Autonomic nervous system overactivity in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia

Mendelian randomization study supports positive bidirectional causal relationships between genetically predicted insomnia symptom and liability to benign prostatic hyperplasia

BACKGROUND

Sleep quality may be related to benign prostatic hyperplasia (BPH), however causal associations have not been established. This study aimed to evaluate causal relationships between six sleep traits ([i] day time napping, [ii] daytime sleepiness, [iii] insomnia, [iv] long sleep duration, [v] short sleep duration, and [vi] sleep duration per hour) and BPH through a bidirectional Mendelian randomization (MR) study.

METHODS

Genome-wide association summary statistics of sleep traits and BPH were downloaded from public databases. Inverse variance weighting (IVW) was used as the main approach for causal inference. For causal estimates identified by IVW, various sensitivity analyses were performed to assess the reliability of the results: (i) four additional MR methods to complement IVW; (ii) Cochran's Q test to assess heterogeneity; (iii) MR-Egger intercept test and MR-PRESSO global test to assess horizontal pleiotropy; and (iv) leave-one-out method to assess stability.

RESULTS

Forward MR analyses indicated that genetically predicted insomnia symptom significantly increased BPH risk (OR = 1.267, 95% CI: 1.003-1.601, P = 0.048), while reverse MR analyses identified that genetically predicted liability to BPH significantly increased the incidence of insomnia (OR = 1.026, 95% CI: 1.000-1.052, P = 0.048). In a replicate MR analysis based on summary statistics including exclusively male participants, the finding of increased risk of BPH due to genetically predicted insomnia symptom was further validated (OR = 1.488, 95% CI: 1.096-2.022, P = 0.011). No further causal links were identified. In addition, sensitivity tests demonstrated the reliability of the MR results.

CONCLUSION

This study identified that a higher prevalence of genetically predicted insomnia symptoms may significantly increase the risk of BPH, while genetically predicted liability to BPH may in turn increase the incidence of insomnia symptom. Therefore, improving sleep quality and reducing the risk of insomnia could be a crucial approach for the prevention of BPH.

Insights into the associative role of hypertension and angiotensin II receptor in lower urinary tract dysfunction

In men, the lower urinary tract comprises the urinary bladder, urethra, and prostate, and its primary functions include urine storage and voiding. Hypertension is a condition that causes multi-organ damage and an age-dependent condition. Hypertension and the renin-angiotensin system activation are associated with the development of lower urinary tract dysfunction. Hypertensive animal models show bladder dysfunction, urethral dysfunction, and prostatic hyperplasia. In the renin-angiotensin system, angiotensin II and the angiotensin II type 1 receptor, which are expressed in the lower urinary tract, have been implicated in the pathogenesis of lower urinary tract dysfunction. Moreover, among the several antihypertensives, renin-angiotensin system inhibitors have proven effective in human and animal models of lower urinary tract dysfunction. This review aimed to elucidate the hitherto known mechanisms underlying the development of lower urinary tract dysfunction in relation to hypertension and the angiotensin II/angiotensin II type 1 receptor axis and the effect of renin-angiotensin system inhibitors on lower urinary tract dysfunction. Possible mechanisms through which hypertension or activation of Ang II/AT1 receptor axis causes LUTD such as bladder dysfunction, urethral dysfunction, and prostatic hyperplasia. LUT: lower urinary tract, LUTD: lower urinary tract dysfunction, AT1: angiotensin II type 1, ACE: angiotensin-converting enzyme.

Effects of autonomic nervous system disorders on male infertility

The male reproductive functions are largely regulated by the autonomic nervous system. Male sexual behavior and fertility primarily depend on the normal function of the higher neural centers related to the autonomic nervous system, the hypothalamic-pituitary-gonadal axis, the autonomic nervous components within the spinal cord and spinal nerves, and certain somatic nerves in the pelvic floor. In this review article, we will summarize the role of the autonomic nervous system in regulating male reproductive capabilities and fertility, its impact on male infertility under abnormal conditions, including the role of drug-induced autonomic nervous dysfunctions on male infertility. The main purpose of this article was to provide an overview of the effects of autonomic nervous dysfunction on male reproductive function and shed light on the potential therapeutic target for male infertility.

The causal effect of metabolic syndrome and its components on benign prostatic hyperplasia: A univariable and multivariable Mendelian randomization study

BACKGROUND

Previous observational studies have indicated that metabolic abnormalities are associated with benign prostatic hyperplasia (BPH). The limitations of the research methodology of observational studies do not allow causal inference to be drawn; however, Mendelian randomization (MR) can clarify this.

METHODS

Using summary-level data from genome-wide association studies, we conducted a two-sample MR study to examine the causality of the metabolic syndrome (MetS) and its components on BPH (26,358 BPH cases and 110,070 controls). The random-effects inverse-variance weighted was employed as the primary method for MR analyses.

RESULTS

We observed that genetically predicted waist circumference (WC) (odds ratio [OR] = 1.236, 95% confidence interval [CI]: 1.034-1.478, p = 0.020) and diastolic blood pressure (DBP) (OR = 1.011, 95% CI: 1.002-1.020, p = 0.020) were significantly positively associated with BPH risk. We did not identify a causal effect of MetS (OR = 0.975, 95% CI: 0.922-1.031, p = 0.375), systolic blood pressure (OR = 1.004, 95% CI: 0.999-1.008, p = 0.115), triglycerides (OR = 1.016, 95% CI: 0.932-1.109, p = 0.712), high-density lipoprotein (OR = 1.005, 95% CI: 0.930-1.086, p = 0.907), and fasting blood glucose (OR = 1.037, 95% CI: 0.874-1.322, p = 0.678) on BPH. In the multivariable MR analysis, we observed that the risk effect of DBP (OR = 1.013, 95% CI: 1.000-1.026, p = 0.047) on BPH persisted after conditioning with WC (OR = 1.132, 95% CI: 0.946-1.356, p = 0.177).

CONCLUSIONS

Our study provides genetic evidence supporting the causal effect of DBP on BPH, although the effect of WC needs to be further validated.

The bitter taste receptor (TAS2R) agonist denatonium promotes a strong relaxation of rat corpus cavernosum

Bitter taste receptors (TAS2R) are found in numerous extra-oral tissues, including smooth muscle (SM) cells in both vascular and visceral tissues. Upon activation, TAS2R stimulate the relaxation of the SM. Nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) signaling pathway is involved in penile erection, and type 5 phosphodiesterase (PDE5) inhibitors, a cGMP-specific hydrolase are used as first-line treatments for erectile dysfunction (ED). Nevertheless, PDE5 inhibitors are ineffective in a considerable number of patients, prompting research into alternative pharmacological targets for ED. Since TAS2R agonists regulate SM contractility, this study investigates the role of TAS2Rs in rat corpus cavernosum (CC). We performed immunohistochemistry to detect TAS2R10, isometric force recordings for TAS2R agonists denatonium and chloroquine, the slow-release H2S donor GYY 4137, the NO donor SNAP, the β-adrenoceptor agonist isoproterenol and electrical field stimulation (EFS), as well as measurement of endogenous hydrogen sulfide (H2S) production. The immunofluorescence staining indicated that TAS2R10 was broadly expressed in the CC SM and to some extent in the nerve fibers. Denatonium, chloroquine, SNAP, and isoproterenol cause potent dose-dependent SM relaxations. H2S production was decreased by NO and H2S synthase inhibitors, while it was enhanced by denatonium. In addition, denatonium increased the relaxations induced by GYY 4137 and SNAP but failed to modify EFS- and isoproterenol-induced responses. These results suggest neuronal and SM TAS2R10 expression in the rat CC, where denatonium induces a strong SM relaxation per se and promotes the H2S- and NO-mediated inhibitory gaseous neurotransmission. Thus, TAS2R10 might represent a valuable therapeutic target in ED.

Effect of Diabetes Mellitus on Symptomatic Improvement After Surgery for Benign Prostatic Hyperplasia in Patients With Lower Urinary Tract Symptom and its Relations With Prostatic Urethral Angulation

PURPOSE

To compare improvement of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia in diabetic versus nondiabetic patients after transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP).

METHODS

The medical records of 437 patients who underwent TURP or HoLEP at a tertiary referral center from January 2006 to January 2022 were retrospectively analyzed. Among them, 71 patients had type 2 diabetes. Patients in the diabetic mellitus (DM) and non-DM groups were matched 1:1 according to age, baseline International Prostate Symptom Score (IPSS), and ultrasound measured prostate volume. Changes in LUTS were assessed at 3 months after surgery using IPSS and evaluated by categorizing patients according to prostatic urethral angulation (PUA; <50° vs. ≥50°). Medication-free survival after surgery was also investigated.

