Safety and efficacy of alfuzosin 10 mg once-daily in the treatment of lower urinary tract symptoms and clinical benign prostatic hyperplasia: a pooled analysis of three double-blind, placebo-controlled studies

Risks and side effects in the medical management of benign prostatic hyperplasia

Benign prostatic hyperplasia affects up to 80% of men in their lifetime. It causes bladder outflow obstruction, leading to lower urinary tract symptoms, which can have a large impact on quality of life. Lifestyle modifications and pharmacotherapy are often offered as first-line treatments for patients. These include alpha blockers, 5-alpha-reductase inhibitors, phosphodiesterase-5 inhibitors, anticholinergics, B3-agonists, and desmopressin. While often well tolerated, these pharmacotherapies do have significant side effects, which both clinicians and patients should understand and discuss in order to make an informed treatment decision among alternatives. The purpose of this review is to provide a current overview of the risks and side effects of commonly used medications in benign prostatic hyperplasia management.

Treating LUTS in Men with Benign Prostatic Obstruction: A Review Article

Benign prostatic obstruction (BPO) is a prevalent condition that affects men, primarily toward their old age. The condition is often accompanied by lower urinary tract symptoms (LUTS), which can significantly impair a patient's quality of life and lead to other medical complications. Accurate diagnosis of BPO is essential for effective management of complications secondary to BPO, and treatment plans should be tailored patients, and occasionally according to surgeon experience. As such, this literature review aims to analyze the current available data on male LUTS secondary to BPO by providing a comprehensive overview of relevant studies, as well as the surgical and medical management guidelines from the Canadian Urological Association (CUA), American Urological Association (AUA), and European Association of Urology (EAU). By synthesizing the existing literature, this review purports to summarize the current body of knowledge surrounding BPO and male LUTS, and support healthcare providers in making informed decisions about the management of male LUTS secondary to BPO, ultimately improving patient outcomes and quality of life.

Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review

PURPOSE

We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults.

METHODOLOGY

Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults.

RESULTS

Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups.

CONCLUSIONS

The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.

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

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

Effect of alpha-adrenoceptor antagonists on sexual function. A systematic review and meta-analysis

BACKGROUND

Alpha-adrenoreceptor antagonists or alpha-blockers are used in the treatment of hypertension, in the therapy of benign prostatic hyperplasia and in medical expulsive treatment of ureteral stones. These agents may affect the sexual function, with differences between drugs within the same class, depending on their selectivity for receptor subtypes. The aim of this review was to analyze the effects of alpha-blockers on sexual function.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis by searching PubMed, EMBASE and other databases for randomized controlled trials (RCTs) reporting sexual adverse effects in patients treated with alpha-blockers. Odds ratios for sexual dysfunction were calculated using random effects Mantel-Haenszel statistics.

RESULTS

Out of 608 records retrieved, 75 eligible RCTs were included in the meta-analysis. Compared with placebo, alphablockers were associated with increased odds of ejaculatory disorders both in patients with lower urinary tract symptoms (LUTS) associated to benign prostatic hyperplasia (BPH) (OR: 7.53, 95% CI: 3.77-15.02, Z = 5.73, p < 0.00001, I2 = 55%) and in patients with ureteral stones (OR: 2.88, 95% CI: 1.50-5.44, Z = 3.19, p < 0.001, I2 = 31%). Uroselective alpha-blockers showed higher odds of ejaculatory disorders. Conversely, nonselective alpha-blockers were not associated with higher odds of ejaculatory dysfunction. Silodosin was associated with increased odds of ejaculatory dysfunction compared with tamsulosin (OR: 3.52, 95% CI: 2.18-5.68, 15 series, 1512 participants, Z = 5.15, p < 0.00001, I2 = 0%). Naftopidil and alfuzosin showed lower odds of ejaculatory dysfunction compared to uroselective alpha-blockers.No statistically significant differences in the odds of erectile dysfunction were observed when alpha-blockers were compared to placebo.

Comparative Efficacy of Different Drugs for Lower Urinary Tract Symptoms due to Benign Prostatic Hyperplasia: A Bayesian Network Meta-Analysis

Background: Lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) are common in middle-aged and elderly men. The current drugs for treating this disease include α1-adrenoceptor antagonists (ABs), muscarinic receptor antagonists (MRAs), phosphodiesterase five inhibitors (PDE5-Is), and β3-adrenoceptor agonists (B3As). However, direct comparative studies analyzing different therapies are limited; therefore, we conducted a network meta-analysis (NMA) to evaluate the efficacy of different drug regimens for treating BPH/LUTS. Methods: The PubMed, EMbase, Web of Science, and Cochrane Library databases were searched to collect randomized controlled trials (RCTs) of different drug treatments for BPH/LUTS from January 2000 to April 2021. The NMA was performed using R 4.1 software. Results: Fifty-five RCTs were included among a total of 1639 trials. ① ABs + PDE5-Is, ABs + B3As, ABs + MRAs, ABs, and PDE5-IS were superior to the placebo in improving the total International Prostate Symptom Score (IPSS), IPSS-Voiding, and IPSS-storage. ② For increasing the maximum flow rate (Qmax), ABs + PDE5-Is, ABs + MRAs, and ABs were more effective than the placebo. ③ Regarding reducing post-void residual urine (PVR), none of the six treatment plans had significant effects. Conclusion: Combination therapy showed greater efficacy than monotherapy, and ABs + PDE5-Is was the most successful treatment for improving the overall IPSS score. ABs are a primary therapeutic measure to increase Qmax, and ABs + PDE5-I may be a more suitable choice for enhancing Qmax. The combination of MRA and AB+ MRA may lead to an increase in PVR. Systematic Review Registration: [website], identifier [registration number].

Prostate Disease Severity Score: In the management of benign enlargement of prostate

Objective:

Developing a simple, user-friendly objective severity scoring system for symptomatic benign enlargement of prostate (BEP) and comparing with International Prostate Symptom Score (IPSS).

Subjects and Methods:

In this prospective study, patients with BEP completed IPSS proforma. A grading system was developed for peak flow of urine ( Qmax), transitional zone index (TZI), detrusor wall thickness (DWT) and intravesical prostatic protrusion (IPP). Prostate Disease Severity Score (PDSS) was developed as sum of the variables.

Results:

Among 115 patients, obstructive voiding (70.43%) was predominant symptom followed by storage symptom (10.44%). Among predominant obstructive voiders, grades 1–3 TZI was common (97.53%), followed by IPP (64.19%) and DWT (62.96%) of varying grade. IPP, DWT, TZI and Qmax proved to be strong determinants of obstructive voiding ( p < 0.05). The components of PDSS correlated well with total score ( p < 0.05), positively correlated with IPP, DWT and TZI, and negatively with Qmax ( p < 0.05); correlation with IPSS was statistically significant ( p < 0.05). According to PDSS, 92.5% (37/40) patients with severe, 73.02% (46/63) with moderate, 8.33% (1/12) with mild degree of obstruction needed surgical intervention.

Conclusion:

The objective nature, comparable correlation with IPSS, potentiality to predict future need for surgical intervention, makes PDSS, a potential user-friendly assessment tool in management of BEP.

