Can urodynamic assessment of outflow obstruction predict outcome from watchful waiting?--A four-year follow-up study

The Use of Urodynamics Assessment Before the Surgical Treatment of BPH

Lower urinary tract symptoms (LUTS) are a common problem in men especially with aging. The International Continence Society (ICS) revealed an overall prevalence of LUTS of about two-thirds of men age 40 years and above. The treatment approach depends on accurate determination of the underlying etiology. LUTS is not unique to benign prostate enlargement (BPE) and can be secondary to other causes. In the era where quality of care is important, accurate diagnosis and counseling to meet patients' expectations is of extreme paramount. Thus, proper assessment of patients who present with BPE and LUTS should be an important part of the work up process. Accurate diagnosis and identification of the cause will help to improve quality of treatment, optimize counseling, and improve treatment outcomes. Pressure flow urodynamic studies (PFUDs) are not only important tools that help to identify the underlying causes of LUTS; it is considered the "gold standard" for diagnosis of bladder outlet obstruction (BOO) in patients with enlarged prostate [1, 2]. However, there is a continuous debate on the value of using PFUDs and its association with improved outcomes.

Efficacy and safety of propiverine and terazosine combination for one year in male patients with luts and detrusor overactivity

PURPOSE

To evaluate the long term efficacy and safety of the use of propiverine and terazosine combination in patients with LUTS and DO by a placebo controlled study.

MATERIALS AND METHODS

One hundred patients were enrolled in the study. They were randomized into two groups (each group consisted of 50 patients). Terazosine and placebo were administered to the patients in Group 1 and terazosine plus propiverine HCL was administered to Group 2. The patients were evaluated by international prostate symptom score (IPSS), the first four questions of IPSS (IPSS4), the 8th question of IPSS (quality of life-QoL), overactive bladder symptom score questionnaire (OAB-q V8), PSA test, urodynamic studies, post voiding residue (PVR). All patients were followed for one year and were reassessed for comparison.

RESULTS

IPSS, IPSS4, OAB symptoms, QoL score, PVR, and Qmax scores of the groups did not differ. After one year treatment, there was significant improvement in IPSS, IPSS4, OAB symptoms, QoL and Qmax values in Group 2. No significant improvement was noted for the same parameters in Group 1.

CONCLUSION

This is the first study to show long term safety and efficacy of anticholinergic therapy for patients with LUTS. In patients with OAB or DO, long term anticholinergic treatment may be regarded as a treatment option.

Urodynamics: what to do and when is it clinically necessary?

The role of urodynamics in the evaluation and treatment of men with lower urinary tract symptoms is not well defined. Symptoms do not correlate very well with urodynamic findings, but patients with prostatic obstruction fare better after ablative prostatic surgery than those with impaired detrusor contractility. The only proven method for distinguishing between the two is urodynamics, ie, the detrusor pressure/uroflow study. This article reviews urodynamic techniques and the literature pertaining to urodynamics, along with their clinical utility in benign prostatic hyperplasia. The role of urodynamics in clinical practice is discussed as well.

Evidence-based guidelines for the management of lower urinary tract symptoms related to uncomplicated benign prostatic hyperplasia in Italy: updated summary

BACKGROUND AND SCOPE

Despite the high prevalence and huge socio-economic impact of benign prostatic hyperplasia (BPH) in Italy, no national guidelines have been produced so far. This is a summary of the first Italian guidelines on the diagnosis and treatment of lower urinary tract symptoms (LUTS) related to uncomplicated BPH, prepared by a multidisciplinary panel under the auspices of the Italian Association of Urologists and introduced in Italy in 2003. An update compiled by the authors is also included.

