Enlarged prostate: A landmark national survey of its prevalence and impact on US men and their partners

Causal relationship between benign prostatic hyperplasia and prostate cancer: a bidirectional Mendelian randomization analysis

OBJECTIVE

Our aim is to explore the relation between benign prostatic hyperplasia (BPH) and prostate cancer (PCa) from a genetic level utilizing Mendelian randomization (MR).

METHODS

The IEU genome-wide association studies database was surveyed for single nucleotide polymorphisms (SNPs) associated with BPH, PCa, and PCa (validation cohort). Single nucleotide polymorphisms were subjected to stringent quality control based on rigorous screening criteria. BPH and PCa risk were evaluated using the inverse-variance weighted method (IVW), MR-Egger, simple mode, weighted median, and weighted mode. Horizontal pleiotropy of single nucleotide polymorphisms was assessed using the MR-Egger intercept test, while heterogeneity was evaluated using Cochran's Q test. Reverse causality was assessed by evaluating PCa as the exposure and BPH as the outcome. A validation database was used to verify the exposure and outcome.

RESULTS

The risk of PCa increased significantly with genetically predicted BPH (IVW: OR [95% CI] = 1.3849 × 107 [2330, 8.2294 × 1010], P = 2.0814 × 10-4). In reverse MR analysis, PCa also increased the risk of BPH (IVW: OR [95% CI] = 1.0011 [1.0003, 1.0019], P = 0.0031). The findings were consistent with the MR analysis results of the PCa validation cohort. Sensitivity analyses indicated the presence of heterogeneity but no horizontal pleiotropy.

CONCLUSION

The study presents proof of a significant bidirectional causal relationship between genetically predicted BPH and an increased risk of PCa. Key message Three research questions and three bullet points  What is already known on this topic?  Observational studies suggest a controversial relationship between BPH and PCa. MR allows investigation of causality using genetic variants as instrumental variables (IVs). What does this study add?  The study presents proof of a significant bidirectional causal relationship between genetically predicted BPH and an increased risk of PCa. How this study might affect research, practice, or policy?  Recognizing the bidirectional relationship between BPH and PCa, men diagnosed with BPH may benefit from more stringent PCa screening protocols.

Comparative assessment of attitudes and expectations: Iranian patients versus urologists in the management of benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is common and presents as lower urinary tract symptoms (LUTS). Understanding patient concerns and treatment preferences is essential for effective management. This study aimed to investigate the attitudes, preferences, and expectations of Iranian patients with BPH, and compare them with those of urologists in addressing this condition.

METHODS

A cohort of patients diagnosed with BPH underwent assessment during their initial visit. Before any counseling, their attitudes, concerns, and expectations regarding benign prostate enlargement were evaluated using semi-structured interviews. Patient responses were analyzed based on educational levels and age. Additionally, correspondence was initiated with thirty urologists who graduated within the past twelve years to assess their attitudes toward BPH, concerns, and treatment approaches. Interview questions were constructed using the Delphi method, and their validity was confirmed. Responses from both groups were analyzed and compared. Descriptive statistics, independent t-test, Chi-squared test, Mann-Whitney U, and principal component analysis (PCA) with varimax rotation were used for statistical analysis.

RESULTS

The study comprised 261 patients and 30 urologists. Findings revealed that 86.2% of patients and 86.7% of urologists perceived a lack of sufficient patient knowledge about BPH. Patients across all educational levels and age groups expressed a desire for more information about their condition. Primary concerns among patients included exacerbation of urinary symptoms, potential malignancy, and sexual dysfunction. While patients generally preferred pharmacological treatments, those older than 75 years showed a significantly higher preference for surgical options. Conversely, urologists exhibited greater concern for long-term clinical complications associated with BPH. Results indicated significant parallels between the attitudes of urologists and patients in assessing the multifaceted impact of BPH on patient well-being.

CONCLUSION

This study enhances our understanding of patient attitudes and concerns regarding BPH, thereby facilitating more effective treatment strategies. Our findings encourage urologists to enhance patient perspectives by delivering comprehensive information. Furthermore, the comparison between patient and urologist attitudes towards BPH underscores the importance of tailored care and patient-centered approaches in optimizing outcomes for individuals with BPH.

Life disturbance and hospital visit experiences among Chinese patients with benign prostatic hyperplasia: a qualitative study

BACKGROUND

The impact of lower urinary tract symptoms (LUTS) on the quality of life of patients with benign prostatic hyperplasia (BPH) has been rarely reported. Additionally, the challenges faced by these patients in seeking medical care have often been overlooked. In order to explore the personal struggles caused by LUTS and the difficulties or barriers experienced by Chinese patients with BPH when seeking help, we conducted a qualitative interview study.

METHODS

Qualitative interviews were conducted among 46 patients with BPH who were hospitalized in three tertiary hospitals in China from July 2021 to November 2022. Grounded theory was adopted as the methodology for the qualitative study. After obtaining written informed consent from the study participants, semi-structured interviews were conducted according to the question guidelines. The interview process was audio-recorded; subsequently, the recordings were transcribed, coded, and thematically analyzed.

RESULTS

The difficulties faced by Chinese patients with BPH were classified into seven main themes: (i) disturbed life, (ii) mental burden, (iii) disease cognition and communication, (iv) delayed treatment, (v) medication status, (vi) hospital visits barriers, and (vii) medical insurance issues. Further, each theme was subdivided into 2-5 sub-themes.

CONCLUSIONS

LUTS have a certain effect on the life and spirit of patients with BPH. These patients face different degrees of difficulties in treatment and hospital visits. Therefore, better healthcare systems and additional social support are crucial for improving the current plight of these patients.

