An observational urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin

Benign Prostatic Obstruction Relief in Patients with Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Enlargement Undergoing Endoscopic Surgical Procedures or Therapy with Alpha-Blockers: A Review of Urodynamic Studies

Benign prostatic obstruction (BPO) contributes to the genesis of lower urinary tract symptoms as well as to pathologic remodeling of the lower and upper urinary tract in patients with benign prostate enlargement. Urodynamic studies demonstrate that both medical therapy with alpha-blockers (ABs) and endoscopic surgical procedures provide BPO relief. However, the magnitude of improvement is higher after surgery. Among ABs, silodosin is associated with the highest improvement of bladder outlet obstruction index (BOOI). A complex relationship exists between BOOI improvement and variations of both maximum urinary flow (Q _max) and detrusor pressure. When the reduction of BOOI is small, the improvement of Q _max is clinically irrelevant and the BOOI is mainly influenced by a decrease of detrusor pressure. In contrast, when the magnitude of BOOI reduction is robust, a meaningful improvement of both detrusor pressure and urinary flow is evident. When clustering ABs according to their receptor pharmacologic selectivity and urodynamic efficacy, three subgroups can be identified,with silodosin being the only member of a subgroup characterized by the highest levels of BOOI improvement and α-1A/α-1B receptor affinity ratio.

[S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

Overactive bladder and outlet obstruction in men

Lower urinary tract symptoms (LUTS), overactive bladder, (OAB), and benign prostatic hyperplasia (BPH) are very commonly experienced in men. The mainstay of pharmacotherapy for OAB is the antimuscarinic class of drugs. There has been reluctance to prescribe these agents to men with BPH due to the risk of precipitating urinary retention. Several trials have supported the efficacy and safety of antimuscarinics in treating men with LUTS, alone, or in combination with α-blocker therapy. The combination of 5-α-reductase inhibitors with antimuscarinic agents or surgery are other effective treatments for men with BPH and OAB.

Use of sympathetic alpha antagonists in the management of pediatric urologic disorders

PURPOSE OF REVIEW

To update the physician regarding the use of alpha-adrenergic antagonists in the management of various pediatric urologic problems.

RECENT FINDINGS

The use of alpha-adrenergic antagonist for the treatment of pediatric urologic disorders has expanded greatly over the past decade. This review summarizes the current use of these medications in the treatment of pediatric voiding dysfunction, neurogenic bladder, chronic lower urinary tract symptomatology, idiopathic urethritis, and the passage of ureteral calculi.

SUMMARY

Currently alpha antagonist therapy although not useful in the primary treatment of voiding dysfunction is equivalent in potency to biofeedback therapy for the treatment of recalcitrant voiding dysfunction. In the management of neurogenic bladder and chronic lower urinary tract symptomatology, alpha antagonists working alone or in conjunction with anticholinergic medications will improve clinical symptoms, increase bladder compliance, and decrease detrusor instability. In addition, alpha antagonists may decrease the intensity and duration of symptoms in patients with idiopathic urethritis. Compared with placebo, alpha-adrenergic antagonists will also aid significantly in the spontaneous passage of distal ureteral calculi, thereby reducing the need for surgical intervention and analgesia. The findings noted above significantly expand the clinical usefulness of alpha antagonist therapy within the field of pediatric urology.

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.

Combined use of alpha-adrenergic and muscarinic antagonists for the treatment of voiding dysfunction

PURPOSE

We provide an overview of the medical literature supporting the combined use of muscarinic and alpha-adrenergic antagonist therapy for the treatment of voiding dysfunction.

MATERIALS AND METHODS

The MEDLINE database (1966 to 2004) of the United States National Library of Medicine was searched for pertinent studies.