RESULTS

No significant differences were noted between the DM and non-DM groups in baseline characteristics except for comorbidities (i.e., hypertension, cerebrovascular disease, and ischemic heart disease, P=0.021, P=0.002, and P=0.017, respectively) and postvoid residual urine volume (115±98 mL vs. 76±105 mL, P=0.028). Non-DM patients showed significant symptomatic improvement regardless of PUA, while DM patients demonstrated improvement in obstructive symptoms only in those with large PUA (≥51°). Among patients with small PUA, DM patients had worse medication-free survival after surgery compared to controls (P=0.044) and DM was an independent predictor of medication reuse (hazard ratio, 1.422; 95% confidence interval, 1.285-2.373; P=0.038).

CONCLUSION

DM patients experienced symptomatic improvement after surgery only in those with large PUA. Among patients with small PUA, DM patients were more likely to reuse medication after surgery.

Sarcopenia and excess visceral fat accumulation negatively affect early urinary function after I‐125 low‐dose‐rate brachytherapy for localized prostate cancer

OBJECTIVES

To evaluate the effects of sarcopenia and excess visceral fat accumulation on early urinary function after I-125 low-dose-rate brachytherapy for prostate cancer.

METHODS

We retrospectively reviewed consecutive patients who underwent brachytherapy for prostate cancer. Pre-treatment computed tomography was used to measure skeletal muscle index at the L3 level to assess sarcopenia and visceral fat area at the umbilical level. The International Prostate Symptom Score and the University of California Los Angeles Prostate Cancer Index were used to assess quality of life during the 24 months after brachytherapy. Logistic regression analysis was used to examine whether sarcopenia and excess visceral fat accumulation had clinically significant effects on post-treatment quality of life.

RESULTS

Among 246 patients, 92 (37.4%) were stratified into the sarcopenia group and 141 (57.3%) into the excess visceral fat accumulation group. The sarcopenia group had significantly lower University of California Los Angeles Prostate Cancer Index urinary function than the non-sarcopenia group 24 months post-brachytherapy. The excess visceral fat accumulation group had significantly poorer International Prostate Symptom Score total, storage, and voiding scores than the non-excess accumulation group 12 months post-brachytherapy. In the multivariate analysis, sarcopenia had a clinically significant adverse effect on the University of California Los Angeles Prostate Cancer Index urinary function at 12 months. Excess visceral fat accumulation had a clinically significant adverse effect on the International Prostate Symptom Score voiding and storage scores at 12 months.

CONCLUSIONS

Sarcopenia and excess visceral fat accumulation negatively affect urinary function early after I-125 low-dose-rate brachytherapy for prostate cancer.

Updates on androgen replacement therapy and lower urinary tract symptoms: a narrative review

Lower urinary tract symptoms (LUTS) are caused by higher tension at the bladder neck level (due to fibrosis or stiffness) or benign prostatic hyperplasia, which causes static obstruction of the bladder outlet. Both forms cause a group of symptoms such as hesitancy, intermittency, weak stream, nocturia, urine frequency, and urgency. Additionally, LUTS (obstructive or irritative symptoms) are common in elderly men with hypogonadism, identified as the reduced testes capability in producing sex steroids and sperm, and are categorized as testosterone deficiency. Even though the mode of action (MoA) of testosterone therapy (TTh) on hypogonadal men needs more researched and understanding, the effectiveness of TTh in the development of male genital organs has been reported in several studies. This review shows the latest updates of TTh in LUTS including potential adverse effects, advantages, and disadvantages.

The Impact of Transoral Robotic Surgery on Erectile Dysfunction and Lower Urinary Tract Symptoms in Male Patients with Moderate-to-Severe Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), lower urinary tract symptoms (LUTS), and erectile dysfunction (ED) are chronic conditions that seriously affect middle-aged men. This study aimed to evaluate the changes in the presence of these conditions after transoral robotic surgery (TORS) for OSA. This prospective observational study recruited 48 men with moderate-to-severe OSA (mean age 40.6 ± 8.1 years) who underwent TORS from October 2019 to November 2021 at a tertiary center. Baseline polysomnographic parameters, Epworth Sleepiness Scale (ESS), and demographic characteristics were measured. The evaluations of LUTS and ED were based on self-administered International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) questionnaires, respectively, before TORS. The treatment outcomes were assessed three months postoperatively in the patients undergoing TORS due to moderate-to-severe OSA. There was significant Apnea-Hypopnea Index (AHI) reduction from 53.10 ± 25.77 to 31.66 ± 20.34 three months after undergoing TORS (p < 0.001). There was also a significant decrease in the total IPSS score (5.06 ± 5.42 at baseline to 2.98 ± 2.71 at three months postoperatively, p = 0.001), the storage domain, and the voiding domain (p < 0.05). The ED also improved significantly, as seen in the IIEF score (20.98 ± 3.32 to 22.17± 3.60, p = 0.007). The reduction of AHI was associated with changes in body weight and the lowest oxygen saturation (SpO2) levels during sleep (rho = 0.395, p = 0.005; rho = 0.526, p < 0.001, respectively). However, the reduction in AHI was not significantly associated with improvement in IPSS or IIEF scores (p > 0.05). For men with moderate-to-severe OSA, TORS can significantly improve the polysomnography parameters, sleep-related questionnaire scores, and quality of life, and alleviate ED and LUTS. AHI reduction is not a crucial factor for ED and LUTS improvement after TORS for OSA, especially in ED.

In vitro inhibition of phosphodiesterase type 4 enhances rat corpus cavernosum nerve-mediated relaxation induced by gasotransmitters

AIMS

Nitric oxide (NO) and hydrogen sulfide (H2S) are involved in nerve-mediated corpus cavernosum (CC) relaxation. Expression of phosphodiesterase type 5 (PDE5) and type 4 (PDE4), cyclic guanosine monophosphate (cGMP)- and cyclic adenosine monophosphate (cAMP)-specific, respectively, has been described and PDE5- and PDE4-inhibitors induce cavernous smooth muscle relaxation. Whereas the NO/cGMP signaling pathway is well established in penile erection, the cAMP-mediated mechanism is not fully elucidated. The aim of this study is to investigate the localization and the functional significance of PDE4 in rat CC tone regulation.

MAIN METHODS

We performed immunohistochemistry for the detection of the PDE4A isoenzyme. Isometric tension recordings for roflumilast and tadalafil, PDE4 and PDE5 inhibitors, respectively, electrical field stimulation (EFS) and β-adrenoceptor agonist isoproterenol and endogenous H2S production measurement.

KEY FINDINGS

A marked PDE4A expression was detected mainly localized in the nerve cells of the cavernous smooth muscle. Furthermore, roflumilast and tadalafil exhibited strong corpus cavernous relaxations. Endogenous H2S production was decreased by NO and H2S synthase inhibitors and increased by roflumilast. Isoproterenol- and EFS-induced relaxations were increased by roflumilast.

SIGNIFICANCE

These results indicate that PDE4A is mainly expressed within the nerves cells of the rat CC, where roflumilast induces a potent corpus cavernous relaxation per se and potentiates the response induced by β-adrenoceptor activation. The fact that roflumilast enhances H2S production, as well as EFS-elicited responses suggests that PDE4 inhibitors modulate, in a positive feedback fashion, nerve-mediated relaxation induced by gasotransmitters, thus indicating a key role for neuronal PDE4 in penile erection.

Heart rate variability in men with lower urinary tract symptoms: a case-control study

PURPOSE

Measurement of heart rate variability (HRV) allows evaluation of autonomic nervous system activity. Decreased HRV is associated with autonomic disbalance, poor health and higher mortality. Our objective is to evaluate the HRV in men with lower urinary tract symptoms (LUTS) through a case-control study.

METHODS

LUTS were considered as the outcome and HRV variables were considered as exposure. The protocol included anamnesis, LUTS assessment, anthropometry, blood pressure and HRV measurement by analyzing the variation in the time interval between consecutive heartbeats or RR intervals. The mathematical study of HRV indicators allowed the assessment of the cardiac autonomic modulation of the volunteers.