Level of evidence:

Not applicable

IPSS "bother question" score predicts health-related quality of life better than total IPSS score

OBJECTIVE

The objective of this study was to investigate the role of bothersomeness of urinary symptoms on the general health-related quality of life (HRQoL) of patients with benign prostatic hyperplasia. We hypothesised that a higher International Prostate Symptom Score (IPSS) would be associated with a higher score on the IPSS bother question (IPSS-BQ), and a higher IPSS-BQ score would be the dominant factor associated with poorer general HRQoL.

MATERIALS AND METHODS

A case-control, cross-sectional study design was used. Patients were selected according to strict inclusion and exclusion criteria and stratified by IPSS severity group (controls: IPSS < 8; moderately symptomatic: IPSS = 8-18; and severely symptomatic: IPSS > 18). The IPSS-BQ was used to analyse bothersomeness of urinary symptoms. A standardised, multidimensional measure of HRQoL (RAND-36) was used. Data were collected on prostate size, uroflowmetry parameters, prostate specific antigen and comorbidities that were quantified using the Charlson Index and the American Association of Anaesthesiologists (ASA) score. Multiple linear regression models were used to assess the impact of bothersomeness of urinary symptoms on physical and mental HRQoL. Cohen's d was used to determine the effect size.

RESULTS

We included 83 patients in the statistical analysis. Linear regression analyses showed that the IPSS was not an independent predictor of HRQoL. Only the highest IPSS-BQ score was associated with both worse physical (P = 0.021) and mental (P = 0.011) HRQoL in the final model. The effect sizes were small to moderate.

CONCLUSION

The IPSS-BQ score is an important predictor of HRQoL. The IPSS-BQ score as a proxy should be regarded as a standard outcome measure and reported in all LUTS-related research.

Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review

Background: Benign prostatic hyperplasia (BPH) is commonly responsible for lower urinary tract symptoms (LUTS) in men aged 50 or over. Sexual dysfunctions, such as ejaculatory disorders (EjD), go along with LUTS but are frequently overlooked in the initial evaluation. This review aimed to detail BPH-related EjD, as well as their modifications by medical, surgical, and interventional treatments. Methods: We conducted a narrative review looking for publications between 1990 and 2020, regarding physiopathology, epidemiology, evaluation, and therapeutic management (medical, surgical, and interventional) of BPH-related EjD. Results: Sixty-five articles were included in our final analysis. Forty-six percent of men presenting with LUTS reported EjD. If the prevalence increases with age and LUTS severity, the functional impairment is not correlated with age. Several self-questionnaires evaluated the sexual function, but only four approaches are specific to EjD. Medical therapies were exposed to anejaculation, rather than retrograde ejaculation (RE) (4–30% (alpha-blockers), 4–18% (5-alpha-reductase inhibitors)). Regarding surgical therapies, trans-urethral resection of the prostate (TURP) and incision of the prostate (TUIP) are associated with 50–70% and 21–35% of RE. The RE rate is important after open simple prostatectomy but can be reduced with robotic approaches and urethral sparing techniques (19%). Anatomic endoscopic enucleation of the prostate (AEEP) with or without a laser source is associated with an 11–36% RE rate, according to supramontanal preservation. Recent surgical techniques (Rezum©, Aquablation©, or Urolift©) were developed to preserve antegrade ejaculation with promising short-term results. Regardless of the surgical approach, anatomic studies suggest that the preservation of peri-montanal tissue (7.5 mm laterally; 10 mm proximally) is primordial to avoid post-operative RE. Finally, prostate artery embolization (PAE) limits the RE rate but exposes it to a 12 months 10% re-intervention rate. Conclusion: EjD concerns almost half of the patients presenting BPH-related LUTS. Initial evaluation of EjD impairment is primordial before medical or surgical therapy. Peri-montanal tissue preservation represents a key point for antegrade ejaculation preservation, regardless of the surgical option.

A Prospective, Multicenter, Open-Label Study of Dose Escalation Therapy in Male Patients With Nocturia Refractory to 0.2-mg Tamsulosin Monotherapy

Purpose

To investigate the efficacy and safety of 0.4 mg of tamsulosin in patients with nocturia not responding to 0.2 mg.

Methods

Patients with intractable nocturia after treatment with 0.2 mg of tamsulosin for>1 month were included in a multicenter, prospective, observational, single-arm study. Patients were prescribed 0.4 mg of tamsulosin and followed up for 2 months to assess nocturnal voiding and nocturia-related bother. Changes in the mean number of nocturnal voids, the proportion of 50% responders, 3-day frequency-volume chart parameters, and questionnaire scores were assessed.

Results

Sixty-two patients were prescribed 0.2 mg of tamsulosin, of whom 56 were prescribed 0.4 mg of tamsulosin. Ten patients dropped out. A single case of orthostatic hypotension was reported. The mean age was 68 years. After 1 and 2 months of taking 0.4 mg of tamsulosin, 23.9% and 22.7% of patients demonstrated a>50% reduction of nocturia, and 16.1% and 19.4% of patients rated the treatment as “very effective,” respectively. Dose escalation to 0.4 mg of tamsulosin, compared to 0.2 mg, did not show an additional effect on reducing nocturnal urine volume. Multivariate logistic regression analysis showed that lower serum sodium levels (odds ratio [OR], 0.41, P=0.037) and the presence of urge incontinence (OR, 7.08, P=0.036) were predictors of a significant improvement of nocturia in response to 0.4 mg of tamsulosin.

Conclusions

Dose escalation may yield a significant improvement of nocturia in>20% of patients, and may be especially helpful in patients with lower sodium levels and urge incontinence.

Efficacy of an Alpha-Blocker for the Treatment of Nonneurogenic Voiding Dysfunction in Women: An 8-Week, Randomized, Double-Blind, Placebo-Controlled Trial

Purpose

To evaluate the efficacy of an alpha-1 adrenergic receptor (α1-AR) blocker for the treatment of female voiding dysfunction (FVD) through a pressure-flow study.

Methods

This was a randomized, double-blind, placebo-controlled trial. Women aged ≥18 years with voiding symptoms, as defined by an American Urological Association symptom score (AUA-SS) ≥15 and a maximum flow rate (Qmax) <15 mL/sec with a voided volume of >100 mL and/or a postvoid residual (PVR) volume >150 mL, were randomly allocated to either the alfuzosin or placebo group. After 8 weeks of treatment, changes in the AUA-SS, Bristol female lower urinary tract symptoms (BFLUTS) questionnaire, Qmax/PVR, and voiding diary were compared between groups. Patients’ satisfaction with the treatment was compared. Patients were categorized into 3 groups according to the Blaivas-Groutz bladder outlet obstruction (BOO) nomogram: none, mild, and moderate to severe. Subgroup comparisons were also made.

Results

Of a total of 187 women, 154 (79 alfuzosin, 75 placebo) were included in the analysis. After 8 weeks of treatment, the AUA-SS decreased by 7.0 in the alfuzosin group and by 8.0 in the placebo group. Changes in AUA-SS subscores, BFLUTS (except the I-sum), the voiding diary, and Qmax/PVR were not significantly different between groups. Approximately 54% of the alfuzosin group and 62% of the placebo group were satisfied with the treatment. No significant difference was observed between groups according to the presence or grade of BOO.

Conclusions

Alfuzosin might not be more effective than placebo for treating FVD. The presence or the grade of BOO did not affect the results. A further study with sufficient power is needed to determine the efficacy of α1-AR blockers for the treatment of FVD.

