Is chronic prostatic inflammation a new target in the medical therapy of lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH)?

Inflammation is a target of medical treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia

Purpose

To review the role of a persistent prostatic inflammatory status (PIS) in the development and progression of benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) and which medical therapies approved for LUTS/BPH may reduce persistent PIS.

Methods

Literature search in PubMed up to July 2019.

Results

The cause of histologically defined persistent PIS or chronic prostatic inflammation is multifactorial. It is evident in many men with LUTS/BPH, particularly in older men and in men with a large prostate volume or more severe (storage) LUTS. Additionally, persistent PIS is associated with an increased risk of acute urinary retention and symptom worsening. Of medical therapies approved for LUTS/BPH, the current evidence for a reduction of persistent PIS is greatest for the hexanic extract of Serenoa repens (HESr). This treatment relieves LUTS to the same extent as α₁-adrenoceptor antagonists and short-term 5α-reductase inhibitors. Limited evidence is available on the effect of other mainstream LUTS/BPH treatments on persistent PIS.

Conclusions

Persistent PIS plays a central role in both the development and progression of LUTS/BPH. In men with LUTS/BPH who have a high chance of harbouring persistent PIS, HESr will not only improve LUTS, but also reduce (underlying) inflammation. Well-designed clinical studies, with a good level of evidence, are required to better evaluate the impact of BPH/LUTS medical therapies on persistent PIS.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03106-1) contains supplementary material, which is available to authorized users.

Predictors Of Postoperative Lower Urinary Tract Symptoms Improvements In Patient With Small-Volume Prostate And Bladder Outlet Obstruction

Objective

To explore the factors associated with improvement of lower urinary tract symptoms (LUTS) after transurethral plasmakinetic enucleation of the prostate (PKEP) and transurethral resection of the prostate (TURP) in patients with a small-volume prostate and bladder outlet obstruction (BOO).

Methods

The clinicopathologic data of 257 patients with BOO and a small-volume prostate from January 2013 to January 2018 were retrospectively collected preoperatively, 3 months postoperatively, and 12 months postoperatively. Patients were divided into postoperative success and failure groups based on the IPSS, IPSS-v, and IPSS-s. The relationship between each parameter and the improvement of postoperative LUTS was analyzed. Subgroup analysis was performed to compare the differences between the TURP and PKEP groups.

Results

Among patients followed up for 3 months postoperatively, multivariate analysis demonstrated that IPP, PUA, and post-PCB were significant predictors of postoperative IPSS improvement; TZI, IPP, and PUA were significant predictors of postoperative IPSS-v improvement; post-PCB and the surgical procedure were significant predictors of IPSS-s improvement; and IPP and PUA were significant predictors of postoperative Qmax improvement. Among patients followed up for 12 months postoperatively, multivariate analysis revealed that IPP, PUA, and post-PCB were significant predictors of postoperative IPSS improvement; PUA was a significant predictor of postoperative IPSS-v improvement; post-PCB was a significant predictor of IPSS-s improvement; and IPP and PUA were significant predictors of postoperative Qmax improvement. The post-PCB was significantly lower in the PKEP than the TURP group and the prostatic calculi removal rate was significantly higher in the PKEP than the TURP group.

Conclusion

Patients with a greater preoperative IPP and PUA and smaller post-PCB showed greater improvement of postoperative LUTS. PKEP might help to remove calculi from between the transitional and peripheral zones of prostate. Compared with conventional TURP, PKEP may improve the early postoperative storage symptoms of LUTS in patients with a small-volume prostate and BOO.

Microcalcifications, calcium-sensing receptor, and cancer

Calcium stones and calculi are observed in numerous human tissues. They are the result of deposition of calcium salts and are due to high local calcium concentrations. Prostatic calculi are usually classified as endogenous or extrinsic stones. Endogenous stones are commonly caused by obstruction of the prostatic ducts around an enlarged prostate resulting from benign prostatic hyperplasia or from chronic inflammation. The latter occurs mainly around the urethra and is generally caused by reflux of urine into the prostate. Calcium concentrations higher than in the plasma at sites of infection may induce the chemotactic response that eventually leads to recruitment of inflammatory cells. The calcium sensing receptor (CaSR) may be crucial for this recruitment as its expression and activity are increased by cytokines such as IL-6 and high extracellular calcium concentrations, respectively. The links between calcium calculi, inflammation, calcium supplementation, and CaSR functions in prostate cancer patients will be discussed in this review.

Synthesis and Pharmacological Evaluation of Novel Silodosin-Based Arylsulfonamide Derivatives as α1A/α1D-Adrenergic Receptor Antagonist with Potential Uroselective Profile

Benign prostatic hyperplasia (BPH) is the most common male clinical problem impacting the quality of life of older men. Clinical studies have indicated that the inhibition of α_1A-/α_1D adrenoceptors might offer effective therapy in lower urinary tract symptoms. Herein, a limited series of arylsulfonamide derivatives of (aryloxy)ethyl alicyclic amines was designed, synthesized, and biologically evaluated as potent α₁-adrenoceptor antagonists with uroselective profile. Among them, compound 9 (3-chloro-2-fluoro-N-([1-(2-(2-(2,2,2-trifluoroethoxy)phenoxy]ethyl)piperidin-4-yl)methyl)benzenesulfonamide) behaved as an α_1A-/α_1D-adrenoceptor antagonist (K_i(α₁) = 50 nM, EC₅₀(α_1A) = 0.8 nM, EC₅₀(α_1D) = 1.1 nM), displayed selectivity over α₂-adrenoceptors (K_i(α₂) = 858 nM), and a 5-fold functional preference over the α_1B subtype. Compound 9 showed adequate metabolic stability in rat-liver microsome assay similar to the reference drug tamsulosin (Cl_int = 67 and 41 µL/min/mg, respectively). Compound 9 did not decrease systolic and diastolic blood pressure in normotensive anesthetized rats in the dose of 2 mg/kg, i.v. These data support development of uroselective agents in the group of arylsulfonamides of alicyclic amines with potential efficacy in the treatment of lower urinary tract symptoms associated to benign prostatic hyperplasia.