Is Race Associated with the Surgical Treatment for Benign Prostatic Hyperplasia? An Analysis of 30,000 Medicare Lives

BACKGROUNDS

With an increased prevalence and burden of benign prostatic hyperplasia (BPH), effective and equitable treatment is a priority. Limited data exist evaluating treatment disparities for patients with BPH by race. This study examined the association between race and BPH surgical treatment rates among Medicare beneficiaries.

METHODS

Medicare claims data were used to identify men newly diagnosed with BPH from January 1, 2010 through December 31, 2018. Patients were followed until their first BPH surgery, a diagnosis of prostate/bladder cancer, termination of Medicare enrollment, death, or end of study. Cox proportional hazards regression compared the likelihood of BPH surgery between men of different races (White vs. Black, Indigenous, and People of Color (BIPOC)), controlling for patients' geographical region, Charlson comorbidity score, and baseline comorbidities.

RESULTS

The study included 31,699 patients (13.7% BIPOC). BIPOC men had significantly lower BPH surgery rates (9.5% BIPOC vs. 13.4% White; p=0.02). BIPOC race was associated with a 19% lower likelihood of receiving BPH surgery than White race (HR, 0.81; 95% CI 0.70, 0.94). Transurethral resection of the prostate was the most common surgery for both groups (49.4% Whites vs. 56.8% BIPOC; p=0.052). A higher proportion of BIPOC men underwent procedures in inpatient settings compared to White men (18.2% vs. 9.8%; p<0.001).

CONCLUSIONS

Among a cohort of Medicare beneficiaries with BPH, there were notable treatment disparities by race. BIPOC men had lower rates of surgery than White men and were more likely to undergo procedures in the inpatient setting. Improving patient access to outpatient BPH surgical procedures may help address treatment disparities.

Cost-effectiveness analysis of minimally invasive surgical treatments for benign prostatic hyperplasia: implications for Japan's public healthcare system

AIMS

Benign prostatic hyperplasia (BPH) represents a significant public health issue in Japan. This study evaluated the lifetime cost-effectiveness of water vapor energy therapy (WAVE) versus prostatic urethral lift (PUL) for men with moderate-to-severe BPH from a public healthcare payer's perspective in Japan.

MATERIALS AND METHODS

A decision analytic model compared WAVE to PUL among males in Japan. Clinical effectiveness and adverse event (AE) inputs were obtained from a systematic literature review. Resource utilization and cost inputs were derived from the Medical Data Vision database and medical service fee national data in Japan. Experts reviewed and validated model input parameters. One-way and probabilistic sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affect the model results.

RESULTS

Throughout patients' lifetimes, WAVE was associated with higher quality-adjusted life years (0.920 vs. 0.911 year 1; 15.564 vs. 15.388 lifetime) and lower total costs (¥734,134 vs. ¥888,110 year 1; ¥961,595 vs. ¥1,429,458 lifetime) compared to PUL, indicating that WAVE is a more effective and less costly (i.e. dominant) treatment strategy across all time horizons. Lifetime cost-savings for the Japanese healthcare system per patient treated with WAVE instead of PUL were ¥467,863. The 32.7% cost difference between WAVE and PUL was predominantly driven by lower WAVE surgical retreatment rates (4.9% vs. 19.2% for WAVE vs PUL, respectively, at 5 years) and AE rates (hematuria 11.8% vs. 25.7%, dysuria 16.9% vs. 34.3%, pelvic pain 2.9% vs. 17.9%, and urinary incontinence 0.4% vs. 1.3% for WAVE vs PUL, respectively, at 3 months). Model findings were robust to changes in parameter input values.

LIMITATIONS

The model represents a simplification of complex factors involved in resource allocation decision-making.

CONCLUSIONS

Driven by lower retreatment and AE rates, WAVE was a cost-effective and cost-saving treatment for moderate-to-severe BPH in Japan compared to PUL, providing better outcomes at lower costs to the healthcare system.

Simvastatin Improves Benign Prostatic Hyperplasia: Role of Peroxisome-Proliferator-Activated Receptor-γ and Classic WNT/β-Catenin Pathway

Benign prostatic hyperplasia (BPH) is a common disease in elderly men with an uncertain etiology and mechanistic basis. Metabolic syndrome (MetS) is also a very common illness and is closely related to BPH. Simvastatin (SV) is one of the widely used statins for MetS. Peroxisome-proliferator-activated receptor gamma (PPARγ), crosstalking with the WNT/β-catenin pathway, plays important roles in MetS. Our current study aimed to examine SV-PPARγ-WNT/β-catenin signaling in the development of BPH. Human prostate tissues and cell lines plus a BPH rat model were utilized. Immunohistochemical, immunofluorescence, hematoxylin and eosin (H&E) and Masson's trichrome staining, construction of a tissue microarray (TMA), ELISA, CCK-8 assay, qRT-PCR, flow cytometry, and Western blotting were also performed. PPARγ was expressed in both prostate stroma and epithelial compartments and downregulated in BPH tissues. Furthermore, SV dose-dependently triggered cell apoptosis and cell cycle arrest at the G0/G1 phase and attenuated tissue fibrosis and the epithelial-mesenchymal transition (EMT) process both in vitro and in vivo. SV also upregulated the PPARγ pathway, whose antagonist could reverse SV produced in the aforementioned biological process. Additionally, crosstalk between PPARγ and WNT/β-catenin signaling was demonstrated. Finally, correlation analysis with our TMA containing 104 BPH specimens showed that PPARγ was negatively related with prostate volume (PV) and free prostate-specific antigen (fPSA) and positively correlated with maximum urinary flow rate (Qmax). WNT-1 and β-catenin were positively related with International Prostate Symptom Score (IPSS) and nocturia, respectively. Our novel data demonstrate that SV could modulate cell proliferation, apoptosis, tissue fibrosis, and the EMT process in the prostate through crosstalk between PPARγ and WNT/β-catenin pathways.

