Clinical and urodynamic assessment of alpha-adrenolytic therapy in patients with neurogenic bladder function

Tamsulosin: Efficacy and Safety in Patients With Neurogenic Lower Urinary Tract Dysfunction Due to Suprasacral Spinal Cord Injury

PURPOSE

We evaluated the efficacy and safety of tamsulosin in patients with neurogenic lower urinary tract dysfunction secondary to suprasacral spinal cord lesions in a 4-week randomized controlled trial (RCT) followed by a 1-year, open label, long-term study.

MATERIALS AND METHODS

A total of 263 patients were randomized to 4-week double-blind therapy with placebo, or 0.4 or 0.8 mg tamsulosin once daily. Of these, 244 patients completed the RCT, 186 continued long-term tamsulosin therapy (0.4 or 0.8 mg once daily) and 134 completed 1-year treatment. The primary efficacy parameter was maximum urethral pressure (MUP).

RESULTS

Although the mean decrease in MUP at 4 weeks in the RCT did not reach statistical significance over the placebo, it was more pronounced with 0.4 (-12.2 cm H2O or -10%) and 0.8 mg (-9.6 cm H2O or -9%) tamsulosin than placebo (-6.5 cm H2O or -3%). In the long-term study there was a statistically significant mean decrease in MUP (-18.0 cm H2O, p <0.001 or -15%) from baseline to end point. In the long-term study tamsulosin also decreased maximum urethral closure pressure, improved several cystometry parameters related to bladder storage and emptying, and increased to a statistically significantly degree, from baseline to end point, mean voided volume based on the micturition diary. There was statistically significant improvement for the International Prostate Symptom Score Quality of Life, as well as several questions about symptoms related to urinary leakage, and 1 question on bladder emptying and frequency, bother and severity of symptoms of autonomic dysreflexia. Finally, 71% of patients improved according to investigators (44% slightly and 27% much improved). Both doses were effective and well tolerated.

CONCLUSIONS

Long-term tamsulosin treatment (0.4 and 0.8 mg once daily) seems to be effective and well tolerated in patients with neurogenic lower urinary tract dysfunction. The results suggest that it improves bladder storage and emptying, and decreases symptoms of autonomic dysreflexia.

Alfuzosin in the treatment of high leak-point pressure in children with neurogenic bladder

OBJECTIVE

To decrease the detrusor leak-point pressure (LPP) of > 40 cmH2O in children with a neurogenic bladder, using the alpha1-adrenergic blocking agent alfuzosin.

PATIENTS AND METHODS

Videocystometry was used to measure the detrusor LPP and several other variables before and 3 weeks after the oral administration of alfuzosin (2.5-7.5 mg/day) in 17 children (mean age 6.3 years) with an upper motor neurone lesion.

RESULTS

The mean (sd) detrusor LPP decreased from 68 (37) to 46 (31) cmH2O (P < 0.01), reflex volume (defined as the volume at the first uninhibited bladder contraction of > 15 cmH2O) increased from 78 (69) to 112 (118) mL (+ 44%), bladder compliance increased from 9.3 (6.1) to 19.6 (14.6) mL/cmH2O (+ 111%), maximal vesical pressure decreased from 84 (40) to 70 (47) cmH2O (- 17%), and the mean number of uninhibited bladder contractions decreased from 6.3 to 3.5 (- 44%). The therapy was well tolerated; side-effects were rare and not severe. Intermittent catheterization could be avoided in six children.

CONCLUSION

Alfuzosin decreases the detrusor LPP in children with a neurogenic bladder caused by an upper motor neurone lesion, significantly and therapeutically, and should be considered as an alternative or addition to intermittent catheterization and anticholinergic drugs in selected patients.

Phenoxybenzamine in the management of neuropathic bladder following spinal cord injury

BACKGROUND

The present study aims to show the clinical and urodynamic effects of phenoxybenzamine on the neuropathic bladder of spinal cord-injured patients who failed to be free of catheter by attaining satisfactory voiding function, despite initial bladder training.

METHODS

Forty-six spinal cord-injured patients were subjected to pharmacological manipulation with phenoxybenzamine. It was used as an adjunct in the management of neuropathic bladder dysfunction that caused failure of the bladder to empty, by tapping or crede to achieve satisfactory residual urine volume of < 100 mL. Phenoxybenzamine was started with a dose of 10 mg daily, increased by 10 mg every 3 days to a dose of 30 mg daily; this was maintained from 3 weeks to 6 months (mean: 39 days). The pre-treatment residual urine volume ranged between 100 and 1050 mL (mean: 360 mL). Follow-up periods ranged between 12 and 36 months (mean: 16 months).