The burden of prostatic calculi is more important than the presence

Prostatic calculi are a common finding on transrectal prostate ultrasound. However, it remains unclear whether they are significantly associated with lower urinary tract symptoms (LUTS). Our objective was to evaluate the association between prostatic calculi and LUTS with a focus on “calculi burden” because no studies have investigated prostatic calculi using “calculi burden” as an indicator. A total of 606 participants who received transrectal prostate ultrasound were divided into two groups according to the presence of prostatic calculi. “Calculi burden” was defined as the sum of the transverse diameters of all visible calculi within the prostate. The International Prostatic Symptom Score (IPSS) and a quality of life (QoL) score were collected. Both groups were compared, and a multivariate analysis was performed to predict moderate/severe LUTS. Linear correlation was evaluated between calculi burden and IPSS in the calculi group. No differences in total IPSS, voiding IPSS, or QoL score were detected between the two groups, but storage IPSS was significantly higher in the calculi group than that of controls. The multivariate analysis showed that the presence of prostatic calculi was not an independent predictor of moderate/severe LUTS. A positive linear correlation was detected between calculi burden and storage IPSS in calculi group (r = 0.148). However, no correlation was found between calculi burden and total IPSS, voiding IPSS, or QoL score. Our results showed that the presence of prostatic calculi was not a significant factor predicting moderate/severe LUTS. However, an increased calculi burden may be associated with aggravating storage symptoms.

Arylsulfonamide derivatives of (aryloxy)ethyl pyrrolidines and piperidines as α1-adrenergic receptor antagonist with uro-selective activity

A series of arylsulfonamide derivatives of (aryloxy)ethyl pyrrolidines and piperidines was synthesized to develop new α₁-adrenoceptor antagonists with uroselective profile. Biological evaluation for α₁- and α₂-adrenorecepor showed that tested compounds 13-37 displayed high-to-moderate affinity for the α₁-adrenoceptor (K_i=34-348nM) and moderate selectivity over α₂-receptor subtype. Compounds with highest affinity and selectivity for α₁-adrenoceptor were evaluated in vitro for their intrinsic activity toward α_1A- and α_1B-adrenoceptor subtypes. All compounds behaved as antagonists at both α₁-adrenoceptor subtypes, displaying 2- to 6-fold functional preference to α_1A-subtype. Among them, N-{1-[2-(2-methoxyphenoxy)ethyl]piperidin-4-yl}isoquinoline-4-sulfonamide (25) and 3-chloro-2-fluoro-N-{[1-(2-(2-isopropoxyphenoxy)ethyl)piperidin-4-yl]methyl}benzene sulfonamide (34) displayed the highest preference to α_1A-adrenoceptor. Finally, compounds 25 and 34 (2-5mg/kg, iv), in contrast to tamsulosin (1-2mg/kg, iv), did not significantly decrease systolic and diastolic blood pressure in normotensive anesthetized rats to determine their influence on blood pressure.

Serenoa repens, lycopene and selenium versus tamsulosin for the treatment of LUTS/BPH. An Italian multicenter double-blinded randomized study between single or combination therapy (PROCOMB trial)

BACKGROUND

Phytotherapy has been used to treat patients with lower urinary tract symptoms (LUTS). We evaluated the efficacy and tolerability of combination therapy between Serenoa Repens (SeR), Lycopene (Ly), and Selenium (Se) + tamsulosin versus single therapies.

METHODS

PROCOMB trial (ISRCTN78639965) was a randomized double-blinded, double-dummy multicenter study of 225 patients between 55 and 80 years old, PSA ≤ 4 ng/ml, IPSS ≥12, prostate volume ≤60 cc, Qmax ≤15 ml/sec, postvoid residual urine (PVR) <150 ml. Participants were randomized group A (SeR-Se-Ly), group B (tamsulosin 0.4 mg), group C (SeR-Se-Ly + tamsulosin 0.4 mg). The primary endpoints of the study were the reduction of IPSS, PVR, and increase of Qmax in group C versus monotherapy groups.

RESULTS

The decrease for combination therapy was significantly greater versus group A (P < 0.05) and group B (P < 0.01) for IPSS and versus group A (P < 0.01) for PVR from baseline to 6 months. A greater decrease in IPSS was observed for Group C versus group A (P < 0.01) and increase in Qmax versus group B (P < 0.01), from 6 months to 12 months. At one year, the changes of IPSS and Qmax were greater for Group C versus monotherapies (each comparison <0.05). The proportions of men with a decrease of at least three points (each comparison P < 0.05) and decrease of 25% for IPSS (each comparison P < 0.01) were greater for Group C.

CONCLUSION

SeR-Se-Ly + tamsulosin therapy is more effective than single therapies in improving IPSS and increasing Qmax in patients with LUTS.