Pharmacotherapy vs. minimally invasive therapies as initial therapy for moderate-to-severe benign prostatic hyperplasia: a cost-effectiveness study

BACKGROUND

Recently, minimally invasive therapies (MITs), such as water vapor thermal therapy (WVTT) and prostatic urethral lift (PUL) have become an alternative to surgery or pharmacotherapy to manage benign prostatic hyperplasia (BPH), offering symptom relief with a favorable safety profile. The objective of this study was to evaluate the cost-utility of MITs (WVTT and PUL) compared to pharmacotherapy as initial treatment for patients with moderate-to-severe BPH.

METHODS

In this model-based economic evaluation we simulated BPH progression in men (mean age 65 years, average International Prostate Symptom Score 16.6) over their lifetime and estimated healthcare costs (from the US public payer perspective) per quality-adjusted life year (QALY), discounted at 3% annually. Various clinical scenarios were evaluated given that most men undergo several lifelong therapies up to surgical intervention and potentially thereafter. As such, in the study model men could receive up to three lines of therapy: (1) initial pharmacotherapy with MIT as second-line, and transurethral resection of the prostate (TURP) or pharmacotherapy as third-line; (2) initial MIT (WVTT or PUL) with MIT again, TURP or pharmacotherapy as second-line, and TURP as third-line. Model was populated using data from the published literature. Probabilistic analyses were performed.

RESULTS

Initial treatment with WVTT led to the highest QALYs (13.05) and the lowest cost ($15,461). The cumulative QALYs and lifetime costs were 12.92 QALYs and $20,280 for pharmacotherapy followed by WVTT, 12.87 QALYs and $22,424 for pharmacotherapy followed by PUL, 12.86 QALYs and $20,930 for initial treatment with PUL. In the cost-utility analysis, WVTT as initial treatment dominated all three strategies, i.e., generated more QALYs at a lower cost.

CONCLUSION

WVTT is an effective and cost-saving procedure, and may be an appropriate first-line alternative to pharmacotherapy for moderate-to-severe BPH patients who seek faster improvement and no lifelong commitment to daily medications.

Free combination of dutasteride plus tamsulosin for the treatment of benign prostatic hyperplasia in South Korea: analysis of drug utilization and adverse events using the National Health Insurance Review and Assessment Service database

Objective

To assess the use and safety of free combination therapy (dutasteride and tamsulosin), dutasteride monotherapy, or tamsulosin monotherapy in patients with benign prostatic hyperplasia (BPH).

Methods

This non-interventional retrospective cohort study used claims data from the Korea Health Insurance Review and Assessment-National Patient Sample database. Patients with BPH ≥ 40 years of age receiving combination therapy (dutasteride 0.5 mg and tamsulosin 0.4 mg daily) or dutasteride 0.5 mg, or tamsulosin 0.4 mg daily dose between 2012 and 2017 were included. The frequency, duration of treatment and risk of any adverse event (AE) or serious AE (SAE) was compared for combination therapy versus each monotherapy using non-inferiority testing.

Results

Of 14,755 eligible patients, 1529 (10.4%) received combination therapy, 6660 (45.1%) dutasteride monotherapy, and 6566 (44.5%) tamsulosin monotherapy. The proportion of patients treated with combination therapy exceeded the pre-specified 3% threshold for ‘frequent’ use. Safety results indicated a similar risk of any AE and SAE irrespective of treatment group. The adjusted relative risk for any AE over the treatment observation period comparing combination therapy with dutasteride monotherapy was 1.07 (95% confidence interval [CI] 1.03, 1.12), and with tamsulosin monotherapy was 0.98 (95% CI 0.95, 1.02) demonstrating non-inferiority. The adjusted relative risk for any SAE was 1.07 (95% CI 0.66, 1.74) and 0.90 (95% CI 0.56, 1.45), compared with dutasteride and tamsulosin monotherapy, respectively. Although the SAE results did not statistically demonstrate non-inferiority of combination therapy based on pre-specified margins, the 95% CI for the risk ratio estimates included the null with a lower limit below the non-inferiority margins, indicating no meaningful differences in SAE risk between groups. Absolute SAE risks were low.

Conclusion

Combination therapy with dutasteride and tamsulosin is frequently used in real-world practice in South Korea for treatment of BPH and demonstrates a safety profile similar to either monotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00941-1.

Cellular senescence as a possible link between prostate diseases of the ageing male

Senescent cells accumulate with age in all tissues. Although senescent cells undergo cell-cycle arrest, these cells remain metabolically active and their secretome - known as the senescence-associated secretory phenotype - is responsible for a systemic pro-inflammatory state, which contributes to an inflammatory microenvironment. Senescent cells can be found in the ageing prostate and the senescence-associated secretory phenotype and can be linked to BPH and prostate cancer. Indeed, a number of signalling pathways provide biological plausibility for the role of senescence in both BPH and prostate cancer, although proving causality is difficult. The theory of senescence as a mechanism for prostate disease has a number of clinical implications and could offer opportunities for targeting in the future.

Preservation of antegrade ejaculation after surgical relief of benign prostatic obstruction is a valid endpoint

PURPOSE

To review the current data on retrograde ejaculation (RE) and ejaculatory dysfunction (EjD) after endoscopic and minimally invasive surgical treatment of benign prostatic obstruction (BPO) and, their perceived impact in the quality of life (QoL) and sexual life of patients and their partners.

