Treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in relation to the patient's risk profile for progression

Baseline characteristics predict risk of progression and response to combined medical therapy for benign prostatic hyperplasia (BPH)

OBJECTIVE

To better risk stratify patients, using baseline characteristics, to help optimise decision-making for men with moderate-to-severe lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) through a secondary analysis of the Medical Therapy of Prostatic Symptoms (MTOPS) trial.

PATIENTS AND METHODS

After review of the literature, we identified potential baseline risk factors for BPH progression. Using bivariate tests in a secondary analysis of MTOPS data, we determined which variables retained prognostic significance. We then used these factors in Cox proportional hazard modelling to: i) more comprehensively risk stratify the study population based on pre-treatment parameters and ii) to determine which risk strata stood to benefit most from medical intervention.

RESULTS

In all, 3047 men were followed in MTOPS for a mean of 4.5 years. We found varying risks of progression across quartiles. Baseline BPH Impact Index score, post-void residual urine volume, serum prostate-specific antigen (PSA) level, age, American Urological Association Symptom Index score, and maximum urinary flow rate were found to significantly correlate with overall BPH progression in multivariable analysis.

CONCLUSIONS

Using baseline factors permits estimation of individual patient risk for clinical progression and the benefits of medical therapy. A novel clinical decision tool based on these analyses will allow clinicians to weigh patient-specific benefits against possible risks of adverse effects for a given patient.

A pilot randomized controlled trial of the feasibility of a self-directed coping skills intervention for couples facing prostate cancer: rationale and design

BACKGROUND

Although it is known both patients' and partners' reactions to a prostate cancer diagnosis include fear, uncertainty, anxiety and depression with patients' partners' reactions mutually determining how they cope with and adjust to the illness, few psychosocial interventions target couples. Those that are available tend to be led by highly trained professionals, limiting their accessibility and long-term sustainability. In addition, it is recognised that patients who might benefit from conventional face-to-face psychosocial interventions do not access these, either by preference or because of geographical or mobility barriers. Self-directed interventions can overcome some of these limitations and have been shown to contribute to patient well-being. This study will examine the feasibility of a self-directed, coping skills intervention for couples affected by cancer, called Coping-Together, and begin to explore its potential impact on couples' illness adjustment. The pilot version of Coping-Together includes a series of four booklets, a DVD, and a relaxation audio CD.

METHODS/DESIGN

In this double-blind, two-group, parallel, randomized controlled trial, 70 couples will be recruited within 4 months of a prostate cancer diagnosis through urology private practices and randomized to: 1) Coping-Together or 2) a minimal ethical care condition. Minimal ethical care condition couples will be mailed information booklets available at the Cancer Council New South Wales and a brochure for the Cancer Council Helpline. The primary outcome (anxiety) and additional secondary outcomes (distress, depression, dyadic adjustment, quality of life, illness or caregiving appraisal, self-efficacy, and dyadic and individual coping) will be assessed at baseline (before receiving study material) and 2 months post-baseline. Intention-to-treat and per protocol analysis will be conducted.

DISCUSSION

As partners' distress rates exceed not only population norms, but also those reported by patients themselves, it is imperative that coping skills interventions target the couple as a unit and enhance both partners' ability to overcome cancer challenges. This pilot study will examine the feasibility and potential efficacy of Coping-Together in optimising couples' illness adjustment. This is one of the first feasibility studies to test this innovative coping intervention, which in turn will contribute to the larger literature advocating for psychosocial care of couples affected by prostate cancer.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000438954.

Risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in a community based population of healthy aging men: the Krimpen Study

PURPOSE

We explored risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia in the open population.

MATERIALS AND METHODS

A longitudinal, population based study with a followup of 6.5 years was done in 1,688 men who were 50 to 78 years old. Data were collected on transrectal ultrasound of prostate volume, urinary flow rate, ultrasound estimated post-void residual urine volume, generic and disease specific quality of life, and symptom severity based on the International Prostate Symptom Score. Lower urinary tract symptoms suggestive of benign prostatic hyperplasia were defined as an International Prostate Symptom Score of greater than 7 after a report of a score of less than 7 in the previous round. A multivariate Cox proportional hazard model was constructed to determine risk factors for clinical benign prostatic hyperplasia after correcting for patient age.

RESULTS

Total followup was 4,353 person-years. During followup 180 events of attaining an International Prostate Symptoms Score of greater than 7 occurred. Multivariate analysis showed that functional bladder capacity, post-void residual urine volume, treatment for cardiac diseases, education level, antidepressant use, calcium antagonist use, erectile function or dysfunction, prostate specific antigen and a family history of prostate cancer were determinants with a significant HR.

CONCLUSIONS

In addition to age, we established 9 significant determinants for lower urinary tract symptoms suggestive of benign prostatic hyperplasia. However, not all risk factors for lower urinary tract symptoms suggestive of benign prostatic hyperplasia are accounted for since we can conclude that 1 of 3 men without these risk factors will still be diagnosed with lower urinary tract symptoms suggestive of benign prostatic hyperplasia between ages 50 and 80 years.

