The role of nocturia in the quality of life of men with lower urinary tract symptoms

Effects of a proprietary mixture of extracts from Sabal serrulata fruits and Urtica dioica roots (WS® 1541) on prostate hyperplasia and inflammation in rats and human cells

Introduction: Phytotherapeutics, particularly extracts from Sabal serrulata (saw palmetto) fruit or Urtica dioica (stinging nettle) root, are popular for the treatment of male lower urinary symptoms in many countries, but their mechanism of action is poorly understood. We performed in vivo and in vitro studies to obtain deeper insight into the mechanism of action of WS® 1541, a proprietary combination of a Sabal serrulata fruit and an Urtica dioica root extract (WS® 1473 and WS® 1031, respectively) and its components. Methods: We used the sulpiride model of benign prostatic hyperplasia in rats and tested three doses of WS® 1541 in comparison to finasteride, evaluating weight of prostate and its individual lobes as well as aspects of inflammation, oxidative stress, growth and hyperplasia. In human BPH-1 cells, we studied the effect of WS® 1473, WS® 1031, WS® 1541 and finasteride on apoptosis, cell cycle progression and migrative capacity of the cells. Results: WS® 1541 did not reduce prostate size in sulpiride treated rats but attenuated the sulpiride-induced changes in expression of most analyzed genes and of oxidized proteins and abrogated the epithelial thickening. In vitro, WS® 1473 and WS® 1031 showed distinct profiles of favorable effects in BPH-1 cells including anti-oxidative, anti-proliferative and pro-apoptotic effects, as well as inhibiting epithelial-mesenchymal-transition. Conclusion: This data supports a beneficial effect of the clinically used WS® 1541 for the treatment of lower urinary tract symptoms associated with mild to moderate benign prostate syndrome and provides a scientific rationale for the combination of its components WS® 1473 and WS® 1031.

Budget impact analysis of transurethral water vapor therapy for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia in the Spanish national healthcare system

BACKGROUND

Several surgical treatments are available for managing lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). Water vapor thermal therapy (WVTT) is a new minimally invasive therapy. This study estimates the budget impact of introducing WVTT for LUTS/BPH into the Spanish health care system.

METHODS

A model simulated the evolution of men over 45 years of age with moderate-severe LUTS/BPH after surgical treatment, over a 4-year time horizon, from the Spanish public health care service´s perspective. The technologies in scope included those most used in Spain: WVTT, transurethral resection (TURP), photoselective laser vapourization (PVP) and holmium laser enucleation (HoLEP). Transition probabilities, adverse events and costs were identified from the scientific literature and validated by a panel of experts. Sensitivity analyses were performed by varying the most uncertain parameters.

RESULTS

Per intervention, WVTT resulted in savings of €3,317, €1,933 and €2,661 compared to TURP, PVP and HoLEP. Over a 4-year time horizon, when performed in 10% of the cohort of 109,603 Spanish males with LUTS/BPH, WVTT saved €28,770,125 against the scenario without WVTT availability.

CONCLUSIONS

WVTT could reduce the cost of managing LUTS/BPH, increase the quality of health care and reduce the length of procedure and hospital stay.

Urodynamic findings in female patients with nocturia: An age-matched case-control study

INTRODUCTION

Nocturia negatively impacts the quality of life and is associated with poor general health, but our understanding of its etiologies is incomplete. Urodynamic studies (UDS) findings in patients with nocturia are not well described and may help guide management. Our objective was to compare UDS findings with age-matched patients with and without nocturia.

MATERIALS AND METHODS

We retrospectively reviewed UDS findings of 1124 patients (2010-2017). A total of 484 (43%) presented with nocturia and 821 (73%) were female. Female patients were separated into age-matched groups with and without nocturia. Urinary symptoms, past medical diagnoses, demographic information, and UDS findings were compared.