METHODS

Narrative review of systematic reviews (SR) assessing comparative rates of RE, EjD or erectile dysfunction (EF) was carried out. Relevant articles on the prevalence of RE, EjD or EF and on their impact in the QoL or sexual life of patients and partners were manually selected based on relevance.

RESULTS

Twelve SRs reporting on comparisons of different endoscopic/minimally invasive treatments of BPO were found. Data on outcomes varied widely. Overall, after conventional TURP or laser techniques 42-75% of patients present RE. Prostatic incision and ablative procedures present lowest rates of de novo RE or EjD whereas laser adenomectomy and ejaculation preservation procedures preserve antegrade ejaculation in 46-68% of patients. EjDs is associated to LUTS and present in 10% of sexualy active men before intervention. It modulates the QoL and sexual life of the couple. In spite of the scarce literature assessing patient's and partner's perception of postoperative EjD, it strongly suggests that both parties value the maintenance of the ejaculatory function.

CONCLUSION

Ejaculation-preserving techniques and minimally invasive techniques successfully prevent BPO treatment-induced RE or EjD in 70-100% of the cases. While this is appealing to patients and spouses, technique selection and treatment durability are issues to be discussed with the couple.

Eight Days of Water-Only Fasting Promotes Favorable Changes in the Functioning of the Urogenital System of Middle-Aged Healthy Men

The aim of this study was to determine whether, after 8 days of water-only fasting, there are changes in the efficiency of the lower urinary tract, the concentration of sex hormones, and the symptoms of prostate diseases in a group of middle-aged men (n = 14). For this purpose, before and after 8 days of water-only fasting (subjects drank ad libitum moderately mineralized water), and the following somatic and blood concentration measurements were made: total prostate specific antigen (PSA-T), free prostate specific antigen (PSA-F), follicle stimulating hormone (FSH), luteotropic hormone (LH), prolactin (Pr), total testosterone (T-T), free testosterone (T-F), dehydroepiandrosterone (DHEA), sex hormone globulin binding (SHGB), total cholesterol (Ch-T), β-hydroxybutyrate (β-HB). In addition, prostate volume (PV), volume of each testis (TV), total volume of both testes (TTV), maximal urinary flow rate (Qmax), and International Prostate Symptom Score (IPSS) values were determined. The results showed that after 8 days of water-only fasting, Qmax and IPSS improved but PV and TTV decreased significantly. There was also a decrease in blood levels of PSA-T, FSH, P, T-T, T-F, and DHEA, but SHGB concentration increased significantly. These results indicate that 8 days of water-only fasting improved lower urinary tract functions without negative health effects.

Evaluation of a 3-item screening tool to identify men with benign prostatic enlargement/obstruction in a primary care cohort

BACKGROUND

Benign prostatic hyperplasia (BPH), a progressive condition and common cause of lower urinary tract symptoms (LUTS), is underdiagnosed in primary care, impacting patient outcomes. Here, we evaluate the utility of a BPH screening tool in general practice, to identify men confirmed to have BPH after urologist assessment of diagnostic test results.

METHODS

A 3-item questionnaire was developed to discriminate between LUTS due to BPH versus other conditions and was translated and validated cross-culturally. Its utility was assessed in a cohort study (FDC116114/NCT02757963) conducted in 47 centers across France, Germany, Italy, Russia, and Spain. The study enrolled men ≥50 years of age presenting to general practice clinics with a score of ≥3 on the BPH screening tool or ≥8 on the International Prostate Symptom Score (IPSS). In total, 561 men completed the study. The primary endpoint was the proportion of patients with a urologist-confirmed BPH diagnosis among those with a positive result on the BPH screening tool (score ≥3) and serum prostate specific antigen (PSA) ≥2 ng/mL.

RESULTS

The primary endpoint was fulfilled; 88.3% (95% CI: 84.9, 91.2) of patients had urologist-confirmed BPH diagnoses among those with positive results on the BPH screening tool and serum PSA≥2 ng/mL, similar to the proportion seen with IPSS≥8 and serum PSA≥2 ng/mL (87.7%; 95% CI: 84.6, 90.4).

CONCLUSIONS

The BPH screening tool, in conjunction with serum PSA, demonstrated adequate predictive value by allowing general practitioners to quickly screen men presenting with different medical conditions but identified as having urological symptoms.

Benign prostatic hyperplasia - what do we know?

OBJECTIVES

To present historical and contemporary hypotheses on the pathogenesis of benign prostatic hyperplasia (BPH), and the potential implications for current medical therapies.

METHODS

The literature on BPH was reviewed. BPH is a prevalent disease with significant health and economic impacts on patients and health organisations across the world, whilst the cause/initiation of the disease process has still not been fully determined.

RESULTS

In BPH, pathways involving androgens, oestrogens, insulin, inflammation, proliferative reawakening, stem cells and telomerase have been hypothesised in the pathogenesis of the disease. A number of pathways first described >40 years ago have been first rebuked and then have come back into favour. A system of an inflammatory process within the prostate, which leads to growth factor production, stem cell activation, and cellular proliferation encompassing a number of pathways, is currently in vogue. This review also highlights the physiology of the prostate cell subpopulations and how this may account for the delay/failure in treatment response for certain medical therapies.

CONCLUSION

BPH is an important disease, and as the pathogenesis is not fully understood it impacts the effectiveness of medical therapies. This impacts patients, with further research potentially highlighting novel therapeutic avenues.