RESULTS

Although the mechanism of action of alpha-adrenergic antagonist therapy for voiding dysfunction has traditionally been assumed to be relaxation of the periurethral, prostatic and bladder neck smooth muscle, substantial evidence supports action at extraprostatic sites involved in micturition, including the bladder dome smooth muscle, peripheral ganglia, spinal cord and brain. Likewise the mechanism of action of anticholinergic therapy has been traditionally assumed to be inhibition of the M3 muscarinic receptor subtypes that mediate normal bladder contractions. However, M2 receptor mediates hypertrophied bladder contractions and there is evidence for an M2 component to the suprasacral control of voiding.

CONCLUSIONS

Based on the physiology of alpha-adrenergic and muscarinic receptors the inhibition of each one would be expected to be more beneficial than that of either alone because they would work on 2 components of detrusor function. Patients who would likely benefit from this combination therapy are men with lower urinary tract symptoms, women with urgency/frequency syndrome (overactive bladder), patients with uninhibited bladder contractions due to neurogenic bladder, and patients with pelvic pain and voiding symptoms, ie interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome.

Diagnosis and treatment of primary bladder neck obstruction in men

Although primary bladder neck obstruction was first described approximately 70 years ago, it is within the past 20 years that the symptoms, signs, and methods of diagnosis and treatment have been elucidated. This article describes its typical presenting symptoms and signs that commonly may lead to a missed diagnosis for a number of years in many cases. The treatments typically available are pharmacologic or surgical. Unfortunately, most treatments have not been studied in prospective, randomized trials to assess true efficacy. The natural history of this disorder, both treated and untreated, demands much further study to determine its effect on progression of symptoms and bladder and renal function.

Change in parameters before and after alpha-1-blocker therapy for men with lower urinary tract symptoms using color doppler ultrasound urodynamics: possible application for prediction of clinical outcome

INTRODUCTION

We previously developed a noninvasive video urodynamic study using color Doppler ultrasonography. We sought the best flow velocity-related parameter which would allow prediction of an improvement in lower urinary tract symptoms (LUTS) after alpha 1-blocker treatment.

METHODS

Twenty-two men with benign prostatic hyperplasia who were treated with a nonselective alpha 1-blocker (urapidil) were included. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) before and after alpha 1-blocker treatment. We measured the flow velocities using a transperineal ultrasound technique in the distal prostatic urethra just proximal to the external urethral sphincter (V1) and in the sphincteric urethra (V2), and used them to obtain the velocity ratio (VR=V1/V2). The corresponding functional cross-sectional areas of the urethra at these two sites (A1 and A2) were calculated as Q(max)/V. All these parameters obtained by the velocity-flow urodynamics were compared before treatment and after 4 weeks.

RESULTS

After treatment, V1 and VR were decreased, and A1 was increased. V2 correlated best with the change in IPSS before and after alpha 1-blocker therapy, with Spearman's rho of 0.584. All men with V2 exceeding 50 cm/s did not show an improvement in the LUTS.

CONCLUSIONS

The maximum flow velocity at the sphincteric urethra (V2) can predict the subjective outcome of alpha 1-blocker treatment. The velocity-flow parameters changed after alpha 1-blocker treatment. We confirmed that the transperineal ultrasound urodynamic study is not only noninvasive but also informative.

Overactive bladder in the male patient: bladder, outlet, or both?

Generations of urologists have presumed that the cause of lower urinary tract symptoms (LUTS) in men is infravesical (prostatic) obstruction. When symptoms such as urinary urgency and frequency can't easily be explained directly by obstruction, secondary effects of obstruction on the bladder are identified as causative factors. Although to some extent this explanation may still be accurate, emerging concepts in the pathophysiology of LUTS in men may be at odds with these traditional explanations. The idea that primary bladder pathology may explain the symptom complex in at least one subset of men with LUTS has both experimental and clinical support. This review discusses the physiologic and clinical observations used to explain the mechanisms underlying LUTS. Specifically, this review focuses on two data sets: one supporting infravesical obstruction as the causative factor for LUTS, and another positing that a primary bladder abnormality is responsible.