RESULTS

A total of 596 female patients were included, 298 (50%) with nocturia and 298 without. Past medical history, including diabetes mellitus and cardiovascular disease, did not differ between groups. Patients with nocturia were more likely to have pelvic pain (p = 0.0014) and other daytime symptoms (frequency, urgency, and urgency incontinence). On UDS, patients with nocturia were more likely to have bladder outlet obstruction (BOO) (p = 0.025) and dysfunctional voiding (DV) (p < 0.0001). There was no difference in the frequency of detrusor overactivity (DO). Bladder capacity and postvoid residual volumes were lower, though not significantly, in the nocturia group.

CONCLUSIONS

When comparing UDS findings in contemporary, age-matched groups of female patients with and without nocturia, we found only BOO and DV to be associated with nocturia. While the treatment of nocturia is often aimed at managing DO, our data suggest that this may not be the primary urodynamic correlation with nocturia. Further studies are needed to assess whether successful treatment of BOO and DV can improve nocturia.

Advances in Assistive Electronic Device Solutions for Urology

Recent technology advances have led urology to become one of the leading specialities to utilise novel electronic systems to manage urological ailments. Contemporary bladder management strategies such as urinary catheters can provide a solution but leave the user mentally and physically debilitated. The unique properties of modern electronic devices, i.e., flexibility, stretchability, and biocompatibility, have allowed a plethora of new technologies to emerge. Many novel electronic device solutions in urology have been developed for treating impaired bladder disorders. These disorders include overactive bladder (OAB), underactive bladder (UAB) and other-urinary-affecting disorders (OUAD). This paper reviews common causes and conservative treatment strategies for OAB, UAB and OUAD, discussing the challenges and drawbacks of such treatments. Subsequently, this paper gives insight into clinically approved and research-based electronic advances in urology. Advances in this area cover bladder-stimulation and -monitoring devices, robot-assistive surgery, and bladder and sphincter prosthesis. This study aims to introduce the latest advances in electronic solutions for urology, comparing their advantages and disadvantages, and concluding with open problems for future urological device solutions.

Overactive bladder: A review and update

Overactive bladder syndrome is a chronic, disabling condition with physical, psychological and social consequences that significantly affects the quality of life of millions of patients worldwide. The economic impact of this disorder is crucial. Overactive bladder syndrome is a little-known condition, with different manifestations from patient to patient, which causes a great deal of frustration to the medical staff involved. The patient requires a clear explanation and the full support of the attending physician. It is extremely important to establish a correct diagnosis and an effective individualized treatment. The collaboration and understanding of these patients are extremely important aspects. Improving the quality of life in these patients is the main purpose in managing this condition. There are several treatment modalities that may be used progressively, with favorable albeit inconsistent results. This condition remains extremely challenging for specialists and, unfortunately, always one of maximum interest.

The Microbiome’s Function in Disorders of the Urinary Bladder

The introduction of next generation sequencing techniques has enabled the characterization of the urinary tract microbiome, which resulted in the rejection of the long-held notion of urinary bladder sterility. Since the discovery and confirmation of the human bladder microbiome, an increasing number of studies have defined this microbial community and understand better its relationship to urinary pathologies. The composition of microbial communities in the urinary tract is linked to a variety of urinary diseases. The purpose of this review is to provide an overview of current information about the urinary microbiome and diseases as well as the development of novel treatment methods.

Correlation of prostatic morphological parameters and clinical progression in aging Chinese men with benign prostatic hyperplasia: Results from a cross-sectional study

OBJECTIVES

Our study aimed to investigate the correlation of prostatic morphological parameters and benign prostatic hyperplasia (BPH) clinical progression in aging Chinese men.

METHODS

In this retrospective study, a total of 1038 patients were reviewed. Prostatic morphology was measured by transrectal ultrasound (TRUS). Detailed medical history of all candidates was recorded and analyzed after being classified by specific prostatic measurements. Univariate and multivariate logistic regression analyses were used to estimate the correlation between variables.