The use of Tiemann tip catheters for male intermittent self-catheterisation

Male catheterisation can be difficult to perform, especially in patients with an enlarged prostate gland or other potentially obstructive conditions in the lower urinary tract. Repeated and unsuccessful catheterisations, as well as causing trauma, pain and distress, can cause other conditions such as urethral strictures and 'false passages' (when the catheter is pushed through the urethral wall instead of passing down the urethra), which then require more costly interventions to correct. With an increasingly ageing population these complications are expected to rise, putting added strain on an already stretched health service. This article discusses the use of the Coudé (or Tiemann) tip catheter in patients presenting with these challenging catheterisations and, in particular, male patients performing intermittent self-catheterisation. Device design can help overcome obstructive difficulties, making catheterisation easier, less traumatic and more comfortable for the patient. A survey of 200 nurses working in the urology and continence field was undertaken to understand their awareness and usage of Coudé/Tiemann tip catheters in practice. It was found that many nurses and doctors were unaware of this type of catheter and its advantages and therefore did not use or offer it as an alternative to the more commonly used straight-tipped catheter. In the vast majority of cases when Tiemann tip catheters were used this occurred after failure with a straight-tipped catheter, or they were used with patients with benign prostatic hyperplasia or other potentially obstructive conditions. In many cases, the catheterisation was consultant initiated, despite the fact that intermittent self-catheterisation is instigated and taught mainly by nurses. This survey highlighted the need for better education for nurses and doctors in assessing the alternative catheter tips available to ensure successful catheterisation on first attempt.

Controlled release of dutasteride from biodegradable microspheres: in vitro and in vivo studies

The aim of the present work was to study the in vitro/in vivo characteristics of dutasteride loaded biodegradable microspheres designed for sustained release of dutasteride over four weeks. An O/W emulsion-solvent evaporation method was used to incorporate dutasteride, which is of interest in the treatment of benign prostatic hyperplasia (BPH), into poly(lactide-co-glycolide) (PLGA). A response surface method (RSM) with central composite design (CCD) was employed to optimize the formulation variables. A prolonged in vitro drug release profile was observed, with a complete release of the entrapped drug within 28 days. The pharmacokinetics study showed sustained plasma drug concentration-time profile of dutasteride loaded microspheres after subcutaneous injection into rats. The in vitro drug release in rats correlated well with the in vivo pharmacokinetics profile. The pharmacodynamics evaluated by determination of the BPH inhibition in the rat models also showed a prolonged pharmacological response. These results suggest the potential use of dutasteride loaded biodegradable microspheres for the management of BPH over long periods.

Sleep and partner-specific quality of life in partners of men with lower urinary tract symptoms compared with partners of men from the general population

OBJECTIVE

The aims of this study were to examine differences between partners of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) and partners of men from the population regarding sleep and two aspects of quality of life, partner-specific quality of life and health-related quality of life (HRQoL), and to identify factors related to the partner-specific quality of life and the parameter sleep efficiency.

MATERIALS AND METHODS

The design was descriptive and comparative. The subjects were partners of men with LUTS suggestive of BPO (n = 126) and partners of randomly selected men from the general population (n = 131). Self-administered questionnaires about demography, comorbidity, sleep, sexuality, partner-specific quality of life and HRQoL were used.

RESULTS

Partners of men with LUTS suggestive of BPO were significantly more affected in all variables measuring partner-specific quality of life compared with partners from the population. The most impaired aspects were compassion and worry about an operation or cancer. In logistic regression, the only explanatory factors were having a partner belonging to the LUTS group for impaired partner-specific quality of life and having a bed partner for high sleep efficiency. There were no significant differences between the two groups regarding the quantity and quality of sleep or the HRQoL.

CONCLUSIONS

The partner-specific quality of life was impaired in partners of men with LUTS suggestive of BPO. Sleep and HRQoL did not differ between partners of men with LUTS and partners from the population.

Burden of male lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) - focus on the UK

KEY MESSAGES

Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) can be bothersome and negatively impact on a patient's quality of life (QoL). As the prevalence of LUTS/BPH increases with age, the burden on the healthcare system and society may increase due to the ageing population. This review unifies literature on the burden of LUTS/BPH on patients and society, particularly in the UK. LUTS/BPH is associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning, and through its negative impact on QoL for patients and partners. LUTS/BPH is often underdiagnosed and undertreated. Men should be encouraged to seek medical advice for this condition and should not accept it as part of ageing, while clinicians should be more active in the identification and treatment of LUTS/BPH. To assess the burden of illness and unmet need arising from lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH) from an individual patient and societal perspective with a focus on the UK. Embase, PubMed, the World Health Organization, the Cochrane Database of Systematic Reviews and the York Centre for Reviews and Dissemination were searched to identify studies on the epidemiological, humanistic or economic burden of LUTS/BPH published in English between October 2001 and January 2013. Data were extracted and the quality of the studies was assessed for inclusion. UK data were reported; in the absence of UK data, European and USA data were provided. In all, 374 abstracts were identified, 104 full papers were assessed and 33 papers met the inclusion criteria and were included in the review. An additional paper was included in the review upon a revision in 2014. The papers show that LUTS are common in the UK, affecting ≈3% of men aged 45-49 years, rising to >30% in men aged ≥85 years. European and USA studies have reported the major impact of LUTS on quality of life of the patient and their partner. LUTS are associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning. While treatment costs in the UK are relatively low compared with other countries, the burden on health services is still substantial. LUTS associated with BPH is a highly impactful condition that is often undertreated. LUTS/BPH have a major impact on men, their families, health services and society. Men with LUTS secondary to BPH should not simply accept their symptoms as part of ageing, but should be encouraged to consult their physicians if they have bothersome symptoms.