Overactive bladder in men: special considerations for evaluation and management

Lower urinary tract symptoms (LUTS) in men may arise from a variety of underlying causes, including benign prostatic hyperplasia. LUTS may have a significant component of storage symptoms (urgency, frequency, urge incontinence) at presentation; however, the absence of overactive bladder (OAB) symptoms does not necessarily imply pure outlet obstruction nor does their presence indicate the lack thereof. Symptomatic correlates to urodynamic findings are high when considering isolated OAB symptoms. However, mixed presentations or more overtly obstructive scenarios have less correlation with baseline symptom appraisal instruments. The ideal approach for diagnosis and management is predicated on a graded approach, with more invasive evaluation withheld for those men in whom presumptive therapy fails or who present with associated complex symptoms and in whom a higher level of intervention is being considered. The increasing incidence of LUTS with age implies a partial detrusor contribution, which must be considered in the overall management schema.

alpha-Blockade improves symptoms suggestive of bladder outlet obstruction but fails to relieve it

PURPOSE

We investigated the effect of the alpha-blockers alfuzosin, terazosin and tamsulosin on urodynamic parameters after 6 months of therapy.

MATERIALS AND METHODS

Between February 1992 and June 1998, 163 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction were treated with alfuzosin (60), terazosin (66) and tamsulosin (37). Patients were evaluated with urodynamic studies, including pressure flow analysis, before treatment and after 6 months of therapy. Initially, all patients were also assessed by the International Prostate Symptom Score questionnaire and measurement of urinary flow rate.

RESULTS

The majority of patients had no clear improvement in obstructive parameters, regardless of the alpha-blocker used, as urethral resistance factor and detrusor pressure maximum flow rate decreased by only 4 cm. H2O. There was a clear subjective and statistically significant decrease in International Prostate Symptom Score and quality of life scores of 6 and 2 points, respectively. No relevant statistical difference was noted among the effects of the 3 alpha-blockers on relieving symptoms or improving urodynamic parameters of obstruction.

CONCLUSIONS

The alpha-blockers are effective for treating symptoms suggestive of bladder outlet obstruction in patients presenting with lower urinary tract symptoms but not for treating the obstruction.

Tamsulosin in men with confirmed bladder outlet obstruction: a clinical and urodynamic analysis from a single centre in New Zealand

OBJECTIVE

To evaluate the clinical and pressure-flow effects of tamsulosin 0.4 mg once daily in patients with lower urinary tract symptoms (LUTS) caused by benign prostatic obstruction (BPO), as documented by pressure-flow studies performed according to a standardized protocol in one centre.

PATIENTS AND METHODS

A single-centre study was conducted with an open-label design comprising a 2-week, single-blind, placebo run-in period and a 12-week active treatment period with tamsulosin 0.4 mg once daily. Eligible patients were men (aged > or = 45 years) with LUTS (total International Prostate Symptom Score, IPSS, > or = 13) with a free-flow maximum urinary flow rate (Qmax) of > or = 4 mL/s for a voided volume of > or = 120 mL. After the 2-week placebo run-in period, only patients with BPO (i.e. in the obstructed zone of the Abrams-Griffiths, AG, nomogram) received active treatment with tamsulosin. The two primary efficacy variables were the change in detrusor pressure at maximum flow (PdetQmax) and the total IPSS, from baseline to endpoint. A standardized protocol was used for all pressure-flow studies.

