tissue averaged 28.4 gm. Incidental carcinoma of the prostate was diagnosed by histological examination in 9.8% of patients. Urinary peak flow rate increased significantly to 21.6 +/- 9.4 ml per second (baseline 10.4 +/- 6.8 ml per second, 1 tail p <0.0001), while post-void residual decreased to 31.1 +/- 73.0 ml (baseline 180.3 +/- 296.9 ml, 1-tail p <0.0001).

CONCLUSIONS

In a large scale evaluation comprising 44 mostly nonacademic urological departments in Bavaria, unique real-world data for transurethral prostate resection were prospectively generated. This most contemporary information should be of use to potential patients and facilitate subsumption of emerging surgical and nonsurgical benign prostatic hyperplasia treatment options.

Correlation of the International Prostate Symptom Score bother question with the Benign Prostatic Hyperplasia Impact Index in a clinical practice setting

OBJECTIVE

To evaluate the association between the International Prostate Symptom Score (IPSS) bother question (BQ) and a validated disease-specific quality-of-life questionnaire, the Benign Prostatic Hyperplasia (BPH) Impact Index (BPH-II), using the BPH Registry and Patient Survey database.

PATIENTS AND METHODS

The BPH Registry and Patient Survey is a multicentre, longitudinal, observational database of management practices and patient outcomes in a population of patients with BPH in the USA, managed with watchful waiting or pharmacotherapy. Men enrolled in the BPH Registry who completed the IPSS BQ and the four-item BPH-II at enrolment were identified. The association between the IPSS BQ score and the BPH Impact Index was assessed using Spearman rank correlation.

RESULTS

At baseline (enrolment visit), 6439 men (mean age 66 years) completed the IPSS BQ and the BPH-II. The mean (sd) score of the IPSS BQ was 2.5 (1.4) and of the BPH-II was 2.8 (2.8). Based on responses to the BPH-II, at least half the men reported that their urinary symptoms were associated with physical discomfort, worry about their health, and bothersomeness. The IPSS BQ score was significantly correlated (P < 0.001) with the BPH-II (r = 0.68) and each of its four questions (physical discomfort, r = 0.52; worry about health, r = 0.53; bothersomeness of trouble with urination, r = 0.67; and time kept from usual activities, r = 0.44).

CONCLUSIONS

The IPSS BQ score has a strong and positive correlation with the BPH-II among men enrolled in the BPH Registry. The IPSS BQ is a convenient tool for assessing disease-specific quality of life when determining treatment strategies and evaluating treatment outcomes in men with BPH.

The benign prostatic hyperplasia registry and patient survey: study design, methods and patient baseline characteristics

OBJECTIVE

To describe the design and baseline cohort characteristics of the Benign Prostatic Hyperplasia (BPH) Registry and Patient Survey, an ongoing, prospective, observational, disease registry documenting management practices and patient outcomes in men in the USA with lower urinary tract symptoms associated with BPH (LUTS/BPH) in actual clinical practice settings.

PATIENTS AND METHODS

Men with LUTS/BPH who were either untreated or treated with alpha(1)-adrenergic blockers (ABs), 5alpha-reductase inhibitors (5ARIs), a combination of these medications, or anticholinergics, and who met selection criteria, were enrolled at sites throughout the USA. At each visit, standardized forms and validated questionnaires were completed to assess the physicians' management practices and patients' clinical characteristics, sexual function, and health-related quality of life.

RESULTS

At the close of recruitment (February 2005), 6909 men (mean age 66.0 years) were enrolled at 402 sites by urologists and primary-care physicians. Before enrolment, 49% of the men were managed with watchful waiting (WW), 21% with uroselective AB monotherapy, 11% with non-uroselective AB monotherapy, 6% with 5ARI monotherapy, 11% with AB + 5ARI, and 2% with anticholinergics. After enrolment, 42% were on WW and 26% were on selective AB monotherapy; changes in other management groups were minimal. Overall, 33% of the men had mild, 52% had moderate and 15% had severe LUTS. The most common comorbidities were hypertension (53%), high cholesterol (45%) and sexual dysfunction (36%).