RESULTS

The cumulative incidence of BPH clinical progression was 63.68% (661/1038) in the study population. Prostate volume (PV), transitional zone volume (TZV), transitional zone index (TZI), and intravesical prostatic protrusion (IPP) were all positively associated with BPH progression (all p < .001). Patients with a PV > 60 ml, TZV > 15 ml, TZI > 0.5, or IPP > 5 mm had a significantly higher possibility of overall BPH clinical progression (adjusted odds ratio (OR): 2.485, 1.678, 1.886, and 1.924, respectively; 95% confidence interval (CI): 1.559-3.960, 1.131-2.489, 1.379-2.579, and 1.357-2.728, correspondingly).

CONCLUSION

Prostatic morphological parameters are significantly associated with BPH clinical progression. Patients with larger prostatic morphological parameters are more easily prone to clinical progress. As a result, reasonable managements should be timely considered for those patients before clinical progression occurs.

Association of nocturia and cardiovascular disease: Data from the National Health and Nutrition Examination Survey

AIMS

To investigate the association of nocturia with the prevalence of cardiovascular disease (CVD) using the National Health and Nutrition Examination Survey (NHANES) data.

METHODS

Among the 40 790 individuals who participated in NHANES from 2005 to 2012, 14 114 adults were analyzed in this study. A participant was considered to have nocturia if they have two or more voiding episodes nightly. In addition, participants with nocturia more than four times in a day were considered to have severe nocturia. A multivariate logistic regression analysis with adjustment for confounding variables, including age, sex, race, body mass index (BMI), smoking status, alcohol consumption, sleeping time, dyslipidemia, hypertension, and diabetes mellitus was performed with 1:1 propensity score matching (PSM).

RESULTS

Nocturia occurred in 4610 individuals (32.7%). The prevalence of CVD was significantly higher in men, older individuals, those with higher BMI, smokers, and those with diabetes, hypertension, and hyperlipidemia. There was also a significantly higher prevalence of nocturia in the participants with CVD. Multivariate analysis showed that odds ratios (ORs) of mild and severe nocturia for CVD were 1.23 (95% confidence interval [CI]: 1.08-1.39) and 1.74 (95% CI: 1.39-2.17), respectively. After 1:1 PSM, the ORs of mild and severe nocturia were 1.27 (95% CI: 1.10-1.48) and 1.73 (95% CI: 1.33-2.26), respectively, showing statistical significance.

CONCLUSION

Data from the NHANES indicate that CVD was significantly associated with the prevalence of nocturia, after taking major confounding factors into account. Furthermore, the risk for CVD increases with increasing nocturia severity.

Pharmacologic management of nocturnal polyuria: a contemporary assessment of efficacy, safety, and progress toward individualized treatment

This narrative review synthesizes current evidence on the medical management of nocturnal polyuria, including antidiuretic replacement therapy as well as other emerging modalities, with particular emphasis on areas of active investigation and future research directions. Relative to earlier formulations, the pharmacological profiles of novel desmopressin acetate nasal spray and orally disintegrating tablet formulations appear favorable in optimizing the balance between efficacy and safety. Additionally, several highly selective small-molecule arginine vasopressin 2 receptor agonists are under active development, while appropriately timed short-acting diuretics, pharmacotherapy for hypertension, nonsteroidal anti-inflammatory drugs, and sex hormone replacement therapy are also a focal point of extensive ongoing nocturnal polyuria research. Emerging laboratory technologies now make feasible a sub-stratification of nocturnal polyuria patients into substrate-based phenotypes for individualized treatment. An increasingly refined understanding of the pathogenesis of nocturnal polyuria, and arginine vasopressin dysregulation in particular, has also introduced new opportunities for point-of-care testing in patients with nocturnal polyuria.