RESULTS

Eighty nine patients were included in the study, with 34 allocated to the case group (with LUTS) and 55 to the control group (without LUTS). The patients were similar in terms of age and systolic and diastolic blood pressure. Among the HRV variables, the mean VLF index for the very low frequency of the spectrum associated with the frequency domain was significantly higher in volunteers without LUTS. Control group patients presented a mean of 113.18 ± 166.74 ms², while patients with LUTS presented a mean of 69.21 ± 61.98 ms² (p = 0.032).

CONCLUSIONS

Men 50-59 years of age without chronic diseases and with LUTS have an unfavorable cardiac autonomic profile indicated by significantly lower levels of the VLF component of HRV compared to men without LUTS.

The Effect of Chronic Psychological Stress on Lower Urinary Tract Function: An Animal Model Perspective

Chronic psychological stress can affect urinary function and exacerbate lower urinary tract (LUT) dysfunction (LUTD), particularly in patients with overactive bladder (OAB) or interstitial cystitis–bladder pain syndrome (IC/BPS). An increasing amount of evidence has highlighted the close relationship between chronic stress and LUTD, while the exact mechanisms underlying it remain unknown. The application of stress-related animal models has provided powerful tools to explore the effect of chronic stress on LUT function. We systematically reviewed recent findings and identified stress-related animal models. Among them, the most widely used was water avoidance stress (WAS), followed by social stress, early life stress (ELS), repeated variable stress (RVS), chronic variable stress (CVS), intermittent restraint stress (IRS), and others. Different types of chronic stress condition the induction of relatively distinguished changes at multiple levels of the micturition pathway. The voiding phenotypes, underlying mechanisms, and possible treatments of stress-induced LUTD were discussed together. The advantages and disadvantages of each stress-related animal model were also summarized to determine the better choice. Through the present review, we hope to expand the current knowledge of the pathophysiological basis of stress-induced LUTD and inspire robust therapies with better outcomes.

Heat-Killed and Live Enterococcus faecalis Attenuates Enlarged Prostate in an Animal Model of Benign Prostatic Hyperplasia

In the present study, we investigated the inhibitory effect of heat-killed Enterococcus faecalis (E. faecalis) and live E. faecalis on benign prostatic hyperplasia (BPH). The BPH rat model was established by administering male rats with testosterone propionate (TP, 5 mg/kg, in corn oil) via subcutaneous injections daily for four weeks after castration. The rats were divided into five groups: Con, corn oil-injected (s.c.) + DW administration; BPH, TP (5 mg/kg, s.c.) + DW administration; BPH+K_EF, TP (5 mg/kg, s.c.) + heat-killed E. faecalis (7.5 × 10¹² CFU/g, 2.21 mg/kg) administration; BPH+L_EF, TP (5 mg/kg, s.c.) + live E. faecalis (1 × 10¹¹ CFU/g, 166 mg/kg) administration; BPH+Fi, TP (5 mg/kg, s.c.) + finasteride (1 mg/kg) administration. In both of BPH+K_EF and BPH+L_EF groups, the prostate weight decreased and histological changes due to TP treatment recovered to the level of the Con group. Both of these groups also showed regulation of androgen-signaling factors, growth factors, and apoptosis-related factors in prostate tissue. E. faecalis exhibited an inhibitory effect on benign prostatic hyperplasia, and even heat-killed E. faecalis showed similar efficacy on the live cells in the BPH rat model. As the first investigation into the effect of heat-killed and live E. faecalis on BPH, our study suggests that heat-killed E. faecalis might be a food additive candidate for use in various foods, regardless of heat processing.

Dietary reversal reverts diet-induced alterations in obstructed bladders of Wistar rats

OBJECTIVES

The aim of this study was to investigate the effects of diet reversal to standard chow on diet-induced changes in structure and function of normal and obstructed bladders in male Wistar rats.

METHODS

Eighty animals were equally divided into sham-surgery and bladder outlet obstruction (BOO) dietary groups and fed standard chow (control), high-carbohydrate, high-fat, and high-protein diets. BOO groups had surgically induced BOO, whereas sham surgery was performed on sham groups at the end of week 8. Animals were continued on the treatment diets for 4 wk after surgery, then the diets were all changed to standard chow for the remainder of the study period. Bladder weight, detrusor contractility, Rho-associated protein kinase (Rho-kinase), and myosin light chain kinase were determined. Polymerase chain reaction was used to assay for transforming growth factor-β, connecting tissue growth factor, hypoxia-inducible factor-1α, and platelet-derived growth factor subunit A levels in the bladder. C-reactive protein, insulin-like growth factor-1, nerve growth factor, and C-X-C motif chemokine ligand 12 concentrations were determined by enzyme-linked immunosorbent assay. The collagen content of the bladder was estimated by liquid chromatography/mass spectrometry.

RESULTS

Reversal of diet to standard chow resulted in reversal of diet-induced changes in all variables measured in obstructed bladders. High-fat-diet-induced alterations in normal bladders were also reversed.

CONCLUSION

The results suggested that in obstructed bladders of animals, reversal of the diet could reverse all diet-associated changes that increase inflammation and fibrosis in obstructed bladders. This is especially important in changes related to high consumption of fatty diets and associated lower urinary tract symptoms.

A multi-omic investigation of male lower urinary tract symptoms: Potential role for JC virus

Male lower urinary tract symptoms (LUTS) comprise a common syndrome of aging that negatively impacts quality of life. The etiology of LUTS is multifactorial, involving benign prostatic hyperplasia, smooth muscle and neurologic dysfunction, inflammation, sexually transmitted infections, fibrosis, and potentially dysbiosis, but this aspect remains poorly explored. We investigated whether the presence of infectious agents in urine might be associated with LUTS by combining next-generation DNA sequencing for virus discovery, microbiome analysis for characterization of bacterial communities, and mass spectrometry-based metabolomics. In urine from 29 LUTS cases and 9 controls from Wisconsin, we found a statistically significant association between a diagnosis of LUTS and the presence of JC virus (JCV), a common neurotropic human polyomavirus (Polyomaviridae, Betapolyomavirus) linked to severe neurologic disease in rare cases. This association (based on metagenomics) was not borne out when specific polymerase chain reaction (PCR) testing was applied to this set of samples, likely due to the greater sensitivity of PCR. Interestingly, urine metabolomics analysis identified dysregulation of metabolites associated with key LUTS processes. Microbiome analysis found no evidence of microbial community dysbiosis in LUTS cases, but JCV-positive samples contained more Anaerococcus species, which are involved in polymicrobial infections of the urinary tract. Neither age nor body mass index were significantly associated with the presence of urinary JCV-in the initial group or in an additional, regionally distinct group. These data provide preliminary support the hypothesis that viruses such as JCV may play a role in the development or progression of LUTS, together with other infectious agents and host metabolic responses.

Marijuana, Alcohol, and ED: Correlations with LUTS/BPH

PURPOSE OF REVIEW

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is a disease complex with enormous societal burden and yet the pathogenesis of LUTS/BPH is poorly understood. We set out to review the literature on the relationship between depression, marijuana usage, and erectile dysfunction (ED) to LUTS/BPH.

RECENT FINDINGS

LUTS/BPH has independent associations with depression as well as with ED. In each case, the causality and mechanistic relationship is unknown. The impact of marijuana, as it increasingly pervades the general population, on the disease complex of LUTS/BPH is not well studied but recent results support short-term benefit and long-term caution. Depression, a form of central nervous dysfunction, and ED, which is likely mediated via endothelial dysfunction, are independently associated with LUTS/BPH. The presence of cannabinoid receptors in urologic organs, coupled with recent population studies, supports a modulatory effect of marijuana on voiding although an enormous knowledge gap remains.

Excessive accumulation of visceral fat is associated with lower urinary symptoms including overactive bladder in female patients

Objective

To assess the relationship between visceral fat accumulation and lower urinary tract symptoms in female patients.

Methods

In this single‐center study, we enrolled all women who underwent screening abdominal computed tomography 3 months before the study, irrespective of whether they experienced lower urinary tract symptoms. The Overactive Bladder Symptom Score was used to assess subjective symptoms. Uroflowmetry and ultrasound assessment of post‐void residual urine were carried out to assess objective signs. We analyzed the relationship between lower urinary tract symptoms and various body fat accumulation parameters, including visceral fat area, visceral fat volume and total abdominal fat volume, assessed using computed tomography scans.