Finasteride treatment alters tissue specific androgen receptor expression in prostate tissues

BACKGROUND

Normal and pathologic growth of the prostate is dependent on the synthesis of dihydrotestosterone (DHT) from testosterone by 5α-reductase. Finasteride is a selective inhibitor of 5α-reductase 2, one isozyme of 5α-reductase found in abundance in the human prostate. The objective of this study was to investigate the effects of finasteride on androgen receptor expression and tissue morphology in human benign prostatic hyperplasia specimens.

METHODS

Patients undergoing transurethral resection of the prostate and either treated or not treated with finasteride between 2004 and 2010 at the University of Wisconsin-Hospital were retrospectively identified using an institutional database. Prostate specimens from each patient were triple-stained for androgen receptor, prostate-specific antigen, and basal marker cytokeratin 5. Morphometric analysis was performed using the multispectral imaging, and results were compared between groups of finasteride treated and non-treated patients.

RESULTS

Epithelial androgen receptor but not stromal androgen receptor expression was significantly lower in patients treated with finasteride than in non-treated patients. Androgen receptor-regulated prostate-specific antigen was not significantly decreased in finasteride-treated patients. Significant luminal epithelial atrophy and basal cell hyperplasia were prevalent in finasteride treated patients. Epithelial androgen receptor expression was highly correlated to the level of luminal epithelial atrophy.

CONCLUSIONS

In this study, finasteride decreased the expression of epithelial androgen receptor in a tissue specific manner. The correlation between epithelial androgen receptor and the extent of luminal epithelial atrophy suggests that epithelial androgen receptor may be directly regulating the atrophic effects observed with finasteride treatment.

Dutasteride on benign prostatic hyperplasia: a meta-analysis on randomized clinical trials in 6460 patients

OBJECTIVE

To investigate the clinical effectiveness of dutasteride in the treatment of benign prostatic hyperplasia by meta-analysis.

MATERIALS AND METHODS

Several databases were searched from inception to June 2013 for prospective clinical studies comparing dutasteride vs placebo. The continuous outcomes of therapeutic efficacy included International Prostate Symptom Score/American Urological Association Symptom Index, maximum flow rate, total prostate volume, and acute urinary retention (AUR). The dichotomous outcomes included surgery risk and the rate of sexual dysfunction. The relative risk for dichotomous outcome and the weighted mean difference for continuous outcomes were estimated using fixed effects model.

RESULTS

Four studies met the inclusion criteria and were included, in which a total of 6460 patients received dutasteride and 6475 received placebo treatment. The average symptom score was improved by 1.98 with 95% confidence interval (CI) 1.77-2.19 (P <.00001); the average maximum flow rate was increased by 1.16 mL/s with 95% CI 0.63-1.70 (P <.0001); the total prostate volume was reduced by 13.86 mL (95% CI 12.76-14.96; P <.00001); the odds ratio for AUR was 0.35 (95% CI 0.27-0.47; P <.00001). The major side effect for dutasteride was the increased rate of sexual dysfunction compared with placebo, with odds ratio of 0.41 (95% CI 0.31-0.54; P <.00001).

CONCLUSION

Dutasteride is highly effective in mitigating benign prostatic hyperplasia symptoms and reducing the size of enlarged prostate and the risks of AUR and surgical intervention. However, dutasteride therapy is related to an increased rate of sexual dysfunction.

Effect of an employer-sponsored health and wellness program on medical cost and utilization

The objective of this study was to examine the impact of PepsiCo's health and wellness program on medical cost and utilization. The authors analyzed health plan and program data of employees and dependents 19-64 years of age, who had 2 years of baseline data (2002 and 2003) and at least 1 year of data from the intervention period (2004 to 2007), resulting in a sample of 55,030 members. Program effects were measured using a difference-in-difference approach based on a multivariate regression model with an individual-level random effect. In its first year, the program was associated with a relative increase in per member per month (PMPM) cost ($66, P<0.01); a relative reduction in PMPM costs of $76 (P<0.01) and $61 (P<0.01) was seen in the second and third year, respectively. Over all 3 years, the program was associated with reduced PMPM costs of $38 (P<0.01), a decrease of 50 emergency room visits per 1000 member years (P<0.01), and a decrease of 16 hospital admissions per 1000 member years (P<0.01). The disease management component reduced PMPM costs by $154 (P<0.01), case management increased PMPM costs by $2795 (P<0.01), but no significant effects were observed for lifestyle management over the 3 intervention years. The implementation of a comprehensive health and wellness program was associated with a cost increase in the first year, followed by a decrease in the following years. These results highlight the importance of taking a long-term perspective when implementing such programs and evaluating their effectiveness.

Prospective, randomized, double-blind, vehicle controlled, multicenter phase IIb clinical trial of the pore forming protein PRX302 for targeted treatment of symptomatic benign prostatic hyperplasia

PURPOSE

We conducted a safety and efficacy evaluation of intraprostatic injection of PRX302, a modified pore forming protein (proaerolysin) activated by prostate specific antigen, as a highly targeted, localized approach to treat lower urinary tract symptoms due to benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 92 patients with I-PSS (International Prostate Symptom Score) 15 or greater, peak urine flow 12 ml or less per second and prostate volume 30 to 100 ml were randomized 2:1 to a single ultrasound guided intraprostatic injection of PRX302 vs vehicle (placebo) in this phase IIb double-blind study. Injection was 20% of prostate volume and 0.6 μg PRX302 per gm prostate. Peak urine flow was determined by a blinded reviewer. Benign prostatic hyperplasia medications were prohibited. The primary data set of efficacy evaluable patients (73) was analyzed using last observation carried forward.