Determinants of Seeking of Primary Care for Lower Urinary Tract Symptoms: The Krimpen Study in Community-Dwelling Men

OBJECTIVES

To determine which factors predict seeking of primary care among men with lower urinary tract symptoms (LUTS).

METHODS

A longitudinal, population-based study with a follow-up period of 6.5 yr was conducted among 1688 men aged 50-78 yr. The following data were collected: prostate volume (using transrectal ultrasonometry), urinary flow rate, ultrasound-estimated postvoid residual urine volume, generic and disease-specific quality of life (QOL), and symptom severity (International Prostate Symptom Score [IPSS]). Information on the seeking of primary care by all participants during 2 yr of follow-up was collected from the general practitioner's (GP) record using a computerised search engine and a manual check of electronically selected files.

RESULTS

Prostate volume, postvoid residual volume, IPSS, and social generic QOL are important determinants of first GP consultation in men with LUTS. Measurements (physical urologic parameters) and self-reported items (symptom severity and QOL) contribute almost equally to GP consultation in these men.

CONCLUSIONS

Both measurements of prostate volume and postvoid residual urine volume and self-reported information about symptoms or QOL can help to select those who will benefit from medical care and to reassure those men not likely to need help in the near future.

Acute urinary retention: who is at risk and how best to manage it?

In recent years, we have begun to understand the progressive nature of benign prostatic hyperplasia. By careful analysis of population studies and clinical trials, we can determine the factors most likely to predict progression to one of its most distressing complications, acute urinary retention. Acute urinary retention is a common urologic emergency and causes significant suffering, although rarely has it any serious consequences. Using our knowledge regarding the progression of benign prostatic hyperplasia, new treatment modalities are being assessed for their effectiveness at halting progression and ultimately preventing this distressing condition.

A mathematical model for the proliferation of bacteria in the urinary bladder due to enlarged prostate

Urinary retention due to enlargement of the prostate (prostate hypertrophy) leads to increased proliferation of bacteria in the bladder. This in turn increases the infection rate. The reason is that the enlarged prostate presses on the urine channel and tends to close it. Thus the out flux of the bladder consists of repeatedly small amounts of fluid during a day. A mathematical dynamic model with differential equations is developed for the proliferation of bacteria in the urinary bladder (vesica urinary). The model accounts for how this proliferation is associated with varying amounts of mass of urine within the bladder. Parameters are estimated from published data and analytical and numerical results are presented. The relationships between the proliferation of bacteria within the bladder and the type of urinal out flux from the bladder are examined. The proliferation is shown to depend on the amount of mass of urine and the out flux of urine from the bladder. In the normal situation the bladder is drained successfully which also drains the bacteria. In the abnormal situation the bladder drains only partly. Despite frequent urination, substantial urine mass in the bladder on the average allows bacteria to proliferate and increase in number through time. The simulations depend on the numerical values of the parameters which again depend on the prostate condition of each male adult under scrutiny. By determining the parameters for each male, the dynamic model can be used as a powerful tool by which the proliferation of bacteria in the bladder can be studied and controlled by different means. Three clinical advices are provided. First, try to achieve that the proliferation rate of bacteria in the bladder is as small as possible, e.g. through altering the pH or chemical composition within the bladder. Second, try to achieve that the out flux of urine from the bladder is substantial, through sufficient drinking. Third, try to achieve that the mass of urine in the bladder is as small as possible, through sufficient urination. The intrinsic parameters for each male can be used to pinpoint the actual out flux during a day necessary to keep the number of bacteria in the bladder low. Suggestions for how to test the model are briefly presented.

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia: latest update on alpha-adrenoceptor antagonists

An update of a systematic review of alpha1-adrenoceptor (AR) antagonists in the treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) showed that these agents have comparable efficacy. The total symptom score is improved by 30-45% and maximum urinary flow rate by 15-30% vs baseline. alpha1-AR antagonists that can be started at their therapeutic dose have a more rapid onset of action than alpha1-AR antagonists that have to be titrated. alpha1-AR antagonists can be differentiated according to their tolerability. Alfuzosin (especially the 10 mg once daily dose) and tamsulosin (especially the 0.4 mg once daily dose) are better tolerated than doxazosin and terazosin. However, alfuzosin might induce more cardiovascular adverse events (AEs) in the elderly and/or patients with cardiovascular comorbidity and/or comedication. Tamsulosin tends to interfere less with blood pressure regulation and induce less vasodilatory AEs than alfuzosin, especially in the elderly, and is well tolerated in patients with cardiovascular comorbidity and/or comedication. Cardiovascular AEs might lead to potentially serious complications such as falls, fractures and institutionalization. Abnormal ejaculation has mainly been reported in placebo-controlled trials with tamsulosin but in direct comparative trials its rate with tamsulosin 0.4 mg was similar to, or only slightly higher than, the rate with alfuzosin. In addition, abnormal ejaculation is not reported as bothersome by the patient or associated with serious complications. It can be concluded that an alpha1-AR antagonist with a low potential to interfere with blood pressure regulation and to induce cardiovascular AEs, also in patients with cardiovascular comorbidity and/or comedication, can be considered a first-choice treatment option in LUTS/BPH.