RESULTS

In all, 42 patients were enrolled into the 2-week placebo run-in period, after which 30 received active treatment with tamsulosin 0.4 mg once daily. All 12 patients (29%) who discontinued during the placebo run-in period failed to fulfil the pressure-flow entry criterion of confirmed obstruction. The 30 patients who received tamsulosin had a high mean PdetQmax (82.1 cm H2O) and high mean AG number (68.1) at baseline, as would be expected in obstructed patients. Tamsulosin produced a significant reduction in mean PdetQmax (-10.6 cm H2O or -13%; P = 0.005 vs baseline). The mean AG number decreased accordingly (-15.5 points or -23%; P < 0.001 vs baseline). The pressure-flow mean Qmax was increased by 2.5 mL/s (36%) from 7.0 mL/s at baseline (P = 0.002 vs baseline). Urodynamic improvements were accompanied by a good symptomatic response; the mean total IPSS was reduced by 6.7 points from a baseline value of 18.1 (-37%, P < 0.001 vs baseline). At the endpoint, 67% of patients had a clinically significant symptomatic response (defined as a decrease in total IPSS of > or = 25% from baseline). Twenty-six patients (87%) were either slightly improved (13) or were much improved (13) in the opinion of the investigator. Twelve patients with LUTS who were unobstructed after the 2-week placebo run-in (PdetQmax 44.1 cm H2O) received tamsulosin treatment outside of the study protocol. Although these patients had no decrease in mean PdetQmax, the magnitude of the symptomatic response (decrease in total IPSS -6.4 or -34%, P = 0.001) was comparable with that in unobstructed patients; the free-flow Qmax was also significantly improved. Possibly or probably drug-related adverse events were reported in nine patients; one discontinued tamsulosin treatment because of a serious adverse event.

CONCLUSION

Tamsulosin 0.4 mg once daily can produce a significant decrease in detrusor pressure, increase in flow rate and a symptomatic improvement in patients with LUTS and confirmed obstruction. Patients with LUTS who are unobstructed and have a low initial detrusor pressure appear to have no improvement in detrusor pressure, but have similar clinical responses to those in obstructed patients. Pressure-flow studies can be reserved for those patients with LUTS who fail to respond to these agents and in whom further diagnosis and management is warranted.

Benign prostatic hyperplasia: challenges for the new millennium

The understanding and therapy of benign prostatic hyperplasia (BPH) has become more complex recently. The molecular mechanisms and growth factors involved in BPH need to be elucidated in the new millennium. The current classification of disease reflects the varied pathophysiologic mechanisms causing lower urinary tract symptoms (LUTS). In addition, symptom scores have improved evaluation of men with BPH, yet 'bother' and 'health-related quality of life' should be better recognized as significant outcome parameters. Clinical evaluation with laboratory markers specific for BPH or LUTS is currently inadequate. Yet, urodynamic evaluation should remain an important aspect of evaluation to guide selection of therapy. Recently medical therapy has expanded to include uroselective alpha blockade and phytotherapy, yet more research is needed. The most significant growth in the field, however, is in minimally invasive therapies of the prostate. Long-term comparative prospective multicenter studies are needed to properly evaluate the outcomes of new technologies compared to traditional procedures that are considered standard of care.

Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder

Lower urinary tract symptoms (LUTS), benign prostatic obstruction (BPO), and the overactive bladder have increasing prevalence with age in both men and women (with the obvious exception). The question is, are they interrelated or independently related to age? The specific issue is whether BPO causes the overactive bladder. There are two pieces of evidence that might appear to suggest such a cause and effect. First, the overactive bladder is more common in men than in women of the same age, although physiologically, men are 5-10 years older at the same biological age. Second, the overactive bladder resolves in two-thirds of individuals after surgical interventions such as transurethral prostatectomy. The symptoms suggestive of an overactive bladder are the most troublesome, even though they may not be the most prevalent. Long-term follow-up studies with repeated urodynamic investigations have shown that the incidence of the overactive bladder and its attendant symptoms increases despite there being no deterioration in outlet obstruction over follow-up periods of 10 and 20 years. These data, and others, indicate that the situation is not as straightforward as some believe. The statement that 'the overactive bladder is secondary to BPO' cannot be made, as there are too many unanswered questions and pieces of the puzzle that do not fit. The overactive bladder is undoubtedly associated with BPO, and it leads to the most troublesome LUTS in older men. Epidemiological research, coupled with urodynamic evaluation, may provide further evidence. We also need better and more relevant models (e.g. ageing animals), together with further histological and other biological data before the waters become crystal clear.