Results

A total of 182 patients were divided into the overactive bladder (n = 71, 39.0%) and the non‐overactive bladder (n = 111, 61.0%) groups. The visceral fat area, visceral fat volume and visceral fat volume/total abdominal fat volume values were all significantly higher in the overactive bladder group than in the non‐overactive bladder group (P < 0.001). Of these parameters, the visceral fat volume/total abdominal fat volume ratio showed the strongest correlation with the total Overactive Bladder Symptom Score (r = 0.394, P < 0.001). The maximum urine flow rate correlated negatively with the visceral fat volume/total abdominal fat volume value (visceral fat volume/total abdominal fat volume r = –0.289, P < 0.001). Subsequent multivariate analysis showed that a high visceral fat volume/total abdominal fat volume value, age and metabolic syndrome‐related diseases were independent risk factors for the presence of overactive bladder.

Conclusions

Excessive accumulation of visceral fat is independently associated with overactive bladder in females.

Increased risk of subsequent benign prostatic hyperplasia in non-Helicobacter pylori-infected peptic ulcer patients: a population-based cohort study

The vagus nerve plays an essential role in homeostasis and inflammation. Clinically, peptic ulcer patients without helicobacter pylori (HP) infection may provide a population for studying the effect of vagal hyperactivity. There were interests in the association of gastrointestinal disease and urogenital disorders. Herein, we try to investigate subsequent risk of benign prostatic hyperplasia (BPH) in non-HP infected peptic ulcer patients. We identified 17,672 peptic ulcer admission male patients newly diagnosed in 1998-2007 from Taiwan Health Insurance Database, and 17,672 male comparison without peptic ulcer, frequency matched by age, and index-year. We assessed subsequent incidence of BPH in each cohort by the end of 2013, and then compared the risk of developing BPH between individuals with and without peptic ulcer. In addition, peptic ulcer patients underwent surgery were also examined. There were 2954 peptic ulcer patients and 2291 comparisons noted with the occurrence of BPH (25.35 and 16.70 per 1000 person-years, respectively). Compared to comparisons, peptic ulcer patients had a 1.45- and 1.26-fold BPH risk in multivariable Cox model and Fine and Gray model (95% CI 1.37-1.54 and 1.19-1.34). In age-stratified analysis, the highest risk of BPH was in 45-59 years (interaction p < 0.05). Regarding surgery types, peptic ulcer patients who underwent simple suture surgery (i.e.: with integrated vagus nerve) had a significant higher BPH risk than comparison (HR 1.50 and 95% CI 1.33-1.74; SHR 1.26 and 95% CI 1.07-1.48), while patients underwent truncal vagotomy/pyloroplasty showed a lower incidence of BPH. In this study, non-HP-infected male peptic ulcer patients were found to have an increased risk of subsequent BPH. Indicating that there might be a role of vagus nerve. Based on the limitations of retrospective nature, further studies are required.

Association between sodium intake and lower urinary tract symptoms: does less sodium intake have a favorable effect or not?

Background

Sodium intake is known to be related with hypertension (HTN), which could impact lower urinary tracts symptoms (LUTS) indirectly. To date, only limited clinical evidences exist upon the association between sodium preference and LUTS. This cross-sectional study analyzed the association between sodium preference and the severity of LUTS in men.

Methods

A cross-sectional analysis has been performed and a total of 86,637 participants among total registered population of 229,226 in Korean Community Health Survey (KCHS) were included for final analysis. The adjusted odds ratio (OR) or coefficient with 95% confidence interval (CI) estimates were described to show the association between sodium preference and LUTS using negative binomial regression (for the IPSS total, IPSS voiding, and IPSS storage symptoms), ordinal logistic regression (for the IPSS grade), and binomial logistic regression (for the IPSS nocturia symptoms).

Results

Preference of salty taste group (high sodium preference) were significantly associated with higher IPSS total score (Coef =0.31; 95% CI: 0.27, 0.35), increased risk of severe IPSS grade (OR =1.46; 95% CI: 1.35, 1.57), higher IPSS voiding score (Coef =0.38; 95% CI: 0.32, 0.44), higher IPSS storage score (Coef =0.25; 95% CI: 0.22, 0.29), and increased risk of having IPSS nocturia symptoms (OR =1.21; 95% CI: 1.16, 1.27) compared to subjects with neutral group (normal sodium preference). Prediction of IPSS score according to salty taste preference showed u shaped distribution.

Conclusions

Sodium preference for taste were significantly associated with LUTS including voiding symptom, storage symptom and nocturia. Both higher and lower intake of sodium could be unfavorable factor for severity of LUTS.

Can Botulinum Toxin A Still Have a Role in Treatment of Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia Through Inhibition of Chronic Prostatic Inflammation?

Patients with benign prostatic hyperplasia (BPH) can exhibit various lower urinary tract symptoms (LUTS) owing to bladder outlet obstruction (BOO), prostatic inflammation, and bladder response to BOO. The pathogenesis of BPH involves an imbalance of internal hormones and chronic prostatic inflammation, possibly triggered by prostatic infection, autoimmune responses, neurogenic inflammation, oxidative stress, and autonomic dysfunction. Botulinum toxin A (BoNT-A) is well recognized for its ability to block acetylcholine release at the neuromuscular junction by cleaving synaptosomal-associated proteins. Although current large clinical trials have shown no clinical benefits of BoNT-A for the management of LUTS due to BPH, BoNT-A has demonstrated beneficial effects in certain subsets of BPH patients with LUTS, especially in males with concomitant chronic prostatitis/chronic pelvic pain syndrome and smaller prostate. We conducted a review of published literature in Pubmed, using Botulinum toxin, BPH, BOO, inflammation, LUTS, and prostatitis as the key words. This article reviewed the mechanisms of BPH pathogenesis and anti-inflammatory effects of BoNT-A. The results suggested that to achieve effectiveness, the treatment of BPH with BoNT-A should be tailored according to more detailed clinical information and reliable biomarkers.

Association between benign prostate enlargement-related storage and voiding symptoms and systolic blood pressure: a single-center cross-sectional study

BACKGROUND

Lower urinary tract symptoms significantly worsen quality of life. The hypothesis that they might lead to serious systolic blood pressure alterations through inducing sympathetic nervous activity has not been studied so far.

OBJECTIVES

To investigate the relationship between benign prostate enlargement-related storage and voiding symptoms and systolic blood pressure.

DESIGN AND SETTING

Cross-sectional single-center study on data from a hospital patient record system.

METHODS

We evaluated the medical records of all consecutive patients with benign prostate enlargement-related lower urinary tract symptoms admitted between January 2012 and December 2017. Storage and voiding symptoms were assessed separately. International Prostate Symptom Score, uroflowmetry, postvoiding residual urine volume and systolic blood pressure were recorded. Pearson correlation and linear regression analysis were used.

RESULTS

Positive correlations were found between systolic blood pressure and all of the storage symptoms. Among these, urgency had the most significant effect. There were 166 patients (41.4%) with urgency for urination, which increased mean systolic blood pressure from 124.88 mmHg (average value in elevated blood pressure group) to 132.28 mmHg (average value in stage-1 hypertension group). Hesitancy in urinating and feeling of incomplete bladder emptying had weak positive correlations with systolic blood pressure. There was a negative correlation between systolic blood pressure and intermittency of urination.

CONCLUSIONS

With increasing numbers of urine storage symptoms, systolic blood pressure also increases, while the opposite occurs for voiding symptoms in patients with benign prostate enlargement. We conjecture that storage symptoms may lead to this increase through inducing sympathetic hyperactivity. Further prospective studies with larger groups are needed to confirm these findings.

[Impact of body mass index on lower urinary tract disorders in multiple sclerosis]

INTRODUCTION

Lower urinary tract symptoms (LUTS), and principally overactive bladder, are common in multiple sclerosis (MS). However, their origin is not necessarily unique. Obesity is widely recognized as a risk factor for stress urinary incontinence (SUI) and overactive bladder (OAB) in the general population. We wanted to evaluate the influence of body mass index (BMI) on LUTS in the MS population.

MATERIALS AND METHODS

We conducted an uncontrolled monocentric retrospective study in 260 subjects classified into 4 BMI groups: underweight, normal weight, overweight, obese people. Comparisons by Mann-Whitney test were made between different BMI groups, in the overall population and then by gender. LUTS (SUI, OAB, BOO (bladder outlet obstruction) were assessed using USP questionnaire.