Changes in autonomic nervous system activity after treatment with alpha-blocker in men with lower urinary tract symptoms

Purpose

To determine changes in autonomic nervous system activity after treatment in men with lower urinary tract symptoms (LUTS), we evaluated changes in patients' symptoms, uroflowmetry, and heart rate variability (HRV) after treatment with alpha-blockers for 12 weeks.

Materials and Methods

Ninety-five men who had LUTS (International Prostate Symptom Score [IPSS] ≥8) were included in this study. We divided them into two groups on the basis of a low frequency/high frequency (LF/HF) ratio of 1.6. After treatment with Xatral XL (Handok Inc., Korea) 10 mg for 3 months, we rechecked their IPSS, uroflowmetry, HRV and compared these with the baseline measurements.

Results

Fifty-four men were assigned to the low LF/HF group (group A: LF/HF ≤1.6) and 41 men to the high LF/HF group (group B: LF/HF >1.6). At baseline and 12 weeks, none of the parameters differed significantly between the groups except for HF, which is one of the parameters of HRV. IPSS, the IPSS-voiding subscore, and the IPSS-storage subscore decreased and maximal uroflow increased significantly after 12 weeks of treatment. Whereas the baseline LF/HF ratio increased from 0.89±0.407 to 1.80±1.804 after treatment in group A, it decreased from 3.93±5.471 to 1.79±1.153 in group B.

Conclusions

The efficacies of Xatral XL were clear in both groups. We found that the LF/HF ratio in the two groups merged to a value of approximately 1.79 after treatment. We suggest that this could be a clue to the importance of balance in autonomic nervous system activity in men with LUTS.

Effects of Combination Treatment of Alpha 1-Adrenergic Receptor Antagonists on Voiding Dysfunction: Study on Target Organs in Overactive Bladder Rats

PURPOSE

Overactive bladder (OAB) causes urinary urgency, usually accompanied by frequency and nocturia. Alpha 1-adrenergic receptor (α₁-AR) antagonists are known to improve lower urinary tract symptoms associated with OAB. The α₁-AR antagonists constitute a variety of drugs according to the receptor subtype affinity. This study investigated the efficacy of tamsulosin, naftopidil, and a combination of the two on OAB rats.

METHODS

The OAB rat model was induced by an intraperitoneal injection of cyclophosphamide for 14 days. The experimental groups were divided into 5 groups: control group, OAB-induction group, OAB-induction and tamsulosin monotherapy group, OAB-induction and naftopidil monotherapy group, and OAB-induction and tamsulosin-naftopidil combination therapy group. For the drug-treated groups, each drug was administrated for 14 days after the OAB induction. Cystometry for urodynamic evaluation and immunohistochemical stain for c-Fos and nerve growth factor (NGF) expressions in the central micturition centers were performed.

RESULTS

Increased contraction pressure and time with enhanced c-Fos and NGF expressions in the central micturition centers were found in the OAB rats. Tamsulosin suppressed contraction pressure and time while inhibiting c-Fos and NGF expressions. Naftopidil showed no significant effect and combination therapy showed less of an effect on contraction pressure and time. Naftopidil and combination therapy exerted no significant effect on the c-Fos and NGF expressions.

CONCLUSIONS

Tamsulosin showed the most prominent efficacy for the treatment of OAB compared to the naftopidil and combination. The combination of tamsulosin with naftopidil showed no synergistic effects on OAB; however, further studies of addon therapy might provide opportunities to find a new modality.

Ejaculatory dysfunction in the treatment of lower urinary tract symptoms

The link between lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) and sexual dysfunction is well established. Sexual dysfunction can encompass both ejaculatory dysfunction (EjD) and erectile dysfunction (ED). Ejaculatory dysfunction can consist of premature ejaculation, delayed ejaculation, retrograde ejaculation, anejaculation, decreased force of ejaculation and pain upon ejaculation. The impact of different medical and surgical therapies on ejaculatory function will be reviewed. We reviewed the various categories of LUTS treatment including the canonical epidemiology and pathophysiology as well as the surgical and medical treatments for LUTS/BPH. We note that most surgeries and several medical treatments have a certain but ill-defined negative impact on ejaculatory function. Several MISTs and selected medical therapies appear to have little impact on EjD. Both EjD and BPH are very common disorders in men under the care of an urologist. It is well documented that there is a clinical association between these two entities. Unfortunately many of the medical treatments and almost all surgical treatment impact the ejaculatory function of the patient. The surgical treatment of BPH often leads to retrograde ejaculation while medical treatment leads to anejaculation.

The pathophysiology of delayed ejaculation

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1–4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

Nocturia: aetiology and treatment in adults

Nocturia is an extremely common condition that has major sequelae for affected patients. Through disruption of sleep, nocturia impairs quality of life and worsens health outcomes, and is associated with a variety of morbidities including diabetes, coronary artery disease, obstructive sleep apnoea, obesity, metabolic syndrome, and depression. Unsurprisingly, several studies have also linked nocturia with reduced survival. Nocturia is not simply a consequence of lower urinary tract disease; rather, it is a multifactorial disorder that is often a manifestation of an underlying renal or systemic disease. Through the use of the frequency volume chart, clinicians can accurately quantify nocturia and determine its aetiology. Evaluation of quality of life and sleep using simple measures is essential in order to assess the impact of nocturia on a patient. Numerous treatment options for nocturia exist, but most are associated with minor benefit or lack sufficient evidence supporting their use. By systematically analysing an individual's causes of nocturia, clinicians can design appropriate treatment strategies to most effectively treat this condition.

Saw Palmetto for Symptom Management During Radiation Therapy for Prostate Cancer

CONTEXT

Lower urinary tract symptoms (LUTSs) affect 75%-80% of men undergoing radiation therapy (RT) for prostate cancer.

OBJECTIVES

To determine the safety, maximum tolerated dose (MTD), and preliminary efficacy of Serenoa repens commonly known as saw palmetto (SP) for management of LUTS during RT for prostate cancer.

METHODS

The dose finding phase used the time-to-event continual reassessment method to evaluate safety of three doses (320, 640, and 960 mg) of SP. Dose-limiting toxicities were assessed for 22 weeks using the Common Terminology Criteria for Adverse Events for nausea, gastritis, and anorexia. The exploratory randomized controlled trial phase assessed preliminary efficacy of the MTD against placebo. The primary outcome of LUTS was measured over 22 weeks using the International Prostate Symptom Score. Additional longitudinal assessments included quality of life measured with the Functional Assessment of Cancer Therapy-Prostate.

RESULTS

The dose finding phase was completed by 27 men who reported no dose-limiting toxicities and with 20 participants at the MTD of 960 mg daily. The exploratory randomized controlled trial phase included 21 men, and no statistically significant differences in the International Prostate Symptom Score were observed. The prostate-specific concerns score of the Functional Assessment of Cancer Therapy-Prostate improved in the SP group (P = 0.03). Of 11 men in the placebo group, two received physician-prescribed medications to manage LUTS compared with none of the 10 men in the SP group.

CONCLUSION

SP at 960 mg may be a safe herbal supplement, but its efficacy in managing LUTS during RT needs further investigation.