Factors Associated With Nocturia-Related Quality of Life in Men With Lower Urinary Tract Symptoms and Treated With Tamsulosin Oral Controlled Absorption System in a Non-Interventional Study

Nocturia impairs quality of life (QoL). We have performed a non-interventional study in which men with lower urinary tract symptoms (LUTS) were treated for at least 3 months with tamsulosin oral controlled absorption system (0.4 mg q.d.). Other than observing efficacy and tolerability of this drug formulation, the study was designed to explore the relative roles of number of nocturia episodes and of non-urological causes of nocturia on nocturia-related QoL at baseline and treatment-associated changes thereof. The study enrolled 5775 men seeking treatment of their LUTS. Tamsulosin improved LUTS, e.g. International Prostate Symptom Score from 19.5 ± 5.9 to 10.1 ± 4.9 (means ± SD). This was associated by clinically meaningful improvements in the Nocturia QoL score (from 45 ± 19 to 73 ± 17 points) and other QoL scores. Number of nocturnal voids was the key driver of all QoL scores at baseline; change of number of nocturia episodes that of improvement of all QoL scores upon treatment. In contrast, non-urological causes of nocturia such as heart failure, diabetes, sleep apnea, fluid or alcohol intake or use of diuretics or hypnotics had only small if any effects on baseline QoL or treatment-associated improvements thereof. The observed effects of non-urological causes on QoL apparently were largely driven by their effect on number of nocturnal voids. These data further support the idea that improvement of nocturia may be an important treatment goal in male LUTS.

Can we predict the success of prostatic surgery for male lower urinary tract symptoms: ICI-RS 2018?

AIMS

Male lower urinary tract symptoms (LUTS) are common and bothersome symptoms in the aging population, of which the etiology is multifactorial. Prostatic surgery may be considered to alleviate some of these LUTS, especially in patients in which benign prostatic obstruction is believed to be the underlying cause. The aim of this paper is to discuss underlying pathophysiology, signs, and conditions that may lead to success or failure after prostatic surgery in male patients with LUTS.

METHODS

The paper is a report of presentations and subsequent discussions at the annual International Consultation on Incontinence Research Society, in June 2018 in Bristol.

RESULTS AND CONCLUSIONS

Unfavorable outcomes after prostatic surgery are reported in 25% to 30% of the patients. This may be due to persistent or de novo symptoms, related to the multifactorial origin of symptoms. Specific underlying conditions such as with detrusor overactivity, detrusor underactivity, and nocturnal polyuria are discussed in their relationship with prostatic surgery. Knowledge gaps are addressed and specific research questions proposed.

The Economic Burden of Nocturia on the U.S. Health Care System and Society: A National Health and Nutrition Examination Survey Analysis

BACKGROUND

Nocturia, characterized as waking during the main sleep period to urinate, is a common condition. Persistent nocturia results in sleep fragmentation with deleterious effects on health and well-being. Yet, there are limited data on the economic burden of nocturia in the United States.

OBJECTIVE

To assess the association of nocturia with health care resource utilization (HRU), work productivity, and self-rated health while estimating the societal costs of nocturia in the United States in 2017.

METHODS

A retrospective cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES; 2005-2006 to 2013-2014). Adults aged ≥ 18 years (excluding pregnant women) were stratified into individuals with nocturia (≥ 2 voids/night) and individuals without nocturia (< 2 voids/night), based on the threshold for clinically significant nocturia. Outcomes were self-reported and included HRU (hospitalizations, outpatient visits); work productivity (weekly hours worked, employment); and current health status. Multivariable regression analyses adjusting for age, race, sex, body mass index, insurance status, education level, alcohol use, smoking status, and self-reported comorbid conditions were used to compare the 2 cohorts, overall and stratified by age group (20-44 years, 45-64 years, and 65+ years) to distinguish the effects on different age groups including the Medicare-aged population. Excess direct health care costs and indirect productivity costs associated with nocturia in the United States were then calculated using a prevalence-based approach and available literature (i.e., nocturia prevalence estimates, aggregated unit costs by HRU type, and average hourly earnings in the United States).