RESULTS

In women, the mean OAB score was higher for obese women, 10.27 (SD=4.5) than for normal weight women, 7.96 (SD=4.58), P=0.024. The SUI score was lower for normal weight, 1.69 (SD=2.38) than for overweight, 3.19 (SD=2.91), P=0.002 and obese subjects, 3.80 (SD=3.23), P=0.0005. As in the overall population, the BOO score was higher in subjects with normal weight, 4.09 (SD=3.33) than in subjects with overweight, 1.91 (SD=2.03), P=0.0003 and in obese subjects, 2.33 (SD=2.37), P=0.013. The same comparisons in men were not significant.

CONCLUSION

In this series, increased BMI was associated with higher OAB and SUI USP questionnaire scores, in women presenting with MS.

LEVEL OF EVIDENCE

4.

Safety and Efficacy of Intracavernosal Injections of AbobotulinumtoxinA (Dysport®) as Add on Therapy to Phosphosdiesterase Type 5 Inhibitors or Prostaglandin E1 for Erectile Dysfunction-Case Studies

Erectile dysfunction (ED) is a highly prevalent condition with a variety of possible risk factors and/or etiologies. Despite significant advances regarding ED pharmacological management, there are still insufficient responders to existing pharmacological treatments e.g., approximately 30% of patients are insufficient responders to phosphodiesterase type 5 inhibitors (PDE5-Is). It has been recently proposed that botulinum toxin A intracavernosally (IC) delivered could be effective in these patients. Data from a retrospective uncontrolled single center study of 47 ED patients, consecutively recruited, insufficient responders to existing pharmacological treatments e.g., PDE5-Is or IC PGE1 injections treated with IC abobotulinumtoxinA 250 or 500 U as free combination with their existing treatment have been analyzed. Response rate, according to the International Index of Erectile Function-Erectile Function domain score, 6 weeks following IC abobotulinumtoxinA in combination with prior pharmacological treatment, was 54%. Two patients have reported mild penile pain on injection or during the 3 days following injection. Therapeutic efficacy did not seem to be influenced by the etiologies and/or risk factors for ED. Conversely, the less severe ED, the higher the response rate. Preliminary evidence for the therapeutical potential with acceptable safety of IC abobotulinumtoxinA as add-on therapy for ED not sufficiently responsive to standard therapy should be confirmed in randomized clinical trials.

Functional Balance and Gait Characteristics in Men With Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia

The purpose of this cross-sectional study was to compare gait characteristics and functional balance Babilities in men with LUTS secondary to benign prostatic hyperplasia (BPH) to those of community-dwelling older adults under different conditions of increasing difficulties, and to aid health-care providers to identify those patients with decreased level of activity and increased risk of falls. We recruited a group of 43 men diagnosed with symptomatic BPH and a control group of 38 older men. Participants performed the timed up and go and 10-m walking tests under different conditions-namely, single task, dual-task motor, and dual-task cognitive. Time to complete the tests and spatial and temporal gait parameters were compared between groups and conditions via mixed-design ANOVA. Under dual-task conditions, individuals in both groups performed significantly worse compared to the single functional balance and walking tasks. As the complexity of the walking task increased-from dual-task motor to dual-task cognitive-significant differences between groups emerged. In particular, men with BPH performed worse than older adults in tasks demanding increased attentional control. Results suggest that dual-task decrements in functional balance and gait might explain decreased level of physical activity and increased risk of falls reported in men with LUTS. Health-care providers for men with LUTS due to BPH should assess for abnormal gait and remain vigilant for balance problems that may lead to decreased mobility and falls. The dual-task approach seems a feasible method to distinguish gait and balance impairments in men with BPH.

Factors Associated with Bothersome Lower Urinary Tract Symptoms in Middle-Aged Men Receiving Health Checkup

The prospective study is to investigate the associations between serum testosterone levels and LUTS among middle-aged men ≥40 years receiving health check-up. Lower urinary tract symptoms were evaluated by the self-administered International Prostate Symptom Score questionnaire. Serum prostate specific antigen and total testosterone level were checked in all subjects. A total of 1752 men were enrolled into the study. The mean age was 55.6 ± 9.7 years. All study subjects were stratified into low, medium and high testosterone levels by two cut-off, 3.0 and 4.11 ng/mL. We found that testosterone levels were significantly associated with metabolic syndrome and body fat components. Compared to those with low testosterone levels, subjects with high and medium testosterone had a significantly higher IPSS (5.84 ± 5.55 vs 6.71 ± 5.68 and 6.34 ± 5.66, p = 0.032) and storage score (2.76 ± 2.29 vs 3.20 ± 2.49 and 2.90 ± 2.49; p = 0.009), and a more moderate/severe LUTS (IPSS ≧ 8) (26.5% vs 35.7% and 29.9%; p = 0.002). Multivariate analyses showed that high vs low testosterone levels (OR, 1.76; 95% CI, 1.26–2.45) and prostate volume ≧25 vs <25 mL (OR, 1.38; 95% CI, 1.04–1.82) significantly associated with the presence of moderate/severe LUTS. Pearson correlation analyses showed significantly positive correlations between testosterone level and IPSS in whole study sample (Pearson correlation coefficient, 0.066; p < 0.01) and in the subgroup of moderate/severe LUTS (Pearson correlation coefficient, 0.038; p < 0.05). In conclusion, high testosterone and prostate volume adversely impacted LUTS in our target population.

Phosphodiesterase inhibitors for lower urinary tract symptoms consistent with benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) refers to non-malignant enlargement of the prostate gland that may cause bothersome lower urinary tract symptoms (LUTS). Alpha-blockers (ABs) and 5-alpha reductase inhibitors (5-ARIs) are the mainstay of medical treatment. Recently, phosphodiesterase inhibitors (PDEIs) that so far have been used mainly to treat erectile dysfunction were introduced to treat male LUTS.

OBJECTIVES

To assess the effects of PDEIs compared to placebo and other standard of care drugs (ABs and 5-ARIs) in men with LUTS consistent with BPH.

SEARCH METHODS

We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and clinical trials registries of the World Health Organization (WHO) and the National Institutes of Health (NIH) (updated 2 August 2018). We performed citation tracking and handsearching of abstracts and conference proceedings. We also contacted study authors to ask for additional information.

SELECTION CRITERIA

We considered for inclusion in this systematic review randomised controlled trials (RCTs) comparing PDEIs versus placebo, ABs, or 5-ARIs for at least four weeks in men with BPH-LUTS.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened the literature and extracted data. Primary outcomes were effects on urinary symptoms as assessed by the International Prostate Symptom Score (IPSS-total; score ranging from 0 to 35, with higher values reflecting more symptoms), urinary bother as assessed by the Benign Prostatic Hyperplasia Impact Index (BPHII; score ranging from 0 to 13, with higher values reflecting more bother), and adverse events (AEs). We used GRADE to rate the quality of evidence. We considered short-term (up to 12 weeks) and long-term (12 weeks or longer) results separately.

MAIN RESULTS

We included a total of 16 randomised trials in this review. The results for primary outcomes are as follows.PDEI versus placebo: PDEIs may result in a small improvement in IPSS-total score (mean difference (MD) 1.89 lower, 95% confidence interval (CI) 2.27 lower to 1.50 lower; n = 4293; low-quality evidence) compared to placebo, and may reduce the BPHII score slightly (MD 0.52 lower, 95% CI 0.71 lower to 0.33 lower; n = 3646; low-quality evidence). Rates of AEs may be increased (risk ratio (RR) 1.42, 95% CI 1.21 to 1.67; n = 4386; low-quality evidence). This corresponds to 95 more AEs per 1000 participants (95% CI 47 more to 151 more per 1000). Study results were limited to a treatment duration of six to 12 weeks.PDEI versus AB: PDEIs and ABs probably provide similar improvement in IPSS-total score (MD 0.22 higher, 95% CI 0.49 lower to 0.93 higher; n = 933; moderate-quality evidence) and may have a similar effect on BPHII score (MD 0.03 higher, 95% CI 1.10 lower to 1.16 higher; n = 550; low-quality evidence) and AEs (RR 1.35, 95% CI 0.80 to 2.30; n = 936; low-quality evidence). This corresponds to 71 more AEs per 1000 participants (95% CI 41 fewer to 264 more per 1000). Study results were limited to a treatment duration of six to 12 weeks.PDEI and AB versus AB alone: the combination of PDEI and AB may provide a small improvement in IPSS-total score (MD 2.56 lower, 95% CI 3.92 lower to 1.19 lower; n = 193; low-quality evidence) compared to AB alone. We found no evidence for BPHII scores. AEs may be increased (RR 2.81, 95% CI 1.53 to 5.17; n = 194; moderate-quality evidence). This corresponds to 235 more AEs per 1000 participants (95% CI 69 more to 542 more per 1000). Study results were limited to treatment duration of four to 12 weeks.PDEI and AB versus PDEI alone: the combination of PDEI and AB may provide a small improvement in IPSS-total (MD 2.4 lower, 95% CI 6.47 lower to 1.67 higher; n = 40; low-quality evidence) compared to PDEI alone. We found no data on BPHII or AEs. Study results were limited to a treatment duration of four weeks.PDEI and 5-ARI versus 5-ARI alone: in the short term (up to 12 weeks), the combination of PDEI and 5-ARI probably results in a small improvement in IPSS-total score (MD 1.40 lower, 95% CI 2.24 lower to 0.56 lower; n = 695; moderate-quality evidence) compared to 5-ARI alone. We found no evidence on BPHII scores or AEs. In the long term (13 to 26 weeks), the combination of PDEI and 5-ARI likely results in a small reduction in IPSS-total score (MD 1.00 less, 95% CI 1.83 lower to 0.17 lower; n = 695; moderate-quality evidence). We found no evidence about effects on BPHII scores. There may be no difference in rates of AEs (RR 1.07, 95% CI 0.84 to 1.36; n = 695; low-quality evidence). This corresponds to 19 more AEs per 1000 participants (95% CI 43 fewer to 98 more per 1000).We found no trials comparing other combinations of treatments or comparing different PDEI agents.