Placebo Medication and Sham Surgery Responses in Benign Prostatic Hyperplasia Treatments: Implications for Clinical Trials

Placebo medications and sham surgeries have long been thought to be inert treatments. These groups served as a threshold to which an active treatment should be compared in a randomized trial to determine the true efficacy of the active treatment. However, surprising changes in subjective symptom scores and objective measures of voiding have been demonstrated in numerous placebo medication or sham surgery arms of trials. The exact mechanisms by which these inactive treatments augment patient outcomes are not clearly defined and multiple theories have been proposed to explain the often pronounced response. It appears that urologic outcomes are particularly prone to these effects and the astute physician should keep these responses in mind when interpreting any trial on a new therapy.

Effects of Silodosin and Tamsulosin on the Seminal Vesicle Contractile Response

OBJECTIVES

To understand the mechanisms underlying ejaculation dysfunction caused by α1A-adrenocetor (AR) antagonists, the effects of α1A-AR antagonists on the contractile responses of the seminal vesicle were investigated.

METHODS

Isolated seminal vesicles from guinea pigs were cannulated and pressurized, and the changes in the intraluminal pressure were recorded. Periodic applications of electrical stimulation (ES) caused biphasic increase in the intraluminal pressure, that is, initial and subsequent contractions. The effects of silodosin and tamsulosin, α1A-AR antagonists, on the contractile responses were examined.

RESULTS

The ES-induced biphasic contractions were blocked by tetrodotoxin (TTX). Silodosin and tamsulosin suppressed the initial contractions in a dose-dependent manner, while also exerting various inhibitory effects on the subsequent contractions. Increases in the intraluminal pressure facilitated spontaneous phasic contractions. The spontaneous contractions were not affected by TTX or α1A-AR antagonists, but were abolished by nifedipine.

CONCLUSIONS

The initial contractions triggered by neuronal excitations were suppressed by silodosin and tamsulosin, suggesting that the ejaculation dysfunction may be attributed to the α1A-AR antagonist-mediated suppression of nerve-evoked contractions in the seminal vesicle. The subsequent contractions may be induced by mechanical stimulation associated with the initial, nerve-evoked contractions. Alternatively, other transmitters may be involved to various degrees in the neuromuscular transmission of the seminal vesicle.

The prostatic urethral angle can predict the response to alpha adrenoceptor antagonist monotherapy for treating nocturia in men with lower urinary tract symptom: A multicenter study

BACKGROUND

We evaluated ultrasonography variables associated with the improvement of nocturia after administration of alpha adrenoceptor antagonist (alpha blocker) monotherapy.

METHODS

From February to October 2014, 679 men with lower urinary tract symptoms (LUTS) underwent ultrasonography including prostate volume, transitional zone volume, prostatic urethral length, the ratio between prostatic urethral length and prostate volume (RPUL), intravesical prostatic protrusion (IPP), and prostatic urethral angle (PUA). Among them, 108 men who had pre-treatment nocturia without nocturnal polyuria (nocturnal polyuria index < 33%) and were treated with alpha blocker monotherapy over 3 months were enrolled. Patients were divided into the improved (< 2 times of nocturia) and non-improved group (more than 2 times) after administration of alpha blockers. Along with ultrasonography, international prostate symptom score (IPSS) and uroflowmetry was assessed.

RESULTS

After alpha blocker treatment, 25.0% of patients (27/108) showed improvement of nocturia. These patients were significantly younger (59.6 vs 68.0 years, P = < 0.001) with lower PUA (31.8 vs. 39.4°, P = 0.009) compared with the non-improved group. In ROC analysis, the area under the curve using the PUA was 0.653 (95% CI = 0.532-0.774, P = 0.018). Using 33.5° as a cut-off level, the sensitivity and specificity for predicting the improvement of nocturia after medication reached 67.9% and 55.6%, respectively. Patients with lower PUA (PUA < 33.5°) had more improvement of nocturia (36.6 vs. 17.9%, P = 0.030), lower IPSS score (14.2 vs. 18.3, P = 0.005), and better quality of life index (3.1 vs 3.8, P = 0.021).

CONCLUSIONS

In the patients with lower PUA (particularly lower than 33.5°), nocturia was improved by administration of alpha blocker monotherapy.

Alpha-Blocker Treatment Response in Men With Lower Urinary Tract Symptoms Based on Sympathetic Activity: Prospective, Multicenter, Open-Labeled, Observational Study

Purpose:

In this study, we compared the treatment outcomes for an α-blocker between 2 groups of men, one with high sympathetic activity (HSA) and another with low sympathetic activity (LSA) or normal sympathetic activity.

Methods:

A total of 159 men (≥50 years of age) with lower urinary tract symptoms resulting from benign prostatic hyperplasia were analyzed. We assigned patients to groups according to their sympathetic activity, which was evaluated by heart ratevariability measurements. HSA was defined as a low frequency/high frequency ratio greater than 1.6. All patients received 10mg of alfuzosin once a day for 12 weeks. The primary end point was a change in the total International Prostate SymptomScore (IPSS) at 12 weeks from baseline.

Results:

Sixty-seven men were assigned to the HSA group and 92 men were assigned to the LSA group. The baseline characteristics were not significantly different between the 2 groups, and the response to alfuzosin was good in both groups. Themean total IPSS change was not different between the groups. Both groups were not significantly different with respect to the changes in maximal flow rate, IPSS voiding or storage symptom subscores, quality of life, and rates of adverse drug events. TheHSA group showed a similar willingness to continue treatment compared to the LSA group, although their treatment satisfaction rating was lower.

Conclusions:

The therapeutic effects of alfuzosin did not differ in regards to the differences in sympathetic activity, but treatment satisfaction ratings were lower in the HSA group.

A synopsis of drugs currently in preclinical and early clinical development for the treatment of benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common disease among men and significantly impacts quality of life by causing lower urinary tract symptoms (LUTS). Current medical therapies are not always adequate in controlling LUTS or slowing disease progression, and there is unmet need for new effective therapeutic options.

AREAS COVERED

The authors review the standard current medical therapies for BPH which include the use of α-1 blockers, 5-α reductase inhibitors, combination therapy and PDE inhibitors. Following this, the authors then discuss new therapies that are currently undergoing preclinical and clinical investigation.

EXPERT OPINION

Existing preclinical and clinical trials have highlighted many promising therapies to treat BPH. Further investigation with larger clinical trials is needed to establish these drugs as standard therapies. As the number of drugs in the arsenal against BPH continues to grow, providers and patients will have to engage in a discussion that weighs the risks and benefits of each therapy.

Flurbiprofen alone and in combination with alfuzosin for the management of lower urinary tract symptoms

INTRODUCTION

We aimed to investigate the effectiveness and safety of flurbiprofen, a non-steroidal anti-inflammatory drug with dual cyclooxygenase inhibition, and α-blocker alfuzosin, both alone and in combination with each other for lower urinary tract symptoms suggestive of benign prostatic obstruction (LUTS/BPO).

MATERIAL AND METHODS

Ninety patients complaining of moderate-to-severe LUTS/BPO were randomly assigned into 3 groups (30 patients each) to receive alfuzosin XL 10 mg, or flurbiprofen SR 200 mg, or combination of alfuzosin XL 10 mg and flurbiprofen SR 200 mg, once daily for 4 weeks. Patients were evaluated using the international prostate symptom score (IPSS) (total and IPSSstorage, IPSSempty subscores), uroflow-metry (maximum (Qmax) and average (Qave) flow rates) and postvoid residual urine (PVR) both at baseline and following the drug therapy course.