RESULTS

22,300 individuals were identified, and 24% had nocturia (≥ 2 voids/night). Median age was 55.2 and 43.2 years among individuals with and without nocturia, respectively, and the proportion of males was 43.3% and 51.3%, respectively. Individuals with nocturia had significantly more HRU, including hospitalizations and outpatient visits, worked significantly fewer hours weekly, and were significantly less likely to be employed when compared with those without nocturia. They were also significantly less likely to report being in very good/excellent health. These comparisons remained statistically significant across age groups. Total excess direct health care costs were $62.9 billion (hospitalization: $47.6 billion; outpatient: $15.3 billion). Total excess indirect productivity costs were $151.7 billion. Altogether, costs were estimated at $214.5 billion, equivalent to $3,491 per individual with nocturia. Individuals aged 20-44 years incurred 23.5% of total excess costs, while those aged 45-64 and 65+ years incurred 48.2% and 28.3%, respectively. Sensitivity analyses based on lower prevalence estimates resulted in costs of $94.0 billion, while those based on higher prevalence estimates reached up to $231.1 billion.

CONCLUSIONS

Nocturia is associated with a substantial economic burden in the United States even when evaluated based on lower prevalence estimates. This study underscores the importance of timely diagnosis and management of nocturia patients to alleviate health-related and economic consequences to patients and society.

DISCLOSURES

This work was supported by Ferring Pharmaceuticals, which contributed to and approved the study design and participated in the interpretation of data, review, and approval of the manuscript. Gauthier-Loiselle, Gagnon-Sanschagrin, and Wu are employees of Analysis Group, which received consultancy fees from Ferring Pharmaceuticals for work on this study. Jhaveri is a full-time employee of Ferring Pharmaceuticals. Parts of this work were presented as a poster presentation at AMCP Nexus 2018; October 22-25, 2018; Orlando, FL.

Management Strategies for Nocturia

PURPOSE OF REVIEW

Nocturia is defined as awakening due to the desire to void during a period of intended sleep. The pathophysiology of nocturia is multifactorial and management remains a challenge. Herein, we provide an overview of the management strategies for nocturia and summarize the existing evidence for treatment of nocturia across the condition's broad etiologic categories: nocturnal polyuria, diminished bladder capacity, and global polyuria.

RECENT FINDINGS

Treatment should begin with behavioral modification. A high level of evidence supports the efficacy of desmopressin in the treatment of nocturnal polyuria. Data supporting the efficacy of α-blockers, antimuscarinics, and surgical bladder outlet procedures in the treatment of nocturia remains limited. Treatment options for nocturia are determined by underlying mechanism. Desmopressin is effective in treating nocturnal polyuria. Surgical intervention, α-blockers, and antimuscarinics may improve nocturia when associated with lower urinary tract symptoms or overactive bladder in the setting of diminished bladder capacity.

Overactive Bladder Syndrome: Evaluation and Management

Overactive bladder (OAB) syndrome is a chronic medical condition which has a major influence on the quality of life in a significant amount of the population. OAB affects performance of daily activities and has an estimated prevalence of 16.5%. Many sufferers do not seek medical help. Moreover, many family physicians and even gynecologists are not familiar with this issue. Usually patients suffer from OAB in advanced age. Nocturia is reported as the most bothersome symptom in the elderly population. The aim of our review was to discuss all aspects of this challenging disorder and suggest tools for assessment and management strategies. Practitioners can easily overlook urinary complains if they not directly queried. We would like to encourage practitioners to give more attention to this issue.

Population-level and Individual-level Bother of Lower Urinary Tract Symptoms Among 30- to 80-year-old Men

OBJECTIVE

To estimate the bother using both population- and individual-level bother of lower urinary tract symptoms (LUTS) across a wide age range among men.