CONCLUSION

The BPH Registry and Patient Survey will provide information on physician management practices and outcomes of men with LUTS/BPH, while examining the effects of demographics, socio-economics, comorbidities, and medical therapies.

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.

Dutasteride significantly improves quality of life measures in patients with enlarged prostate

The purpose of this study was to determine the effect of dutasteride on quality of life of men with lower urinary tract symptoms associated with enlarged prostate or benign prostatic hyperplasia (BPH) as measured by symptom problem index (SPI), BPH-specific interference with activities (BSIA), BPH-specific psychological well-being (BPWB) and BPH-specific lifestyle adaptations (BSLA). Data were derived from three randomized, double-blind studies conducted in 4325 men treated with placebo or dutasteride (0.5 mg/day). Primary analyses included changes from baseline in mean SPI, BSIA, BPWB and BSLA scores. Men treated with dutasteride showed significant improvements in SPI, BSIA, BPWB and BSLA scores compared with placebo.

Alfuzosin: an alpha1-receptor blocker for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia

Alpha1-receptor blockers have become first-line therapy for the medical management of lower urinary tract symptoms associated with benign prostatic hyperplasia. However, adverse effects such as cardiovascular intolerance can limit their use. This article focuses on alfuzosin, a clinically uroselective, alpha1-adrenergic antagonist that is available as a novel once-daily formulation that does not require dose titration. Alfuzosin is less vasoactive than other non-subtype selective alpha1-receptor blockers. In addition to effects on lower urinary tract symptoms, it is also used as an adjunct to urethral catheterisation in patients with acute urinary retention related to benign prostatic hyperplasia, and can improve sexual function and health-related quality of life in benign prostatic hyperplasia sufferers.

Effect of dutasteride on the symptoms of benign prostatic hyperplasia, and patient quality of life and discomfort, in clinical practice

OBJECTIVE

To assess the improvements in symptoms, quality of life (QoL), discomfort and satisfaction in patients with symptomatic benign prostatic hyperplasia (BPH) treated with dutasteride in clinical practice.

PATIENTS AND METHODS

In a prospective, multicentre open-label study, we evaluated the efficacy and safety in clinical practice of dutasteride, 0.5 mg/day for 24 weeks, in patients with symptomatic BPH. The primary endpoint was the proportion of patients achieving at least a 3-point decrease from baseline in the International Prostate Symptom Score (IPSS) after 24 weeks of treatment. The secondary endpoints included changes from baseline in measures of QoL (IPSS item 8 and BPH Impact Index score, BII), and patient discomfort and satisfaction (visual analogue scales, VAS) at 12 and 24 weeks.

RESULTS

Of the 366 patients assessed, 72.5% achieved at least a 3-point reduction in IPSS at 24 weeks; the IPSS decreased from 15.3 at baseline to 10.2 at 12 weeks, and to 9.1 at 24 weeks. There were significant (P < 0.001) decreases in all the individual IPSS items at 12 and 24 weeks, with more marked improvements in voiding symptoms than storage symptoms. There were also significant (P < 0.001) improvements in the BII and VAS scores for patient discomfort and satisfaction at both times.

CONCLUSIONS

Dutasteride treatment for 24 weeks significantly improved BPH symptoms, QoL and patient discomfort and satisfaction, and was well tolerated in clinical practice.

Medical and minimally invasive therapies for the treatment of benign prostatic hyperplasia

Over the last decade, management of benign prostatic hyperplasia (BPH) has changed with a substantial decrease in the use of transurethral prostatectomy (TURP) and a simultaneous increase in the use of medical therapy and minimally invasive surgical therapy (MIST). The goal of management of this chronic progressive condition is not only to provide relief of lower urinary tract symptoms (LUTS) but also to reduce the lifetime risk of adverse outcomes. Recent clinical evidence has demonstrated a clear role for medical therapy, particularly with 5-alpha-reductase inhibitors (5ARIs) either alone or in combination with alpha-blockers, to reduce the risk of acute urinary retention and need for surgery and provide symptom relief. Clinical data on MISTs also indicate a more pronounced short-term effect; however, the long-term durability of these therapies remains uncertain. Minimally invasive surgical therapies confer treatment benefits in a single 1-h treatment session under local anesthesia. Recovery times and adverse events are improved compared with TURP, but issues such as hematuria, prolonged catheterization, urinary tract infection and retreatment remain commonly reported issues. Today, urologists are faced with the challenge of identifying the most appropriate treatment option for the long-term management of BPH. The initial choice for any given patient will depend on his presenting circumstances and the influence of treatment risks on these circumstances. Providing patients with informed treatment decisions is a key element of management.