AUTHORS' CONCLUSIONS

Compared to placebo, PDEI likely leads to a small reduction in IPSS-total and BPHII sores, with a possible increase in AEs. There may be no differences between PDEI and AB with regards to improvement in IPSS-total, BPHII, and incidence of AEs. There appears to be no added benefit of PDEI combined with AB compared to PDEI or AB alone or PDEI combined with 5-ARI compared to ARI alone with regards to urinary symptoms. Most evidence was limited to short-term treatment up to 12 weeks and of moderate or low certainty.

Central obesity indicating a higher prevalence of lower urinary tract symptoms: A case-control matching analysis from a Chinese cross-sectional study in males

OBJECTIVE

The aim of this study was to explore the association between central obesity and lower urinary tract symptoms (LUTS) among men in southern China, and test the hypothesis that central obesity measured by the waist-to-hip ratio (WHR) is a predictor of the severity of LUTS.

METHODS

In all, 4303 men from the Fangchenggang Area Male Healthy and Examination Survey (FAMHES) were included in this study. LUTS were assessed by the International Prostate Symptom Score (IPSS), whereas central obesity was evaluated by the WHR. The association between WHR and LUTS was tested using logistic and Cox regression analyses.

RESULTS

After screening, 2917 participants were in the study. Univariate analysis indicated significant differences in WHR in the presence of LUTS (P = .012). After stratification by age, logistic regression indicated that LUTS were more frequent in 60-year-old men with a higher WHR (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.21-6.89) compared with participants <40 years old. Cox regression analysis after pairing of 252 LUTS cases and 252 control subjects from the 2917 eligible participants according to age (±5 years), indicated that central obesity (WHR ≥0.9) may be significantly associated with moderate or severe LUTS (OR 1.95, 95% CI 1.16-3.26). The associations between central obesity and straining (OR 2.44, 95% CI 1.40-4.24) and weak stream (OR 2.37, 95% CI 1.27-4.45) were significant after multivariate adjustment.

CONCLUSIONS

Males with central obesity are at increased risk of LUTS, and increased WHR is associated with worsened straining and weak stream. Further investigations are needed to confirm these associations.

Effect of tadalafil on chronic pelvic pain and prostatic inflammation in a rat model of experimental autoimmune prostatitis

BACKGROUND

Experimental autoimmune prostatitis (EAP) shares important clinical features with clinical chronic prostatitis/chronic pelvic pain. We investigated the effect of tadalafil on pelvic pain and prostatic inflammation in a rat EAP model.

METHODS

EAP was induced in rats by intradermal injection of rat prostate antigen and complete Freund's adjuvant on days 0 and 28. Rats were treated with tadalafil (2 mg/kg, p.o.; EAP-tadalafil) or vehicle (EAP-vehicle) once daily from day 0, while sham-operated animals were treated with vehicle only (Sham). Tactile allodynia was measured on days 28, 35, and 42 by applying von Frey filaments to the lower abdomen as an index of pelvic pain. On day 42, the plasma immunoglobulin G (IgG) concentration and the testosterone/estradiol ratio were measured and histopathological analysis of the prostate was performed.

RESULTS

Tactile allodynia in the pelvic region was observed on days 28, 35, and 42 after EAP induction. The tactile allodynia observed on day 42 was significantly reduced by repeated treatment with tadalafil. Plasma IgG concentrations increased after EAP induction but the increase was not changed by tadalafil treatment. Prostate tissues were characterized by epithelial necrosis, infiltration of neutrophils and/or lymphocytes to acini and stroma, and fibrosis, in addition to a high stroma-to-epithelium ratio. Tadalafil treatment significantly suppressed the severity of the lesions.

CONCLUSIONS

EAP rats developed pelvic pain, prostatic inflammation and increased plasma IgG concentrations. Tadalafil inhibited the chronic pelvic pain and prostatic inflammation, suggesting that its anti-inflammatory action may contribute to its blocking of pain development in the EAP model.

Mediterranean diet after prostate cancer diagnosis and urinary and sexual functioning: The health professionals follow-up study

BACKGROUND

Men with prostate cancer often experience urinary and sexual dysfunction after treatment. Previous studies have demonstrated a relationship between dietary factors and these symptoms among men with diabetes or metabolic syndrome. However, there are limited data on whether diet after prostate cancer diagnosis, including a Mediterranean dietary pattern, affects urinary and sexual function among prostate cancer survivors.

METHODS

Men diagnosed with non-metastatic prostate cancer in the Health Professionals Follow-up Study (n = 2960) from 1986 to 2012 were prospectively followed for a median of 8.3 years after treatment. Participants completed validated dietary questionnaires every 4 years and a health-related quality of life assessment in 2010 or 2012. We used generalized linear models to examine associations between post-diagnosis Mediterranean Diet Score (including individual score components and dietary fat subtypes) and quality of life domains (sexual functioning, urinary irritation/obstruction, urinary incontinence) assessed using the Expanded Prostate Cancer Index Composite Short Form (score 0-100; higher scores indicate better function).

RESULTS

No statistically significant relationships were observed between the Mediterranean Diet Score after prostate cancer diagnosis and urinary or sexual function. However, the associations did vary depending on pre-diagnosis urinary and sexual dysfunction for urinary irritation/obstruction and sexual function scores, respectively (P-interactions < 0.0001). Men with higher post-diagnosis vegetable intake reported higher urinary incontinence scores (72 vs 76 comparing lowest to highest quintile; P-trend = 0.003). Similarly, higher vegetable intake and lower polyunsaturated fat intake were associated with higher urinary irritation/obstruction scores (vegetable: 80 vs 84 comparing lowest to highest quintile, P-trend = 0.01; polyunsaturated fat: 84 vs 78 comparing lowest to highest quintile, P-trend = 0.005), however these associations were observed only among men with urinary symptoms prior to their prostate cancer diagnosis.

CONCLUSIONS

Among men with prostate cancer, diet intake after diagnosis was not significantly associated with urinary or sexual function, although some relationships appeared to differ among men with and without symptoms prior to their prostate cancer diagnosis. Higher vegetable intake and lower polyunsaturated fat intake after prostate cancer diagnosis may be associated with better urinary function. However, this analysis was exploratory, and further research is needed to better delineate these relationships and guide dietary recommendations for men with prostate cancer.

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.

Erectile Dysfunction and Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTSs) and erectile dysfunction (ED) are substantial health concerns with a significant impact on the overall male quality of life.

OBJECTIVE

To evaluate the available evidence of the association between LUTSs and ED in patients with benign prostatic hyperplasia (BPH), and discuss possible clinical implications for the management of LUTS/BPH.

EVIDENCE ACQUISITION

A systematic review of the existing literature published between 1997 and June 2017 and available in the Medline, Scopus, and Web of Science databases was conducted using both the Medical Subject Heading (MeSH) and free-text protocols. The MeSH search was conducted by combining the following terms: "lower urinary tract symptoms," "LUTS," "benign prostatic hyperplasia," "BPH," "erectile dysfunction," "sexual dysfunction," "BPE," and "benign prostatic enlargement." The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed.