RESULTS

There was no difference among the 3 groups regarding age and baseline values of prostate volume, IPSS, IPSSstorage, IPSSempty, Qmax, Qave and PVR (P >0.05). IPSS, IPSSstorage, IPSSempty, and PVR decreased significantly in all the 3 groups after drug therapies (P <0.01). However, Qmax and Qave significantly improved only in the combination group (P <0.01).

CONCLUSIONS

Addition of flurbiprofen increased the therapeutic effectiveness of alfuzosin by further improving symptoms in patients with LUTS/BPO. Combination therapy also improved urine flow compared to baseline. Monotherapy with flurbiprofen was not superior to alfuzosin.

Nocturia: Current Levels of Evidence and Recommendations From the International Consultation on Male Lower Urinary Tract Symptoms

OBJECTIVE

To evaluate published evidence on nocturia in men and derive expert recommendations.

METHODS

The International Consultations on Urological Diseases-Société Internationale d'Urologie convened a Consultation of experts on male lower urinary tract symptoms. The Consultation assigned standardized levels of evidence and grades of recommendation to various studies of nocturia epidemiology, pathophysiology, assessment, and treatment.

RESULTS

Evidence review and consensus recommendations were made in the areas of epidemiology, pathophysiology, assessment, and treatment.

CONCLUSION

The review presents a condensed summary of the International Consultations on Urological Diseases-Société Internationale d'Urologie evaluation of nocturia, which offers contemporaneous expert consensus on this topic, with an assessment algorithm emphasizing the potential contribution of systemic conditions to the symptom.

[Negative effects on sexual function of medications for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia]

PURPOSE

The aim of this review is to discuss the negative effects on sexual function of medications for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS-BPH).

METHODS

An international non-systematic literature review was performed. It included randomized trials of seven drugs of interest and the summaries of the characteristics of these products. This work did not aim comparison between the drugs.

RESULTS

Only maximal reported frequencies are presented in this abstract. With prolonged-release alfuzosin, they were 2.8% vs. 1.3% for erectile dysfunction, compared to placebo and 1% vs. 0% for ejaculatory dysfunction. With doxazosin, the incidence was 5.8% vs. 3.3% for erectile dysfunction, 3.6% vs. 1.9% for reduced libido and 0.4% vs. 1.4% for ejaculatory disorders. The incidence of ejaculatory disorders with tamsulosin, was 11% vs. <1% with the placebo and with silodosin, it was 28.1% vs. 1.1%. With finasteride, at 12 months, the highest frequency was 9% vs. 5% for erectile dysfunction, 4.4% vs. 1.5% for ejaculatory disorders and 6.4% vs. 3.4% for reduced libido. At 24 months, for dutatsteride, frequencies were 7.3% vs. 4.0% for erectile dysfunction, 2.2% vs. 0.8% for ejaculatory disorders and 4.2% vs. 2.1% for reduced libido. For tadalafil, a phosphodiesterase-5 inhibitor, and tolerodine, an anticholinergic drug, no negative effect on ejaculation or libido has been reported. For plant extracts, no sexual adverse effects (AEs) were reported among the most common AEs.

CONCLUSION

The medications for LUTS-BPH may alter erection, ejaculation or libido. A greater knowledge of the adverse effects of each of these drugs could guide physicians in the clinical management of men with BPH-LUTS.

Multicenter, prospective, comparative cohort study evaluating the efficacy and safety of alfuzosin 10 mg with regard to blood pressure in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia with or without antihypertensive medications

Background

The objective of this study was to assess the efficacy and safety of alfuzosin 10 mg monotherapy or combined antihypertensive medication on blood pressure (BP) in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH/LUTS) with or without antihypertensive medication.

Methods

This was a 3-month, multicenter, randomized, open-label study in 335 patients aged ≥45 years with a clinical diagnosis of BPH/LUTS by medical history and clinical examination, a total International Prostatic Symptom Score (IPSS) ≥8 points, a maximum flow rate >5 mL/sec and ≤15 mL/sec, and a voided volume ≥120 mL. Eligible subjects were randomized to receive alfuzosin 10 mg as monotherapy (group 1) or alfuzosin 10 mg + antihypertensive combination therapy (group 2). Based on baseline BP and hypertensive history with or without antihypertensive medications at first medical examination, group 1 was divided into two subgroups of normotensive and untreated hypertensive patients, and group 2 into two subgroups of controlled hypertensive and uncontrolled hypertensive patients. The primary study outcomes were change in IPSS, BP, and heart rate from baseline. Secondary outcomes were change in IPSS-quality of life score, maximum flow rate, average flow rate, voided volume, and post-voided volume.

Results

The overall BP change was not significantly different between groups 1 and 2 (systolic BP, P=0.825; diastolic BP, P>0.999). In patients with uncontrolled or untreated hypertension, alfuzosin 10 mg alone or combined with antihypertensive therapy significantly decreased systolic and diastolic BP. The mean difference in total IPSS and IPSS-quality of life scores from baseline between groups 1 and 2 was 0.45 (95% CI: −1.26, 2.16) and 0.12 (95% CI: −0.21, 0.45), respectively (both P>0.05). Maximum flow rate, average flow rate, voided volume, and post-voided volume at endpoint were numerically, but not significantly, changed from baseline (all P>0.05).

Conclusion

This study shows that alfuzosin 10 mg is effective and well tolerated in patients with BPH/LUTS with or without antihypertensive medications. However, in patients with uncontrolled or untreated hypertension, alfuzosin 10 mg alone or in combination with antihypertensive medication appears to decrease systolic and diastolic BP, and these patients should be warned about a decrease in BP on initiation of therapy.

Efficacy of Long-Term Daily Dosage of Alfuzosin 10 mg upon Sexual Function of Benign Prostatic Hypertrophy Patients: Two-Year Prospective Observational Study

Purpose

To identify sexual function improvement associated with alfuzosin (10 mg daily for 2 years).

Materials and Methods

We enrolled 30 men with lower urinary tract symptom (LUTS) who visited Gyeongsang National University Hospital between 2010 and 2012. At first visit, urinalysis, prostate specific antigen, transrectal ultrasound, and uroflowmetry were performed. The nternational Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF), and Male Sexual Health Questionnaire Ejaculation Function Domain (MSHQ-EjFD) questionnaires were administered, and the subjects answered the same questionnaires at 1 month, 6 months, 1 year, and 2 years of follow-up.

Results

Twelve men completed of the entire study. After administration of alfuzosin, the median IPSS at first visit, 1 month, 6 months, 1 year, and 2 years was 18.00 (interquatile range [IQR]: 14.00~29.75), 20.00 (IQR: 11.50~30.00), 15.50 (IQR: 8.50~25.25), 14.50 (IQR: 9.25~19.50), and 11.50 (IQR: 5.00~17.75), respectively, which showed an improvement. The median QoL at the same times was 4.50 (IQR: 4.00~5.00), 4.50 (IQR: 4.00~5.00), 3.00 (IQR: 2.00~4.00), 3.50 (IQR: 2.25~4.00), and 3.00 (IQR: 1.00~3.00), respectively, and also showed improvement. Likewise, the median IIEF was 36.50 (IQR: 24.50~46.75), 37.50 (IQR: 26.75~47.25), 45.50 (IQR: 35.00~59.75), 48.50 (IQR: 34.75~62.75), and 47.50 (IQR: 43.25~61.00), while the median MSHQ-EjFD was 19.00 (IQR: 12.0~24.75), 19.50 (IQR: 13.50~27.75), 23.00 (IQR: 19.25~32.25), 26.50 (IQR: 18.25~34.50), 27.00 (IQR: 21.50~32.50), respectively, with both showing improvement.