Definition of at-risk patients: baseline variables

Benign prostatic hyperplasia (BPH) represents a significant burden in ageing men due to frequently associated lower urinary tract symptoms (LUTS), which may impair their quality of life. Some men will have progressive disease, mainly characterized by symptom deterioration of > or = 4 points on the International Prostate Symptom Score, but also by the occurrence of acute urinary retention (AUR) and BPH-related surgery. Identifying those at risk of unfavourable outcomes is important to optimize their management. Community-based longitudinal studies provide excellent data on the natural history of BPH. Baseline variables such as age, severe LUTS, low peak flow rate, high postvoid residual urine volume (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels, have been identified as risk factors for AUR and BPH-related surgery in such studies. Placebo arms of controlled studies have more limited value for assessing the natural history, due to strong selection criteria which generate a regression to the mean artefact and narrow the applicability to the general population. Nevertheless, in these controlled studies, baseline serum PSA level and to a lesser extent prostate size consistently predicted the risk of AUR and BPH-related surgery. Conversely, quantitative variables such as baseline symptom severity and peak flow rate behaved paradoxically, probably as a consequence of strict inclusion criteria, resulting regression to the mean, and 'ceiling' effects. Results from the Medical Therapy of Prostatic Symptoms study and the Alfuzosin Long-Term Efficacy and Safety Study also suggest that using the PVR in clinical practice needs to be reconsidered as a predictor of BPH progression. Further research is needed to clarify the role of chronic inflammation in the process of BPH progression.

Risk Factors for Benign Prostatic Hyperplasia in South Korean Men

OBJECTIVES

Benign prostatic hyperplasia (BPH) is the most common prostate disease in middle-aged and elderly men, and leads to severe impairment in later life. Despite the significant effect on public health, the causes of BPH have received little attention. Identifying risk factors for BPH is crucial for understanding the etiology and for determining effective interventions or targeting strategies.

METHODS

This survey was performed in two steps: (1) a pilot study was first conducted prior to the main study in order to estimate baseline characteristics, and (2) the main study investigated the prevalence and risk factors of BPH using clinical diagnostic tests and a questionnaire. A total of 641 males, aged 50-79 years, participated in this community-based cross-sectional study.

RESULTS

Age was the only significant demographic risk factor of BPH. The presence of chronic bronchitis and a high prostate-specific antigen (PSA) level increased the risk by three- and twofold, respectively. The risk decreased as drinking frequency increased. Physical activity 3-5 times/week reduced the risk relative to being active less than twice per week; however, engaging in physical activity nearly everyday increased the risk 1.7-fold relative to being active up to twice per week.

CONCLUSIONS

Although BPH has been considered a disease that is unavoidable with advancing age, the clear identification and control of the underlying risk factors might allow effective prevention by placing a special emphasis on those at risk.

Long-term sustained improvement in symptoms of benign prostatic hyperplasia with the dual 5alpha-reductase inhibitor dutasteride: results of 4-year studies

OBJECTIVE

To report additional analyses of efficacy over the initial 2 years and during a 2-year open-label extension of the three pivotal phase 3 studies in which dutasteride, a dual inhibitor of type 1 and 2 5alpha-reductase, was shown to be effective and well tolerated.

PATIENTS AND METHODS

All patients in the placebo and active groups were eligible for entry into the 2-year open-label extension, with all receiving dutasteride 0.5 mg daily. Mean changes from baseline were calculated for the American Urologic Association Symptom Index (AUA-SI) score at each scheduled time in the double-blind and open-label phase. The additional analyses included a breakdown of the AUA-SI score, including stratifying patients by symptom severity, assessment by baseline age and prostate volume, and the evaluation of symptoms responders.