EVIDENCE SYNTHESIS

Several community-based studies in different geographical areas have provided strong evidence of an age-independent association between LUTSs and ED. Several biological mechanisms have been proposed to explain this association, but further research is required to better understand the molecular pathways involved. It is necessary to evaluate the possible impact of the metabolic syndrome treatment on LUTS/ED management. Considering the possible relationship between LUTSs and ED, their impact on the quality of life, and the possible adverse effects associated with LUTS medical treatment, clinicians should always evaluate ED in patients with LUTSs and take the opportunity to evaluate patients reporting ED for LUTSs.

CONCLUSIONS

Data from the peer-reviewed literature suggest the existence of an association between LUTS/BPH and ED, although their casual relationship has not been established yet. Emerging data also suggest that pathophysiological mechanisms involved in the metabolic syndrome are key factors in both disorders. Considering the association, it is also recommended that men presenting with LUTSs or ED should be evaluated for both disorders. A better understanding of the molecular pathways behind this association may also help identify new possible targets and develop novel therapeutic approaches to manage LUTSs and ED.

PATIENT SUMMARY

In this manuscript, we report on all the available evidence linking erectile dysfunction and lower urinary tract symptoms. Our findings suggest the existence of a strong relationship between these two conditions. On the basis of these findings, we recommend that clinicians always explore both conditions in male patients presenting with either of symptoms.

Metabolic syndrome and voiding dysfunction

PURPOSE OF REVIEW

The metabolic syndrome (MetS) is an ever growing pandemic consisting of a constellation of abnormalities. Many hypotheses have been put forth to establish a link between this syndrome and voiding dysfunction. We created a layout of the possible, probable, and proven relationships connecting the MetS with voiding dysfunction in men.

RECENT FINDINGS

There has been growing interest in the relationship linking MetS and voiding dysfunction, with or without benign prostatic hyperplasia, during the past several years. Different mechanisms have been proposed to establish the connection.

SUMMARY

A clear-cut association between MetS and voiding dysfunction is not clearly defined; rather, voiding dysfunction occurring in men with MetS has been shown to be related to numerous pathologies. MetS is a complex disease that includes numerous pathophysiological aspects that may contribute to the causation and advancement of voiding dysfunction. In light of this association, future research is needed to better define this relationship to enable therapy targeted against MetS in patients with voiding dysfunction.

Does Race/Ethnicity Have a Role in a Link Between Lower Urinary Tract Symptoms and Metabolic Syndrome?

Metabolic syndrome (MS) is a highly prevalent disease related to the risk of cardiovascular disease and diabetes. A large body of evidence has suggested a link between MS and the components of MS with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) complex. The pathogenesis of MS is complex and not fully understood. Furthermore, recent results from epidemiological studies, including multiple Asian reports, have not been consistent. The risk of BPH is lower in Asian men compared with white men and the prevalence of MS varies by race and ethnicity. An elevated risk of Type 2 diabetes mellitus, hypertension, and dyslipidaemia is closely related to MS and is observed in Asian men even if their body mass index is low. However, the role of race and ethnic disparity in the link between MS and LUTS secondary to BPH is not elucidated. It has been suggested that the pathogenesis of LUTS is multifactorial rather than developing from BPH, which is the traditional concept. Lifestyle and genetic factors may substantially modify the risk of MS and LUTS/BPH. This comprehensive literature review summarises the scientific evidence of the racial/ethnic disparity regarding the association between MS and LUTS/BPH in order to improve current understanding of this controversial issue.

CD8+ T cells promote proliferation of benign prostatic hyperplasia epithelial cells under low androgen level via modulation of CCL5/STAT5/CCND1 signaling pathway

Previous studies by our group have shown that low intra-prostatic dihydrotestosterone (DHT) induced BPH epithelial cells (BECs) to recruit CD8+ T cells. However, the influence of the recruited CD8+ T cells on BECs under a low androgen level is still unknown. Here, we found CD8+ T cells have the capacity to promote proliferation of BECs in low androgen condition. Mechanism dissection revealed that interaction between CD8+ T cells and BECs through secretion of CCL5 might promote the phosphorylation of STAT5 and a higher expression of CCND1 in BECs. Suppressed CCL5/STAT5 signals via CCL5 neutralizing antibody or STAT5 inhibitor Pimozide led to reverse CD8+ T cell-enhanced BECs proliferation. IHC analysis from Finasteride treated patients showed PCNA expression in BECs was highly correlated to the level of CD8+ T cell infiltration and the expression of CCL5. Consequently, our data indicated infiltrating CD8+ T cells could promote the proliferation of BECs in low androgen condition via modulation of CCL5/STAT5/CCND1 signaling. The increased secretion of CCL5 from the CD8+ T cells/BECs interaction might help BECs survive in a low DHT environment. Targeting these signals may provide a new potential therapeutic approach to better treat BPH patients who failed the therapy of 5α-reductase inhibitors.

Correlation of Subjective Symptoms in Patients with Benign Prostatic Hyperplasia and Erectile Dysfunction

Introduction:

Epidemiological studies suggest a link between the symptoms of lower urinary tract (LUTS) caused by benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). Increasing expected period of life, justify the interest of establishing correlations LUTS / BPH and ED in order to find more efficient ways of treating these pathologies.

Goal:

The objective was to evaluate the correlation of symptoms in LUTS/BPH with the degree of ED.

Patients and Methods:

The study was conducted as a prospective study which involved males aged 40-60 yr with present symptoms of LUTS/BPH. All study subjects underwent quantification of subjective symptoms through the International Prostate Symptom Score-IPSS and International Index of Erectile Dysfunction- IIEF-5. The first group of respondents had IPSS 0-8, second group IPSS 9-19 and the third group IPSS 20 to 35.

Results:

The results of ANOVA (F = 112.492, p = 0.000) showed that there was a statistically significant difference (p <0.05) between groups in degree of erectile function (IIEF). Tahmane test showed that there was a statistically significant difference between the first and second group (p = 0.000 <0.05), the first and third group (p = 0.000 <0.05) and the second and third group (p = 0.000 <0.05). Mean degree of ED correlates with IPSS. The results of Fisher’s exact test (p = 0.000) confirmed that there was a statistically significant relationship (p <0.05) between the IPSS score and degree of erectile dysfunction (IIEF).

Conclusion:

Elderly patients have a significantly higher value of IPSS score compared to younger patients. The degree of erectile dysfunction is correlated with symptoms of IPSS score. Severity of symptoms of LUTS/BPH and higher IPSS score, worsens the ED. Results of IIEF-5 score are inversely proportional with symptoms of IPSS score, and increase in IPSS score comes to a decline in IIEF score.

Sildenafil citrate in combination with tamsulosin versus tamsulosin monotherapy for management of male lower urinary tract symptoms due to benign prostatic hyperplasia: A randomised, double-blind, placebo-controlled trial

Objective

To assess the additive effect of sildenafil citrate to tamsulosin in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in men with or without erectile dysfunction (ED).

Patients and methods

In all, 150 men with untreated LUTS/BPH with or without ED were randomised to receive sildenafil 25 mg once daily (OD) or placebo OD (night time) combined with tamsulosin 0.4 mg OD (day time) for 6 months. Changes from pre-treatment scores in International Prostate Symptom Score (IPSS), IPSS-quality of life (QoL) score, maximum urinary flow rate (Q_max), and the five-item version of the International Index of Erectile Function questionnaire (IIEF-5) were assessed at 3 and 6 months. Safety profiles were assessed by physical examination and monitoring clinical adverse events.

Results

Group A comprised of men who received tamsulosin and sildenafil (75 men), whilst those in Group B received tamsulosin and placebo (75). The IPSS was significantly improved in Group A compared to Group B, at −29.3% vs −13.7% (P = 0.039) at 3 months and −37% vs −19.6% (P = 0.043) at 6 months after treatment. Q_max significantly improved in both groups compared with before treatment (P < 0.001). The IIEF-5 scores improved more in Group A than in Group B, at 58.7% vs 11.7% at 3 months and 62.4% vs 12.4% at 6 months after treatment (both P < 0.001).

Conclusion

Sildenafil citrate combined with tamsulosin improved LUTS, erectile function, and patient QoL more than tamsulosin monotherapy with the merit of a comparable safety profile in patients with LUTS/BPH.

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.