RESULTS

PRX302 treatment resulted in an approximate 9-point reduction in I-PSS and 3 ml per second increase in peak urine flow that were statistically significant changes from baseline compared to vehicle. Efficacy was sustained for 12 months. Early withdrawal for other benign prostatic hyperplasia treatment was more common for patients in the vehicle group. Relative to vehicle, PRX302 apparent toxicity was mild, transient, and limited to local discomfort/pain and irritative urinary symptoms occurring in the first few days, with no effect on erectile function.

CONCLUSIONS

A single administration of PRX302 as a short, outpatient based procedure was well tolerated in patients with lower urinary tract symptoms due to benign prostatic hyperplasia. PRX302 produced clinically meaningful and statistically significant improvement in patient subjective (I-PSS) and quantitative objective (peak urine flow) measures sustained for 12 months. The side effect profile is favorable with most effects attributed to the injection itself and not related to drug toxicity.

The 5 alpha-reductase isozyme family: a review of basic biology and their role in human diseases

Despite the discovery of 5 alpha-reduction as an enzymatic step in steroid metabolism in 1951, and the discovery that dihydrotestosterone is more potent than testosterone in 1968, the significance of 5 alpha-reduced steroids in human diseases was not appreciated until the discovery of 5 alpha-reductase type 2 deficiency in 1974. Affected males are born with ambiguous external genitalia, despite normal internal genitalia. The prostate is hypoplastic, nonpalpable on rectal examination and approximately 1/10th the size of age-matched normal glands. Benign prostate hyperplasia or prostate cancer does not develop in these patients. At puberty, the external genitalia virilize partially, however, secondary sexual hair remains sparse and male pattern baldness and acne develop rarely. Several compounds have been developed to inhibit the 5 alpha-reductase isozymes and they play an important role in the prevention and treatment of many common diseases. This review describes the basic biochemical properties, functions, tissue distribution, chromosomal location, and clinical significance of the 5 alpha-reductase isozyme family.

Phase 1 and 2 studies demonstrate the safety and efficacy of intraprostatic injection of PRX302 for the targeted treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

BACKGROUND

PRX302 is a prostate specific antigen (PSA)-activated pore-forming protein toxin under development as a targeted approach for improving lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) without affecting sexual function.

OBJECTIVE

To evaluate the safety and efficacy of PRX302 in men with moderate to severe BPH.

DESIGN, SETTING, AND PARTICIPANTS

Eligible subjects were refractory, intolerant, or unwilling to undergo medical therapies for BPH and had International Prostate Symptom Score (IPSS) ≥12, a quality of life (QoL) score ≥3, and prostate volumes between 30 and 80 g. Fifteen patients were enrolled in phase 1 studies, and 18 patients entered phase 2 studies.

INTERVENTIONS

Subjects received intraprostatic injection of PRX302 into the right and left transition zone via a transperineal approach in an office-based setting. Phase 1 subjects received increasing concentrations of PRX302 at a fixed volume; phase 2 subjects received increasing volumes per deposit at a fixed concentration.

MEASUREMENTS

IPSS, QoL, prostate volume, maximum flow rate (Q(max)), International Index of Erectile Function, serum PSA levels, pharmacokinetics, and adverse events were recorded at 30, 60, 90, 180, 270, and 360 d after treatment with PRX302.

RESULTS AND LIMITATIONS

Sixty percent of men in the phase 1 study and 64% of men in the phase 2 study treated with PRX302 had ≥30% improvement compared to baseline in IPSS out to day 360. Patients also experienced improvement in QoL and reduction in prostate volume out to day 360. Patients receiving ≥1 ml of PRX302 per deposit had the best response overall. PRX302 had no deleterious effect on erectile function. Adverse events were mild to moderate and transient in nature. The major study limitation was the small sample size.

CONCLUSIONS

The promising safety profile and evidence of efficacy in the majority of treated subjects in these phase 1 and 2 studies supports further development of PRX302 as a minimally invasive, targeted treatment for BPH.

Men's lower urinary tract symptoms are also mental and physical sufferings for their spouses

Lower urinary tract symptoms (LUTS) in men may have an adverse effect on spouse health-related quality of life (HRQL), and these effects are probably influenced by cultural and perceptional differences. This study was conducted to explore the impact of LUTS in Korean men on their spousal HRQL in relation to symptom severities and other demographic parameters. A total of 130 spouses, whose husbands had a nocturia, frequency of greater than once per night, who shared a bed with their husbands, and accompanied husbands at consultation, were subsequently enrolled and asked to complete a structured questionnaire. Almost all spouses (98%) suffered one or more inconveniences that affected HRQL to some degree. Sleep disturbance was rated to be most inconvenient. The sleep disturbances were significantly correlated with nocturia frequency and husband co-morbidity. Husband's LUTS caused partners to feel fatigued (62%), embarrassed (79%), concerned about the possibilities of cancer (69%) and surgery (81%), sexual life deteriorated (58%), and dissatisfied, unhappy, or terrible (36%). Spouse's perception on HRQL was found to be well correlated with husband's quality of life. Men with LUTS need to understand that their LUTS is also mental and physical sufferings for their spouses.