METHODS

Relevant papers published from 1998 to 2003 (updated to 2006) were identified through a structured literature review and the quality of evidence presented therein was graded according to the Centre for the Evaluation of Effectiveness in Health Administration (CeVEAS) system. Recommendations were based on evidence from the literature, but also on feedback from practitioners and specialists. MAIN FINDINGS/RECOMMENDATIONS: Given the prevalence of BPH, all men aged > or = 50 years of age should be asked about LUTS and informed about disease characteristics and therapeutic options, while sexual function should always be assessed in patients with severe and long-standing LUTS. Initial assessment should include medical history (including drug and co-morbidity history), digital rectal examination, urinalysis, International Prostate Symptom Score-Quality of Life (IPSS-QoL) and a voiding diary, while prostate-specific antigen (PSA) and measurement of prostate volume by suprapubic ultrasonography are indicated in fully informed patients with a life expectancy of > or = 10 years in whom BPH progression could influence treatment choices. QoL considerations should dictate whether to start active treatment. When QoL is not affected by LUTS, watchful waiting is indicated if symptoms are mild, acceptable if they are moderate. When QoL is affected, medical therapy with alpha1-blockers or 5alpha-reductase inhibitors (the latter indicated in patients with increased prostate volume) is appropriate. Combined therapy with alpha1-blockers + 5alpha-reductase inhibitors should only be considered in patients at high risk for progression (prostate volume > 40 mL or PSA > 4 ng/mL), since the incremental cost of combination therapy vs. monotherapy with alpha1-blockers or finasteride is prohibitive. Selection of the type of surgery should be based on the surgeon's experience, the presence of co-morbid conditions and the size of the prostate. Open prostatectomy and transurethral resection of the prostate (TURP) are recommended in patients with acute or chronic retention of urine, and acceptable in obstructed patients with moderate/severe symptoms and worsened QoL. Transurethral incision of the prostate (TUIP) is acceptable when prostate volume is < or = 30 mL. Holmium laser enucleation of the prostate (HoLEP) may be proposed to motivated patients where expert surgeons are available. Transurethral microwave thermotherapy (TUMT) or transurethral needle ablation (TUNA) may be proposed to motivated patients who prefer to avoid surgery and/or do not respond to medical treatment. The possible effects of medical or surgical treatments on sexual function should always be discussed.

CONCLUSIONS

These guidelines are intended to provide a framework for health professionals involved in BPH management in order to facilitate decision-making in all areas and at all levels of healthcare.

Antimuscarinic therapy in men with lower urinary tract symptoms: What is the evidence?

Lower urinary tract symptoms (LUTS) in men have, until recently, been assumed to arise from bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia. Given this presumption, all manifestations (obstructive and irritative) of LUTS have been presumed to be responsive to therapy for prostatic disorders such as alpha-blockade (with or without the relatively recent addition of 5alpha-reductase inhibitors) or surgical intervention for benign prostatic hyperplasia. However, evidence demonstrates that persistence of irritative urinary symptoms is often encountered in men despite presumed adequate management of their obstructive complaints. Although antimuscarinic drugs have been found to be effective for irritative urinary symptoms attributed to the overactive bladder syndrome, concern regarding the use of this class of drugs in men with even potential coexistent BOO has limited the use of these drugs. Data are now accumulating that suggest that the antimuscarinic class may be used in men with bothersome, irritative symptoms, despite the presence of BOO (as defined by symptoms and urodynamics) and with a reasonable expectation of efficacy and little added risk. Critical evaluation of this evidence suggests that a role may exist for the antimuscarinic class in management of LUTS in men. However, areas of incomplete knowledge, including the risk associated with long-term (greater than 3 months) use of these drugs and the value of the antimuscarinic class as monotherapy in men with LUTS, still remain to be investigated.

TOLTERODINE EXTENDED RELEASE ATTENUATES LOWER URINARY TRACT SYMPTOMS IN MEN WITH BENIGN PROSTATIC HYPERPLASIA

PURPOSE

In this open label, prospective study we determined the efficacy and tolerability of tolterodine extended release (ER) in men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) in whom previous alpha-blocker therapy had failed.

MATERIALS AND METHODS

A total of 43 consecutive men with BPH and LUTS in whom a mean of 5.7 months of alpha-blocker therapy had failed due to adverse events (11) or a lack of efficacy (32) received tolterodine ER (4 mg daily) for 6 months. Primary efficacy end points were American Urological Association symptom score, and mean daytime and nighttime micturition frequency. Secondary end points were the peak urinary flow rate, post-void residual volume, the incidence of urinary retention, total score on the erectile function domain of the International Index of Erectile Function and adverse events.

RESULTS

A total of 39 men (91%) with a mean age of 61 years completed the 6-month trial. Mean 24-hour micturition frequency decreased from 9.8 to 6.3 voids and nocturia decreased from 4.1 to 2.9 episodes nightly. Significant changes in mean American Urological Association symptom scores (-6.1), the peak urinary flow rate (1.9 ml per second) and post-void residual volume (-22 ml) were also observed. Of the men 27 (63%) were potent at baseline and 29 (67%) were potent after 6 months of tolterodine ER treatment. Mean International Index of Erectile Function erectile function domain scores increased (6.9). Four men (9%) discontinued therapy because of intolerable dry mouth. There were no reports of urinary retention.

CONCLUSIONS

Treatment with tolterodine ER in men with BPH and LUTS may be a reasonable therapeutic option as initial therapy or after failed treatment with alpha-blockers.

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

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