Mapping of Small Nerve Trunks and Branches Using Adaptive Flexible Electrodes

Selective stimulation is delivered to the sciatic nerve using different paris of contacts on a split-ring electrode, while simulatneous recordings are acquired by the neural ribbon electrodes on three different branches. Two hook electrodes are also implanted in the muscle to monitor the activated muscle responses. It shows that the high precision implantation of electrodes, increases the efficacy and reduces the incidence of side effects.

Interactions Between Depression and Lower Urinary Tract Symptoms: The Role of Adverse Life Events and Inflammatory Mechanisms. Results From the European Male Ageing Study

OBJECTIVES

Depression and lower urinary tract symptoms (LUTSs) have been found to co-occur among aging men. The present study attempted to clarify the nature of this relationship, considering adverse life events as potential moderators and the inflammation as an underlying biological mechanism.

METHODS

The relationship between depression and LUTS was evaluated using data from the European Male Ageing Study, the largest multicenter population-based study of aging in European men. The sample included 3369 men who were assessed by means of several self-reported questionnaires, including the Beck Depression Inventory-II, the International Prostate Symptom Score, and the Adverse Life Events Scale. Participants were asked to provide information regarding general health and life-style, and medical comorbidities. Biological measures including prostate-specific antigen, testosterone, and C-reactive protein were measured.

RESULTS

LUTS and depressive symptoms were correlated (R = 0.32, β = .10, p < .001), even after adjusting for life-style, psychological, and medical variables. A history of adverse life events was associated with both higher LUTS and Beck Depression Inventory scores. Furthermore, adverse life events moderated the LUTS-depression association (F = 22.62, b = 0.061, p < .001), which increased as a function of the number of life events. C-reactive protein was found to mediate the LUTS-depression association. This mediation effect was moderated by number of adverse life events.

CONCLUSIONS

Participants with a history of adverse life events represent a vulnerable population in whom the association between somatic and depressive symptoms is stronger. One of the biological mechanisms underlying this association could be an activation of the central inflammatory signaling pathways.

Can a simple question predict prolonged uroflow lag times in children?

OBJECTIVE

It is our experience that some children with bowel and bladder dysfunction (BBD) who have bladder neck dysfunction had a tendency to complain of dizziness when we subjected the patients with dizziness to tilt-table testing to confirm the diagnosis of autonomic dysfunction. From these findings we postulated that patients who complain of dizziness are likely to have prolonged lag times that are a proxy for bladder neck dysfunction (BND).

STUDY DESIGN

This was an Institute Review Board-approved study in which we enrolled new patients in a sequential fashion who were referred to our outpatient urology offices for evaluation of BBD over a 3-month period. All patients were asked if they frequently experienced dizziness when they rapidly stood from a sitting or lying down position or when they raised their head rapidly. An analysis of the following parameters was undertaken: prevalence of dizziness, bladder neck dysfunction, and comorbid psychiatric problems. Uroflowmetry findings were analyzed as well.

RESULTS

Tilt-table group: In the tilt-table group the median age of the patients was 14.5 (4.5-18) years for the five males and five females who were tested. All males and four out of five females experienced a blood pressure drops of 20 mmHg or more on table tilting and three experienced syncope. All patients had prolonged lag times, with an average lag time of 16.5 s. All these patients were able to tolerate alpha-blockers once they were adequately hydrated and salt loaded. Alpha-blocker dosing was increased gradually. In the questionnaire group, 212 patients were initially enrolled: 125 girls and 87 boys. Eleven of 12 males and eleven of 16 females had prolonged lag times when dizziness was present. Sensitivity was 92% and 69%, specificity was 80% and 91% respectively for male and females. Analysis of the psychiatric history revealed a statistically significant association with dizziness and neuropsychiatric problems in the patients and family members.

CONCLUSION

We have been able to show a high degree of sensitivity in male patients and a high degree of specificity in female patients that a simple question, "Do you get dizzy on rising in the morning or with rapid standing?", is a reliable marker for BND in children. We have also seen that there is an association between dizziness and psychiatric problems in patients and in family members. It appears from our results and the available literature that autonomic dysfunction is commonly associated with BND and dizziness can be a simple proxy question to identify this problem.

Association between obesity and lower urinary tract symptoms: propensity score matching study between healthy controls and obese patients seeking bariatric surgery

BACKGROUND

To date, the association between obesity and lower urinary tract symptoms (LUTS) is controversial.

OBJECTIVE

To overcome the current inconsistent results regarding the association between obesity and LUTS and to investigate the association between obesity and LUTS using propensity score matching analysis.

SETTING

Bariatric center of excellence and health promotion center at university hospital.

METHODS

From August 2012 to December 2014, a total of 260 obese patients (77 men and 180 women) visited to our bariatric center to undergo bariatric surgery. Patients' International Prostate Symptom Score (IPSS) and overactive bladder symptom score were compared with those of 844 healthy controls who had visited our health center during the same period. To control for the effects of age, 1:1 propensity score matching was used.

RESULTS

After matching propensity score forage, 73 male patients and 176 female patients were included in our study. In men, all IPSS items except "frequency" were significantly different between obese patients and controls; median scores were higher in the obese group. In women, all IPSS items except "feeling of incomplete emptying" were significantly different between the 2 groups. Both voiding and storage subscores also had marked differences in both genders (P<.001). Total IPSS, quality of life, and total overactive bladder symptom score were significantly different in both genders (P< .001).

CONCLUSION

There were marked differences in LUTS between obese and nonobese patients, including in voiding and storage symptoms. Considering the relatively young age of both groups, this case-control study supports the hypothesis of a relationship between obesity and bladder pathophysiology.

NF-κB and androgen receptor variant expression correlate with human BPH progression

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common, chronic progressive disease. Inflammation is associated with prostatic enlargement and resistance to 5α-reductase inhibitor (5ARI) therapy. Activation of the nuclear factor-kappa B (NF-κB) pathway is linked to both inflammation and ligand-independent prostate cancer progression.

METHODS

NF-κB activation and androgen receptor variant (AR-V) expression were quantified in transition zone tissue samples from patients with a wide range of AUASS from incidental BPH in patients treated for low grade, localized peripheral zone prostate cancer to advanced disease requiring surgical intervention. To further investigate these pathways, human prostatic stromal and epithelial cell lines were transduced with constitutively active or kinase dead forms of IKK2 to regulate canonical NF-κB activity. The effects on AR full length (AR-FL) and androgen-independent AR-V expression as well as cellular growth and differentiation were assessed.

RESULTS

Canonical NF-κB signaling was found to be upregulated in late versus early stage BPH, and to be strongly associated with non-insulin dependent diabetes mellitus. Elevated expression of AR-variant 7 (AR-V7), but not other AR variants, was found in advanced BPH samples. Expression of AR-V7 significantly correlated with the patient AUASS and TRUS volume. Forced activation of canonical NF-κB in human prostatic epithelial and stromal cells resulted in elevated expression of both AR-FL and AR-V7, with concomitant ligand-independent activation of AR reporters. Activation of NF-κB and over expression of AR-V7 in human prostatic epithelial cells maintained cell viability in the face of 5ARI treatment.

CONCLUSION

Activation of NF-κB and AR-V7 in the prostate is associated with increased disease severity. AR-V7 expression is inducible in human prostate cells by forced activation of NF-κB resulting in resistance to 5ARI treatment, suggesting a potential mechanism by which patients may become resistant to 5ARI therapy.

Lower urinary tract symptoms, benign prostatic hyperplasia and metabolic syndrome

Epidemiological studies have shown that age is the principal unmodifiable risk factor of lower urinary tract symptoms (LUTS). Until the past decade, the process of lower urinary tract ageing was, therefore, considered unmodifiable - as ageing per se. However, the traditional dogma that BPH-related LUTS (BPH-LUTS) is an immutable consequence of old age is no longer acceptable. Results from multiple preclinical and clinical studies indicate that several modifiable, age-related metabolic aberrations (metabolic syndrome, obesity, dyslipidaemia, diabetes) are important determinants in both the development and the progression of BPH-LUTS. Metabolic syndrome and its related comorbidities, such as sex steroid alterations and low-grade inflammation, have been related to BPH-LUTS development and progression. With the correct treatment and recommended lifestyle changes, many individuals with metabolic syndrome might be able to prevent or delay the onset of metabolic-syndrome-related complications; however, whether promoting healthier lifestyles can really alter a man's propensity to develop BPH-LUTS remains to be clarified.