MATERIALS AND METHODS

A total of 7470 men aged 30-80 years were approached using a postal questionnaire in 2004. The overall response was 58.7% (4384 respondents). The Danish Prostatic Symptom Score was used to evaluate bother of 12 LUTS. In the population-level analysis, prevalence of bother was calculated by relating the number of men with bother to the population size (instead of only affected men). To evaluate the bother at individual level, its prevalence among the men experiencing the symptom was assessed.

RESULTS

In the population-level analysis, postmicturition dribble was the most common cause of bother among 30- and 40-year-old men, as 25% of the men experienced small bother and 4.5% had moderate to major bother. Men aged 70-80 years experienced the most bother from urgency followed closely by nocturia, with about 40% reporting small bother and roughly 20% moderate or major bother. When only symptomatic men were evaluated, incontinence symptoms, especially urge incontinence, were the most bothersome as more than 80% of the men with incontinence reported bother.

CONCLUSION

At population level, the most bothersome symptom varied by age. Men aged 30-40 years experienced bother most commonly from postmicturition dribble. With increasing age, urgency and nocturia became the most bothersome symptoms by age 70-80 years. At individual level, incontinence symptoms were the most bothersome LUTS, with less influence by age.

The Effectiveness of Silodosin for Nocturnal Polyuria in Elderly Men With Benign Prostatic Hyperplasia: A Multicenter Study

Purpose:

To investigate improvement in nocturia and nocturnal polyuria in nocturnal polyuria patients after silodosin administration by using a 3-day frequency volume chart.

Methods:

This was a prospective multicenter study. We enrolled nocturnal polyuria patients (nocturnal polyuria index [NPi]>0.33), aged ≥60 years, diagnosed with the 3-day frequency volume charts of patients with benign prostatic hyperplasia taking α-blockers. Of the 54 patients, 30 (55.6%) completed the study according to the study protocol (per-protocol group), and 24 dropped out (dropout group).

Results:

Of the 24 patients in the dropout group, 5 withdrew consent due to side effects or lack of efficacy, 7 were lost to follow-up at 4 weeks, 8 were lost to follow-up at 12 weeks, and 4 dropped out due to failure to complete 3-day frequency volume charts at 12 weeks. In the per-protocol group, there was significant improvement in the International Prostate Symptom Score (IPSS), especially question numbers 1, 3, 4, 5, 6, 7, and the quality of life question (P=0.001, P=0.007, P<0.001, P=0.003, P=0.049, P<0.001, and P<0.001, respectively). The Leeds sleep evaluation questionnaire (LSEQ) score for the sleep question improved from 64.36 to 70.43 (P=0.039). The NPi reduced from 0.4005 to 0.3573 (P=0.027); however, in many cases, there was no improvement in nocturnal polyuria itself. In intention-to-treat analysis, there were significant improvements in IPSS and LSEQ in 45 patients.

Conclusions:

In elderly nocturnal polyuria patients, silodosin monotherapy exhibits good efficacy in improving nocturia and nocturnal polyuria; however, the mean NPi was still >0.33. Considering the high dropout rate of our study due to no implementation of 3-day frequency volume charts, prospective and large-scale studies are needed to confirm our results.

Evaluation and management of patients with nocturia

Nocturia, or awakening one or more times to void at night, becomes clinically significant with two or more voids a night. In the past, nocturia has typically been viewed as a symptom of benign prostatic hyperplasia and/or overactive bladder syndrome. However, newer evidence supports that this is no longer just a symptom but a medical condition that warrants further workup and treatment given its effect on quality of life. The negative effects of nocturia include sleep fragmentation, decreased productivity at work, and increased risk of falls and fractures. A workup to find the underlying cause of nocturia will help guide treatment, which may include pharmacologic agents.