Interstitial laser coagulation in patients with lower urinary tract symptoms from benign prostatic obstruction: treatment under sedoanalgesia with pressure-flow evaluation

OBJECTIVES

To evaluate the effects on lower urinary tract symptoms and pressure-flow variables after interstitial laser coagulation (ILC) of the prostate using the Indigo diode laser system (Indigo, Palo Alto, USA).

PATIENTS AND METHODS

Forty-nine men (median age 68 years, range 52-80) were assessed using symptom scores and voiding variables before and at 3 and 12 months after ILC. A subset of 26 men (median age 68 years, range 63-72) underwent pressure-flow measurements before and at 6 months after ILC. All treatments were performed in the outpatient department using sedoanalgesia.

RESULTS

The International Prostate Symptom Score decreased from 22 to 11 at 12 months after ILC. The peak urinary flow (Qmax ) was 8.6 mL/s at baseline and increased to 9.9 mL/s at 12 months. Residual urine volumes were unchanged. The median duration of urinary retention after ILC was 3 days. From pressure-flow recordings, 17 patients were categorized as obstructed and seven as equivocally obstructed before ILC (using the International Continence Society definition). Their Qmax increased from 7.7 to 9.0 mL/s after 6 months, the detrusor pressure at Qmax decreased from 68 to 51 cmH2O and the Abrams-Griffiths number decreased from 54 to 29 (P<0.01). Patients with moderate to equivocal obstruction had a greater relief of symptoms than those who were clearly obstructed. Patients with prostate volumes of >40 mL had a greater decrease in the Abrams-Griffiths number than had patients with smaller prostates. Postoperative perineal pain was reported by 72% of patients; the pain subsided after 1-2 weeks. The re-treatment rate was 15% within the first year.

CONCLUSION

Treatment with ILC produced substantial effects on symptoms and moderate to small changes in urodynamic variables. Patients with moderate or equivocal bladder outlet obstruction or large prostates seem to be the best candidates for this treatment. However, treatment was followed by perineal pain for 1-2 weeks in most cases. A long-term follow-up is necessary to determine the role of ILC.

The medical management of lower urinary tract symptoms and benign prostatic hyperplasia

Prostatism is a widely used term assigned to the symptom complex of older men with voiding dysfunction. The cause of the syndrome has routinely been ascribed to an enlarged prostate. More recent thinking recognizes that many men with such symptoms do not, in fact, have prostate enlargement or benign prostatic hyperplasia (BPH) and that such symptoms are not a surrogate for BPH. Such recognition is essential if cost effective medical management of lower urinary tract symptoms (LUTS) is to be achieved. Prostate volume has emerged as a key factor in the selection of medical therapy of LUTS and BPH not only regarding symptom relief but also to the newer concept of the prevention of disease progression and the avoidance of future adverse events in those men with true BPH. In the United States, medical management is now first line therapy for LUTS. The proper selection of therapy based on the patient's individual pathophysiologic characteristics is now made possible by many new recent studies within the medical literature.

Saw palmetto (Serenoa repens) in men with lower urinary tract symptoms: effects on urodynamic parameters and voiding symptoms

OBJECTIVES

To assess the effects of saw palmetto on voiding symptoms and urodynamic parameters in men with lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH).

METHODS

Fifty men with previously untreated LUTS and a minimum International Prostate Symptom Score (IPSS) of 10 or greater were treated with a commercially available form of saw palmetto (160 mg twice per day) for 6 months. The initial evaluation included measurement of peak urinary flow rate, postvoid residual urine volume, pressure-flow study, and serum prostate-specific antigen (PSA) level. Patients completed an IPSS, serum PSA was determined, and flow rate was measured every 2 months during the course of the study. A urodynamic evaluation was repeated at the completion of the 6-month trial.