RESULTS

There was a clinically meaningful improvement in AUA-SI in patients on dutasteride in the double-blind phase, but not in those on placebo. At 48 months, patients on dutasteride in both study phases had greater improvements in AUA-SI score and individual question scores than those on dutasteride in the open-label phase only. The proportion of patients with severe symptoms declined in both study groups, although these changes were more profound in those receiving dutasteride for the 4-year duration of the study.

CONCLUSION

In men with symptomatic benign prostatic hyperplasia, long-term (4-year) treatment with the dual isozyme 5alpha-reductase inhibitor dutasteride resulted in sustained and continued improvements in symptoms and flow rate. For 4 vs 2 years, longer dutasteride therapy resulted in greater symptom improvement.

Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia

OBJECTIVE

To evaluate the efficacy of tamsulosin compared to placebo for treating catheterized patients with acute urinary retention (AUR) caused by benign prostatic hyperplasia (BPH), by comparing the numbers of patients who voided successfully after removing their catheter.

PATIENTS AND METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, multicentre study. Men with AUR secondary to BPH were catheterized and then, if they fulfilled the entry criteria, were randomly assigned to receive either 0.4 mg tamsulosin hydrochloride in a modified-release capsule once daily, or a placebo. After up to eight doses the catheter was removed and the ability to void unaided assessed.

RESULTS

In all, 149 men (mean age 69.4 years) were randomly assigned to receive tamsulosin (75) or placebo (74); eight were not evaluable, so the intent-to-treat population was 141 men. Thirty-four men taking tamsulosin and 18 taking placebo did not require re-catheterization on the day of the trial without catheter (48% and 26% respectively, P = 0.011; odds ratio 2.47, 95% confidence interval, CI, 1.23-4.97). Success using free-flow variables was also higher in the men who received tamsulosin, at 37 (52%) vs 24 (34%) on placebo (P = 0.019; odds ratio 2.34, 95% CI 1.15-4.75). Withdrawals were high (120 men, 81%), mostly because of a need for re-catheterization (89 men, 60%). Dizziness and somnolence occurred in seven (10%) and four (6%) men who received tamsulosin, and two (3%) who received placebo, but overall the incidence of adverse events was similar in the two groups. One patient died from carcinomatosis.

CONCLUSION

Men catheterized for AUR can void more successfully after catheter removal if treated with tamsulosin, and are less likely to need re-catheterization. The side-effect profile was similar for tamsulosin and placebo, and consistent with known pharmacology. From these results tamsulosin can be recommended for treating men after catheterization for AUR, and can reduce the likelihood of the need for re-catheterization.

Transurethral resection in women with lower urinary tract symptoms

BACKGROUND

To evaluate the preliminary safety, efficacy and complications of transurethral resection (TUR) in the management of women with lower urinary tract symptoms.

METHODS

One hundred and eight women (mean age, 57.6 years) with moderate to severe lower urinary tract symptoms underwent TUR between September 1998 and December 2002. At preoperative baseline, 6 months and 24 months postoperatively, all patients underwent clinical evaluations including the standardized American Urological Association symptom score, peak urine flow, postvoid residual urine volume and quality-of-life assessments. Operative time, catheter time, hospital stay and incidence of side-effects were also recorded.

RESULTS

The total mean operative time was 19.25 +/- 6.70 min. The mean catheter time was 26.2 +/- 12.8 h and the mean hospital stay was 2.08 +/- 0.84 days. No patient needed a blood transfusion or experienced hyponatremia. The total storage and voiding symptom scores and quality of life score had improved significantly 6 months after the surgical procedure (P < 0.01). There were little changes in peak flow rate and residual urine volume. Complications of the procedure included urinary tract infections (n = 4) and stress incontinence (n = 3). Two patients later underwent bladder neck suspension procedure.

CONCLUSIONS

In this preliminary study, there was significant clinical improvement maintained at all follow-up intervals and the results were not comparable to TUR of the prostate in men with clinical benign prostatic hyperplasia. The risks associated with TUR in women, especially of stress incontinence, are significant. A multicenter clinical trial is currently underway to determine the long-term efficacy and safety of TUR in women.