Update summarising the conclusions of the international consultation on male lower urinary tract symptoms

The International Consultation on Urological Disease have recently published comprehensive conclusions, based on evidence reviewed by eight committees, on aspects of male lower urinary tract symptoms (LUTS). In this review, we summarise the conclusions from four of the committees, namely, the evidence regarding the epidemiology of male LUTS, patient assessment, nocturia and medical management. It is indisputable that with an expanding and ageing global population the prevalence of male LUTS is likely to increase. Therefore symptom prevention and preservation of quality of life (QoL) feature highly in the guidelines. There are now a number of different medical options, proven to lead to significant improvements in symptom scores, flow rate and QoL available to men with LUTS. Meta-analyses have shown the benefits for alpha blockers, antimuscarinics, 5-α reductase and phosphodiesterase-5 inhibitors. High level evidence also exists for combinations of all of the above with alpha blockers and so men with concomitant storage symptoms, prostate volume > 30 mL, PSA > 1.4 or erectile dysfunction may be considered for combination treatment of an alpha blocker with an antimuscarinic, 5-α reductase inhibitor or phosphodiesterase-5 inhibitor respectively. In an era of personalised medicine, appropriate patient selection is likely to provide the key to the most effective clinical management strategy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Burden of male lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) - focus on the UK

KEY MESSAGES

Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) can be bothersome and negatively impact on a patient's quality of life (QoL). As the prevalence of LUTS/BPH increases with age, the burden on the healthcare system and society may increase due to the ageing population. This review unifies literature on the burden of LUTS/BPH on patients and society, particularly in the UK. LUTS/BPH is associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning, and through its negative impact on QoL for patients and partners. LUTS/BPH is often underdiagnosed and undertreated. Men should be encouraged to seek medical advice for this condition and should not accept it as part of ageing, while clinicians should be more active in the identification and treatment of LUTS/BPH. To assess the burden of illness and unmet need arising from lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH) from an individual patient and societal perspective with a focus on the UK. Embase, PubMed, the World Health Organization, the Cochrane Database of Systematic Reviews and the York Centre for Reviews and Dissemination were searched to identify studies on the epidemiological, humanistic or economic burden of LUTS/BPH published in English between October 2001 and January 2013. Data were extracted and the quality of the studies was assessed for inclusion. UK data were reported; in the absence of UK data, European and USA data were provided. In all, 374 abstracts were identified, 104 full papers were assessed and 33 papers met the inclusion criteria and were included in the review. An additional paper was included in the review upon a revision in 2014. The papers show that LUTS are common in the UK, affecting ≈3% of men aged 45-49 years, rising to >30% in men aged ≥85 years. European and USA studies have reported the major impact of LUTS on quality of life of the patient and their partner. LUTS are associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning. While treatment costs in the UK are relatively low compared with other countries, the burden on health services is still substantial. LUTS associated with BPH is a highly impactful condition that is often undertreated. LUTS/BPH have a major impact on men, their families, health services and society. Men with LUTS secondary to BPH should not simply accept their symptoms as part of ageing, but should be encouraged to consult their physicians if they have bothersome symptoms.

The Nocturia Impact Diary: a self-reported impact measure to complement the voiding diary

BACKGROUND

Nocturia is a chronic, fluctuating disease that disrupts sleep and has a wide-ranging impact on quality of life. Valid tools to measure the patient-reported impact of nocturia are essential for evaluating the value of treatment, but the available tools are suboptimal.

OBJECTIVES

This study reports the development and validation of the Nocturia Impact Diary-an augmented form of the Nocturia Quality of Life questionnaire designed to be completed in conjunction with the widely used 3-day voiding diary.

METHODS

The process comprised three steps: Step 1: Development of a concept pool using the Nocturia Quality of Life questionnaire and data from relevant studies; Step 2: Content validity study; Step 3: Psychometric testing of construct validity, reliability, and sensitivity of the diary in a randomized, placebo-controlled study in patients with nocturia.