Conclusions

After administration of alfuzosin (10 mg daily for 2 years), the IPSS, QoL, IIEF, and MSHQ-EjFD all improved significantly. This means long-term administration of 10 mg of alfuzosin daily would be effective not only for LUTS but also erectile function and ejaculation.

Effect of tadalafil on male lower urinary tract symptoms: an integrated analysis of storage and voiding international prostate symptom subscores from four randomised controlled trials

BACKGROUND

The international prostate symptom score (IPSS) evaluates lower urinary tract symptoms (LUTS) in men with suspected benign prostatic hyperplasia (BPH); the total score does not differentiate between storage and voiding and is unevenly weighted (four questions [57%] on voiding, three questions [43%] on storage).

OBJECTIVE

To evaluate the relative contributions of storage and voiding IPSS subscores to total IPSS at baseline and in response to treatment with tadalafil.

DESIGN, SETTING, AND PARTICIPANTS

Integrated analysis of data from four placebo-controlled, 12-wk studies of tadalafil (5mg once daily) in 1499 men with LUTS/BPH.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships between total IPSS and the storage and voiding subscores were assessed using graphical exploration and linear regression modelling. Linear modelling was performed for the baseline and endpoint and for changes in subscores. The optimal storage subscore to total IPSS (S:T) ratio for IPSS improvement was identified using nonparametric regression and gradient-descent optimisation.

RESULTS AND LIMITATIONS

The contribution of storage and voiding subscores at baseline and endpoint was 38.8% and 61.2%, and 39.2% and 60.7%, respectively. This intuitive 40:60 storage-to-voiding ratio was similar at baseline and endpoint by treatment group and for changes in subscores, but spanned the entire range for individuals. Changes in total IPSS were greatest for a storage subscore percentage contribution to total IPSS of 42.7%. There was no statistical association between S:T ratio (≥ 40% vs < 40%) at baseline and response to tadalafil. The main limitation was the use of unvalidated storage and voiding IPSS subscores.

CONCLUSIONS

A constant S:T ratio of 4:10 was observed at baseline and endpoint. The greatest effect on total IPSS was noted for an S:T percentage contribution of 42.7%. Tadalafil efficacy was unaffected by the level of storage dysfunction at baseline.

PATIENT SUMMARY

This analysis shows that for men with BPH, improvements during treatment with tadalafil apply to both storage and voiding symptoms at a constant ratio. The extent of storage dysfunction before treatment did not affect the response to treatment.

Comparative effectiveness of oral drug therapies for lower urinary tract symptoms due to benign prostatic hyperplasia: a systematic review and network meta-analysis

INTRODUCTION

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are common in elder men and a number of drugs alone or combined are clinically used for this disorder. But available studies investigating the comparative effects of different drug therapies are limited. This study was aimed to compare the efficacy of different drug therapies for LUTS/BPH with network meta-analysis.

MATERIALS AND METHODS

An electronic search of PubMed, Cochrane Library and Embase was performed to identify randomized controlled trials (RCTs) comparing different drug therapies for LUTS/BPH within 24 weeks. Comparative effects were calculated using Aggregate Data Drug Information System. Consistency models of network meta-analysis were created and cumulative probability was used to rank different therapies.

RESULTS

A total 66 RCTs covering seven different therapies with 29384 participants were included. We found that α-blockers (ABs) plus phosphodiesterase 5 inhibitors (PDE5-Is) ranked highest in the test of IPSS total score, storage subscore and voiding subscore. The combination therapy of ABs plus 5α-reductase inhibitors was the best for increasing maximum urinary flow rate (Qmax) with a mean difference (MD) of 1.98 (95% CI, 1.12 to 2.86) as compared to placebo. ABs plus muscarinic receptor antagonists (MRAs) ranked secondly on the reduction of IPSS storage subscore, although monotherapies including MRAs showed no effect on this aspect. Additionally, PDE5-Is alone showed great effectiveness for LUTS/BPH except Qmax.

CONCLUSIONS

Based on our novel findings, combination therapy, especially ABs plus PDE5-Is, is recommended for short-term treatment for LUTS/BPH. There was also evidence that PDE5-Is used alone was efficacious except on Qmax. Additionally, it should be cautious when using MRAs. However, further clinical studies are required for longer duration which considers more treatment outcomes such as disease progression, as well as basic research investigating mechanisms involving PDE5-Is and other pharmacologic agents alleviate the symptoms of LUTS/BPH.

Lower urinary tract symptoms in men

Benign prostatic hyperplasia (BPH) is a highly prevalent and costly condition that affects older men worldwide. Many affected men develop lower urinary tract symptoms, which can have a negative impact on their quality of life. In the past, transurethral resection of the prostate (TURP) was the mainstay of treatment. However, several efficacious drug treatments have been developed, which have transformed BPH from an acute surgical entity to a chronic medical condition. Specifically, multiple clinical trials have shown that α adrenoceptor antagonists can significantly ameliorate lower urinary tract symptoms. Moreover, 5α reductase inhibitors, alone or combined with an α adrenoceptor antagonist, can reverse the natural course of BPH, reducing the risk of urinary retention and the need for surgical intervention. Newer medical regimens including the use of antimuscarinic agents or phosphodiesterase type 5 inhibitors, have shown promise in men with predominantly storage symptoms and concomitant erectile dysfunction, respectively. For men who do not adequately respond to conservative measures or pharmacotherapy, minimally invasive surgical techniques (such as transurethral needle ablation, microwave thermotherapy, and prostatic urethral lift) may be of benefit, although they lack the durability of TURP. A variety of laser procedures have also been introduced, whose improved hemostatic properties abrogate many of the complications associated with traditional surgery.

Current role of treatment in men with lower urinary tract symptoms combined with overactive bladder

Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are highly prevalent in older men. The storage subcategory of LUTS is synonymous with overactive bladder (OAB) syndrome, which is an empirical diagnosis. Traditionally, alpha-blockers are widely prescribed to manage the LUTS of BPH, although storage symptoms may persist in many men despite treatment. Therefore, because therapies that target the prostate often fail to alleviate storage symptoms, they may not be the appropriate therapy for OAB. In past years, most physicians appeared to give more weight in elderly men to voiding symptoms than to storage symptoms and to be more concerned with initial treatment with anticholinergics for males with storage symptoms. Considering the recent increase in data on the efficacy and safety of combination treatment with alpha receptor antagonists and antimuscarinic agents, the standard pharmacologic treatment of patients with LUTS combined with OAB should be an alpha receptor antagonist and an antimuscarinic agent. Beta-3 adrenoreceptor agonists may also potentially be useful for the treatment of male LUTS combined with OAB.