RESULTS

The mean IPSS (+/-SD) improved from 19.5+/-5.5 to 12.5+/-7.0 (P <0.001) among the 46 men who completed the study. Significant improvement in the symptom score was noted after treatment with saw palmetto for 2 months. An improvement in symptom score of 50% or greater after treatment with saw palmetto for 2, 4, and 6 months was noted in 21% (10 of 48), 30% (14 of 47), and 46% (21 of 46) of patients, respectively. There was no significant change in peak urinary flow rate, postvoid residual urine volume, or detrusor pressure at peak flow among patients completing the study. No significant change in mean serum PSA level was noted.

CONCLUSIONS

Saw palmetto is a well-tolerated agent that may significantly improve lower urinary tract symptoms in men with BPH. However, we were unable to demonstrate any significant improvement in objective measures of bladder outlet obstruction. Placebo-controlled trials of saw palmetto are needed to evaluate the true effectiveness of this compound.

Urodynamic effects of various treatment modalities for benign prostatic hyperplasia

PURPOSE

I studied the effects of various treatments for benign prostatic hyperplasia on urethral resistance.

MATERIALS AND METHODS

I reviewed the literature on urodynamic effects of treatments for benign prostatic hyperplasia. Articles that reported pretreatment and posttreatment values of relevant urodynamic parameters were analyzed. Average before and after treatment values of maximum flow rate and detrusor pressure at maximal flow rate for every study were plotted on an Abrams-Griffiths nomogram and classified as obstructed, equivocal or nonobstructed. Average values of maximum flow rate and detrusor pressure at maximal flow rate were calculated for the total number of patients treated by a certain modality.

RESULTS

Based on this analysis, the rank order of urodynamic efficacy was that open prostatectomy is more effective in reducing urethral resistance than is transurethral prostatectomy. These treatments diminish obstruction better than laser treatment or transurethral incision of the prostate, which again are more effective than balloon dilation, alpha-blockers or transurethral microwave thermotherapy. Finally, androgen deprivation performs better than placebo treatment.

CONCLUSIONS

The rank order of urodynamic efficacy as determined in this analysis shows a high level of agreement with reported rank order of symptomatic efficacy of various modalities. After placebo treatment there is no significant change in urethral resistance. This finding indicates that pressure-flow studies are a sensitive way to compare active to placebo treatment and that pressure-flow studies have excellent long-term reproducibility.

Doxazosin in men with lower urinary tract symptoms: urodynamic evaluation at 15 months

OBJECTIVES

To assess the results of doxazosin treatment in men with lower urinary tract symptoms (LUTS) treated for 15 months and to correlate symptomatic changes with alterations in urodynamic measures.

METHODS

After an initial 3-month treatment period with doxazosin 4 mg/day, 50 men with LUTS were given the choice of continued treatment with this agent or other therapeutic options. All patients were evaluated by International Prostate Symptom Score (IPSS) questionnaires and urodynamic evaluation initially and after 3 months of treatment. Patients were followed for an additional 12 months and those who continued doxazosin treatment underwent repeat urodynamic testing.

RESULTS

Among the original 50 patients, 24 men (48%) continued doxazosin treatment for 15 months, 18 men (36%) discontinued therapy, and 8 men (16%) were either dead or lost to follow-up or had been diagnosed and treated for prostate cancer. Comparison of values at 3 and 15 months of follow-up (9.4 versus 13.4, P = 0.03) showed significant worsening of voiding symptoms, as assessed by the IPSS, in the 24 men still receiving doxazosin. This deterioration of subjective results with doxazosin occurred despite continued improvements in peak urinary flow rate (Qmax), detrusor pressure at peak flow (PdetQmax), and objective measures of obstruction (Abrams-Griffiths number) from 3 to 15 months of follow-up.

CONCLUSIONS

Relief of voiding symptoms in men with LUTS treated with doxazosin over prolonged intervals of 15 months does not correlate well with changes in urodynamic measures.