RESULTS

Five patients (11%) were excluded due to either inadequate treatment or inadequate follow-up. Nineteen patients (41%) with reflex (upper motor neurone) bladders showed improvement of bladder evacuation. There was a reduction of the maximum urethral closure pressure, which ranged between 10 and 32 cm of water (mean: 22 cm). Twenty-two patients (48%) did not respond, requiring other measures to be taken which included transurethral surgery (n = 19). Nine of the failures involved areflex (lower motor neurone) bladders, and seven failures involved reflex bladders with an extremely tight outlet and urethral closure pressure of > 50 cm of water. Six failures involved reflex bladders that were lacking strong enough detrusor contractions to attain a balanced bladder responsive to abdominal tapping; response was achieved by administration of a parasympatheticomimetic drug. Neuropathic bladders with uninhibited detrusor contractions responded well to phenoxybenzamine.

CONCLUSIONS

Phenoxybenzamine proved useful in reducing bladder outlet resistance after spinal cord injury, provided that detrusor bladder contractions were present. It is useful in controlling detrusor-sphincter dyssynergia and autonomic hyperreflexia. It was not useful in areflex bladders, perhaps due to the development of spasticity of the striated muscle component of the external sphincter. The presence of bladder neck (internal sphincter) dysfunction may modify or abolish its effect.

Alpha-adrenoceptor antagonists in neurogenic lower urinary tract dysfunction

Lower urinary tract dysfunction is common in patients with a variety of neurological diseases, and may lead to debilitating symptoms and serious complications. Any treatment that can reduce these symptoms or complications is welcome. In many trials, alpha-adrenoceptor antagonists (alpha blockers) have been evaluated as treatment for neurogenic lower urinary tract dysfunction; however, these have generally been small and often nonrandomized, uncontrolled studies. Existing evidence suggests that alpha blockers may have a small but useful effect in the facilitation of storage and emptying, and in the prevention of autonomic dysreflexia. Better understanding of lower urinary tract physiology and larger clinical trials with longer follow-up will hopefully clarify the role of alpha blockers in the future.

Effect of intravenous alfuzosin on urethral pressure in patients with neurogenic bladder dysfunction. DORALI Study Group

In order to assess the ability of a single intravenous (i.v.) injection of alfuzosin, a selective alpha-1 blocker, in reducing high urethral tone in patients with symptomatic neurogenic bladder dysfunction (NBD), 163 patients (mean maximal urethral pressure [MUP] 108 +/- 46 cm H2O) were enrolled in a double-blind, placebo-controlled, parallel-group trial and were randomly allocated to receive 0.5 mg (n = 45), 1 mg (n = 41), 2 mg (n = 39) alfuzosin or placebo (n = 38). The decrease in MUP was dose-dependent and statistically significant (P < or = 0.05) for 1 and 2 mg alfuzosin (respectively, 43 +/- 28 cm H2O and 46 +/- 27 cm H2O decreases vs. baseline) in comparison with placebo (23 +/- 30 cm H2O). The 2 mg dose level was the most effective leading to a > or = 30 or 50% decrease in MUP in, respectively, 69 and 44% of patients. The safety of all three alfuzosin dose levels was satisfactory and comparable to placebo. I.v. alfuzosin induces, in a dose-related manner, a clinically significant decrease in urethral pressure in patients with NBD and high urethral tone, and may be safely used as a pharmacological test as part of an urodynamic investigation.

Conservative management of vesicoureteric reflux in the congenital neurogenic bladder

A series of 31 patients with congenital neurogenic bladder in which vesicoureteric reflux was managed conservatively by methods designed to improve voiding function is reported. Satisfactory results, in terms of the appearance of the upper urinary tracts on IVU, were obtained by indwelling urethral catheter, or by alpha-adrenergic blockade, internal urethrotomy or external urethral sphincterotomy; in the case of the last 3 procedures this was accompanied by diminution or resolution of vesicoureteric reflux. Less satisfactory results were obtained by intermittent self catheterisation and in patients managed in this way a case exists for ureteric reimplantation.