Epidemiology of benign prostatic hyperplasia and comorbidities in racial and ethnic minority populations

In the United States, research into the etiology of benign prostatic hyperplasia (BPH) and the incidence and treatment of lower urinary tract symptoms (LUTS) in racial/ethnic minority patients is just beginning, despite a high incidence of both conditions in these populations. The relative risks for the development of BPH and commonly comorbid conditions in African Americans and Latinos may be increased compared with the white majority population. This heightened risk may be attributable to factors such as autonomic hyperactivity and metabolic abnormalities, which appear at a higher rate in African Americans and Latinos. Differences in genetic factors related to androgen receptor CAG repeats, the androgen signaling pathway, and in the cellular composition of the prostate also contribute to racial/ethnic differences in the incidence of clinical BPH and LUTS. Despite the disproportionately high rates of BPH-associated risk factors and comorbidities associated with the condition, a large proportion of minority patients with BPH and LUTS are undiagnosed and untreated. Expanding the information base on BPH and LUTS in minority patients may help to narrow existing ethnic/racial disparities in treatment and to reduce the impact of LUTS on the quality of life of these patients.

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.

An investigation of the relationship between sex-steroid levels and urological symptoms: results from the Boston Area Community Health survey

OBJECTIVES

To investigate whether circulating levels of sex hormones are associated with urological symptoms, using data from the Boston Area Community Health (BACH) Survey.

SUBJECTS AND METHODS

BACH used a multistage stratified-cluster approach to randomly sample 5506 adults aged 30-79 years in Boston, MA, USA. Anthropometric measures, lifestyle and psychosocial factors, comorbidities and urological symptoms were obtained using a questionnaire administered by an interviewer. Serum testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulphate (DHEAS), dihydrotestosterone (DHT) and oestradiol (E2) levels were measured, and bioavailable testosterone (BT) was calculated in 1899 men (538 Black, 651 Hispanic and 710 White). Regression analysis was used to investigate the relationships between androgen levels and American Urological Association symptom index (AUA-SI), lower urinary tract symptoms (LUTS) (> or = 8 on the AUA-SI), urinary incontinence (UI), dribble and hesitancy.

RESULTS

Of all subjects, 19% reported LUTS, 6% UI, 9% dribble and 4% hesitancy. Testosterone, BT and DHEAS levels were inversely related to the AUA-SI (P = 0.009, <0.001 and <0.001, respectively); SHBG values and the AUA-SI were positively correlated (P < 0.001). Adjusting for age, BT and DHEAS levels had negative relationships with the AUA-SI; BT and DHEAS levels were negatively related to LUTS and SHBG was positively related to LUTS (both P < 0.001); after age adjustment, only LUTS and DHEAS remained related, and only the relationship between dribble and E2 remained significant; no hormone levels were related to hesitancy.

CONCLUSIONS

Circulating levels of sex hormones are generally not significant predictors of urological symptoms in men after adjusting for age. The pathophysiology of LUTS is complex and probably includes factors other than circulating sex steroid levels.

A review of the clinical efficacy and safety of 5α-reductase inhibitors for the enlarged prostate

BACKGROUND

Enlargement of the prostate is common among aging men, with an incidence of 90% by the age of 85 years. It is a progressive condition, with growth in prostate size accompanied by lower urinary tract symptoms that can result in long-term complications (eg, acute urinary retention [AUR], need for enlarged prostate-related surgery). Current pharmacologic treatment options include alpha-blockers (alfuzosin, doxazosin, tamsulosin, and terazosin) and 5alpha-reductase inhibitors (5ARIs) (finasteride and dutasteride).

OBJECTIVES

This article reviews the natural history of enlarged prostate and the data supporting management of this condition with alpha-blocker and 5ARI therapy, either as monotherapy or combination therapy, for symptomatic relief and a reduction in long-term disease progression.

METHODS

Pertinent English-language articles were identified through a search of MEDLINE (1966-week 2, May 2006) using such search terms as 5alpha-reductase inhibitor, alpha-blocker, benign prostatic hyperplasia, dutasteride, efficacy, enlarged prostate, finasteride, and safety.

RESULTS

Clinical trials of alpha-blockers in men with enlarged prostate have reported improvements in total symptom scores of 10% to 20% compared with placebo; however, these agents were not shown to reduce the risk of long-term complications or disease progression. Studies of the 5ARIs have reported significant reductions compared with placebo in the relative risk for AUR and enlarged prostate-related surgery, slowing of disease progression, and relief of symptoms. In studies of dutasteride, improvements in symptom scores were greater after 4 years of therapy compared with 2 years (-6.4 vs -4.3 points, respectively) and flow rates were better (2.6 vs 2.3 mL/sec). Six-year data for finasteride showed maintenance of the decreased risk for AUR and enlarged prostate-related surgery. Use of combination therapy with an alpha-blocker and a 5ARI may be of benefit in patients who require immediate relief of symptoms, with discontinuation of the alpha-blocker after several months of therapy. 5ARIs were generally well tolerated, with sexual dysfunction the most frequently reported adverse effect, although in only a small proportion of men (1%-8%).

CONCLUSIONS

The use of 5ARI therapy is a rational approach to symptom management and prevention of long-term negative outcomes in men with enlarged prostates.V 3.

Public, patient, and professional attitudes towards the diagnosis and treatment of enlarged prostate: A landmark national US survey

This US national survey evaluated beliefs and attitudes towards the enlarged prostate (EP) and its treatment among the men of a national sample aged > or =50 years in the US (400 with and 700 without EP), and a national sample of 100 primary care doctors and 100 urologists. The principal risk of EP was considered to be acute urinary retention among the majority of physicians, while the majority of patients believed it to be prostate cancer. In contrast to physicians' beliefs, the majority of patients with moderate-to-severe symptoms are more concerned with long-term effects of EP than acute symptoms. Furthermore, they are willing to wait up to 3 months for symptom relief if treatment of the underlying condition is achieved. Doctors and patients agree that most patients want to avoid surgery but only 18% of surgery patients were told about drugs that could reduce the risk of surgery. These findings demonstrate significant differences between the beliefs and attitudes of patients and physicians towards EP.