Fixed-dose combination PRO 160/120 of sabal and urtica extracts improves nocturia in men with LUTS suggestive of BPH: re-evaluation of four controlled clinical studies

PURPOSE

To determine the effects of the herbal fixed-dose combination PRO 160/120 (extracts from saw palmetto fruits and stinging nettle roots) on nocturnal voiding frequency, as measured by question 7 of the IPSS questionnaire, in patients with moderate-to-severe LUTS/BPH after 24 weeks of treatment compared to placebo, to the α-blocker tamsulosin, or to the 5α-reductase inhibitor finasteride.

METHODS

The study is about post hoc evaluation of four published randomized, double-blind clinical trials on PRO 160/120, two compared with placebo, one with finasteride and one with tamsulosin. In addition, a pooled data analysis of the two placebo-controlled trials was conducted.

RESULTS

We analyzed data from a total of 922 patients with a mean age of 66 years and a mean baseline nocturnal voiding frequency of 2.1. In the pooled analysis of placebo-controlled trials, nocturnal voids improved by 0.8 (29 %) with PRO 160/120 compared to 0.6 (18 %) with placebo (p = 0.015, Wilcoxon test, one-tailed). The 69 % responder rate to PRO 160/120 was significantly superior to the placebo response (52 %; p = 0.003, χ (2)-test, two-tailed). The majority of responders improved by 1 void/night. Absolute improvements and response rates were consistently higher with PRO 160/120 than with placebo over a range of baseline nocturnal voiding frequencies. There were no differences between PRO 160/120 and finasteride or tamsulosin regarding absolute improvement of nocturnal voids or responds rates.

CONCLUSION

PRO 160/120 significantly improved nocturnal voiding frequency compared to placebo and similar to tamsulosin or finasteride.

Does Baseline Prostate Volume Affect the Short-Term Outcome of Tamsulosin?

OBJECTIVE

To investigate the short-term efficacy of tamsulosin treatment for patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) according to baseline prostate volume (PV).

METHODS

Tamsulosin, 0.2 mg/day, was prospectively given to 112 patients aged 50 years or older who had International Prostate Symptom Scores (IPSS) ≥ 8. The short-term efficacy was analyzed using the IPSS, quality of life (QOL) index, BPH problem index (BPI), maximum flow rate (Qmax ) and postvoid residual urine volume (PVR) at 4 weeks and 3 months after treatment considering the estimated PV at baseline.

RESULTS

Of the 112 patients, 81 and 31 had PV of < 35 and ≥ 35 mL, respectively. The IPSS was significantly improved in patients with PV of < 35 mL (17.8 ± 5.9 at baseline, 13.5 ± 7.0 at 4 weeks, 11.9 ± 6.1 at 3 months) and in those with PV of ≥ 35 mL (17.4 ± 6.7 at baseline, 13.1 ± 7.0 at 4 weeks, 13.4 ± 6.2 at 3 months). There was no significant difference in the changes of the IPSS between the groups in a combined analysis model (P = 0.559). In addition, the model revealed no significant differences in changes in the QOL index, BPI, Qmax and PVR.

CONCLUSION

The short-term efficacy of tamsulosin is observed irrespective of baseline PV. Thus, α1-blocker monotherapy should be considered for all patients with BPH/LUTS to rapidly relieve symptoms, although the long-term outcome is not promising for patients with a large PV at baseline.

Is There a Relation between Reticular Formation and Storage Symptoms in Men

OBJECTIVE

To reveal brainstem originated pathology in men with different types of lower urinary tract symptoms blink reflex latency times were assessed.

METHODS

A total of 32 men, 16 with storage and 16 with voiding symptoms, were enrolled in the study. Blink reflex latency times were analyzed through electrical stimulation of the supraorbital nerve. Two responses in the orbicularis oculi muscle were recorded: the latency times for the early ipsilateral response, R1, and the late bilateral responses, R2.

RESULTS

The mean ages of the patients with storage and voiding symptoms were 57.31 ± 6.87 and 58.06 ± 6.29 years, respectively. The R2 latency times were significantly longer in men with storage symptoms. However, the R1 latency times were similar for the two groups.

CONCLUSION

Late blink latency times were long only in patients who had storage symptoms. An oligosynaptic path through the trigeminal nuclei, which includes one or two interneurons, is responsible for early response; however, late response is relayed through a polysynaptic path, including neurons in the reticular formation. It has also been shown that stimulation of the pontine reticular formation inhibits the micturition contraction. In some patients, storage symptoms may result from pathology that originates with the reticular formation and this pathology may lead to increases in late blink latency times. Additional studies are needed on other reflexes that are mediated through reticular formation, in order to show the possible dysfunction of the reticular formation in men with storage symptoms.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.

Efficacy of alfuzosin after shock wave lithotripsy for the treatment of ureteral calculi

PURPOSE

We evaluated the efficacy of alfuzosin for the treatment of ureteral calculi less than 10 mm in diameter after extracorporeal shock wave lithotripsy (ESWL).

MATERIALS AND METHODS

A randomized, single-blind clinical trial was performed prospectively by one physician between June 2010 and August 2011. A total of 84 patients with ureteral calculi 5 to 10 mm in diameter were divided into two groups. Alfuzosin 10 mg (once daily) and loxoprofen sodium 68.1 mg (as needed) were prescribed to group 1 (n=41), and loxoprofen sodium 68.1 mg (as needed) only was prescribed to group 2 (n=44). The drug administration began immediately after ESWL and continued until stone expulsion was confirmed up to a maximum of 42 days after the procedure.

RESULTS

Thirty-nine of 41 (95.1%) patients in group 1 and 40 of 43 (93.0%) patients in group 2 ultimately passed stones (p=0.96). The number of ESWL sessions was 1.34±0.65 and 1.41±0.85 in groups 1 and 2, respectively (p=0.33). The patients who required analgesics after ESWL were 8 (19.5%) in group 1 and 13 (30.2%) in group 2 (p=0.31). Visual analogue scale pain severity scores were 5.33±1.22 and 6.43±1.36 in groups 1 and 2, respectively (p=0.056). The time to stone expulsion in groups 1 and 2 was 9.5±4.8 days and 14.7±9.8 days, respectively (p=0.005). No significant adverse effects occurred.

CONCLUSIONS

The use of alfuzosin in combination with ESWL seems to facilitate stone passage and to reduce the time of stone expulsion but does not affect the stone-free rate.

Nocturia: current concepts and future perspectives

Nocturia is a prevalent highly bothersome urinary symptom that may significantly detriment the health and well-being of sufferers. It is characterized by waking at night to void, each void preceded and followed by sleep, hence leading to fragmentation of sleep and day-time tiredness. This may result in reduced productivity in the workplace, which contributes to the significant burden to the wider society that nocturia incurs. Nocturia was traditionally viewed as one of the many urinary tract symptoms that occur due to lower urinary tract dysfunction. However, recently it has been recognized that due to its multi-factorial aetio-pathogenesis, nocturia should be viewed as distinct clinical condition in its own right. Careful assessment of the nocturic patient is essential so that treatment strategies are guided by the likely causes. Much research is currently being undertaken into the underlying causes and the optimal management approaches. This review will explore the contemporary status of research on nocturia with a focus on the current and newly available pharmacotherapies.

Latest treatment for lower urinary tract dysfunction: therapeutic agents and mechanism of action

Recent studies suggest that antimuscarinics might suppress bladder afferent activity by blocking muscarinic receptors in the urothelium, myofibroblasts and detrusor, thereby improving overactive bladder symptoms. β(3)-Adrenoceptors are predominantly expressed in the human bladder and mediate relaxation of detrusor muscle. β(3)-Adrenoceptor agonists increase bladder capacity and prolong micturition interval. It is assumed that β(3)-adrenoceptor agonists could exert an inhibitory effect on bladder afferent through β(3)-adrenoceptors in the urothelium and detrusor, which eventually improve the symptom of urgency. Mirabegron is a potent and selective β(3)-adrenoceptor agonist. A Japanese phase 3 study showed that mirabegron has excellent efficacy and safety for treating overactive bladder. α(1)-Adrenoceptor antagonists (α(1)-blockers) have become a mainstay of male lower urinary tract symptoms treatment. The α(1)(A) subtype is known to mediate functional obstruction as a result of benign prostatic enlargement. Recent studies have suggested that α(1)(A)-adrenoceptors are additionally involved in the generation of storage symptoms. The α(1)(D) subtype is thought to play a role in the facilitation of voiding reflex; that is; storage symptoms. α(1)-Blockers often fail to alleviate overactive bladder symptoms. In this context, combination therapy with α(1)-blockers and antimuscarinics has been recommended. Treatment with 5α-reductase inhibitor for 1 year improves urinary symptoms and flow rate by reducing prostatic volume in men with benign prostatic enlargement. A pooled analysis showed that the long-term (2 or 4 years) treatment with 5α-reductase inhibitor reduced the rate of progression to acute urinary retention and surgery. Combination therapy with 5α-reductase inhibitor and α(1)-blocker was shown to provide a rapid improvement in lower urinary tract symptoms, and reduce the relative risk of acute urinary retention and benign prostatic hyperplasia-related surgery. Phosphodiesterase inhibitors might target a nitric oxide-cyclic guanosine monophosphate pathway in the prostate, urethra and bladder. Phosphodiesterase-5 inhibitors (sildenafil or tadalafil) were shown to provide clinically relevant improvements in both male lower urinary tract symptoms and erectile dysfunction.

Superselective α-adrenergic blockers versus transurethral resection of the prostate: a prospective comparison of health-related quality of life outcome after treating patients with benign prostatic hyperplasia

PURPOSE

We prospectively evaluated the impact of transurethral resection of the prostate (TURP) versus superselective α-adrenergic blocker treatment on health-related quality of life (HRQOL) in men with clinically diagnosed benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A total of 219 patients with lower urinary tract symptoms (LUTS) caused by BPH were recruited in this study. Treatment modalities consisted of standard TURP (n = 104) and tamsulosin medical treatment (n = 115). HRQOL was assessed by SF-36-Item Health Survey 1.0. LUTS were estimated by The International Prostate Symptom Score. Patients' outcome 4 weeks after treatment was compared to pre-treatment status and to that of the other group. Statistically significant changes in each HRQOL scale from baseline to follow-up period were investigated.

RESULTS

Baseline characteristics were similar in both groups except for the duration of disease before treatment that was longer in TURP group. Both treatments resulted in statistically significant improvements from pre-treatment in all scales of QOL after 4 weeks, with no significant differences observed between the two groups. In medical treatment group, there was a significant association between higher educational level and better QOL in all 8 scales. Our outcomes revealed a significant decrease in the IPSS in both groups but this improvement was more evident in TURP group.

CONCLUSION

All scales concerning HRQOL were favorably improved 4 weeks after both surgical and medical treatment, and no significant differences were observed between these two treatment modalities for patients with symptomatic BPH. This information may aid patients when deciding which treatment option to take.

What are the factors contributing to failure in improvement of subjective symptoms following silodosin administration in patients with benign prostatic hyperplasia? Investigation using a pressure-flow study

AIMS

To investigate the factors responsible for failure in improvement of subjective symptoms following silodosin treatment on the basis of findings of a pressure-flow study (PFS).

METHODS

A post hoc analysis of a prospective study to investigate the efficacy of silodosin in patients with BPH was conducted, and 104 patients were analyzed. The patients were administered silodosin 8 mg/day for 4 weeks. At the baseline and after treatment, subjective symptoms were evaluated using the IPSS and OABSS. A PFS was conducted to measure storage and voiding function. The patients were divided into two groups: good responders (GR), patients with 25% or more improvement in IPSS, and poor responders (PR), <25% improvement. The clinical and objective findings for the two groups were compared.

RESULTS

The mean IPSS and OABSS significantly improved in GR, but no significant improvement was observed in PR. PFS analysis revealed that all voiding and storage function parameters improved significantly in GR. Although PR showed a significant improvement in the voiding function parameters, it did not show significant changes in the storage function. Involuntary detrusor contraction (IDC) resolved in 68.6% of the patients in GR and in only 30% of the patients in PR, thereby showing a significant difference in the remedial effect between the two groups.

CONCLUSIONS

The findings suggest that insufficient improvement in storage function is a contributing factor to the failure in improvement of subjective symptoms after silodosin treatment in patients with BPH.

Assessment of tamsulosin as a potential male contraceptive in healthy volunteers

OBJECTIVE

To investigate the efficacy and safety of tamsulosin, an α(1A)-adrenoceptor antagonist, as a potential male contraceptive.

METHODS

Forty healthy male volunteers were equally divided into 2 groups, each of which received placebo and tamsulosin sequentially in a crossover manner. Ejaculatory profile was examined 4 to 6 hours after administration and adverse effects were noted.

RESULTS

Anejaculation occurred in all subjects after taking 0.8-mg of tamsulosin. Total functional sperm count was significantly reduced in subjects after taking 0.4-mg of tamsulosin. Six subjects receiving 0.8-mg of tamsulosin complained of tolerated discomfort, which disappeared 10 hours after administration.

CONCLUSION

When administered at 0.8 mg, tamsulosin can cause anejaculation with some transient side effects. Our results imply that tamsulosin and related drugs might potentially be used as male contraceptive agents in the future, which needs more studies to verify.

α-Blockers for benign prostatic hyperplasia: the new era

PURPOSE OF REVIEW

α1-Adrenoceptor blockers are the most frequently prescribed medical therapy in the treatment of lower urinary tract symptom suggestive of benign prostatic hyperplasia (LUTS/BPH). The purpose of this review is to highlight the evolution of adrenoceptor blockers with emphasis on newly approved drugs.

RECENT FINDINGS

Over the past years new formulations of several α1-adrenoceptor blockers were introduced to the market. Five long-acting α1-blockers are currently approved by the Food and Drug Administration for treatment of symptomatic LUTS/BPH: terazosin, doxazosin, tamsulosin, alfuzosin and silodosin. Silodosin is the only adrenoceptor blocker that exhibits true selectivity for the α1-adrenoceptor subtypes. This unique adrenoceptor selectivity profile likely accounts for the very favorable cardiovascular safety profile.

SUMMARY

Tamsulosin, alfuzosin slow release and silodosin do not require dose titration. Alfuzosin, terazosin, doxazosin and silodosin have all been shown to be effective in relieving LUTS/BPH independent of prostate size. Low incidence of orthostatic hypotension has been reported for silodosin, but abnormal ejaculation is the most commonly reported adverse effect.