RESULTS

Step 1: Fourteen items and 4 domains were included in the first draft of the diary. Step 2: Twenty-three patients with nocturia participated in the cognitive debriefing study. Items were adjusted accordingly, and the content validity was high. Step 3: Fifty-six patients were randomized to desmopressin orally disintegrating tablet or placebo. The diary demonstrated high construct validity, with good sensitivity and a good fit to Rasch model, as well as high internal consistency, discriminatory ability, and acceptable sensitivity to change. Results indicated that the diary was unidimensional.

CONCLUSIONS

The Nocturia Impact Diary is a convenient, validated patient-reported outcome measure. It should be used in conjunction with a voiding diary to capture the real-life consequences of nocturia and its treatment.

The impact of adding low-dose oral desmopressin therapy to tamsulosin therapy for treatment of nocturia owing to benign prostatic hyperplasia

PURPOSE

To evaluate the efficacy and safety of adding a low-dose oral desmopressin to tamsulosin therapy for treatment of nocturia in patients with benign prostatic hyperplasia (BPH).

METHODS

Eligible patients with BPH and nocturia ≥2/night were randomly allocated to two treatment groups; the first of which received 3-month treatment scheme of daily oral dose of tamsulosin OCAS 0.4 mg and desmopressin MELT 60 mcg (D/T group), while the second one received tamsulosin OCAS 0.4 mg only (T group). Patients were followed on monthly basis and changes in the parameters from baseline to 3 months after treatment were assessed on I-PSS/QoL questionnaire, 7-day voiding diary, urinalysis, serum sodium, abdominal ultrasonography and uroflowmetry.

RESULTS

A total of 248 patients were included within the study; 123 patients in the combined D/T group and 125 patients in T group. The frequencies of night voids decreased by 64.3% in D/T group compared to 44.6% in T group. The first sleep period, significantly increased from 82.1 to 160.0 min and from 83.2 to 123.8 min in D/T and T group, respectively; and significant differences between both groups were observed at the end of study (p < 0.001). I-PSS, QoL score, post-void residual urine volume and Q max were significantly improved with no statistical difference between both groups. No serious adverse effects were reported in both groups.

CONCLUSION

The addition of low-dose oral desmopressin therapy to an α-blocker tamsulosin provides effective treatment for nocturia in patients with LUTS/BPH.

Nocturia is the Lower Urinary Tract Symptom With Greatest Impact on Quality of Life of Men From a Community Setting

PURPOSE

Lower urinary tract symptoms are numerous, but the specific impact of each of these symptoms on the quality of life (QoL) has not been evaluated in community-dwelling men. An assessment of these symptoms and their effects on QoL was the focus of this study.

METHODS

We performed a cross-sectional study with 373 men aged >50 years from a community setting. Patients completed the International Prostate Symptom Score questionnaire, which includes questions on each of the specific urinary symptoms and a question addressing health-related QoL that are graded from 0 to 5. We used the Pearson correlation test to assess the impact of each symptom on QoL.

RESULTS

Nocturia (58.9%) was the most prevalent urinary symptom. The mean score was 0.9±1.4 for incomplete emptying, 1.0±1.5 for frequency, 0.9±1.3 for intermittency, 0.8±1.3 for urgency, 1.0±1.5 for weak stream, 0.5±1.0 for straining, and 2.0±1.6 for nocturia. Nocturia and frequency were the only symptoms associated with poorer QoL, with nocturia showing a stronger association.

CONCLUSIONS

Nocturia affects 50% of community dwelling men aged >50 years, and is the lower urinary tract symptom with the greatest negative impact on QoL.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of dutasteride on nocturia in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH): a pooled analysis of three phase III studies

PURPOSE

To assess the impact of dutasteride compared with placebo on nocturia in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, using pooled data from dutasteride phase III studies.

METHODS

Nocturia was assessed using Question 7 of the International Prostate Symptom Score questionnaire. Efficacy measures included: mean change in nocturia at 24 months; proportion of patients with improvement/worsening in nocturia; nocturnal voiding frequency at baseline and study end, overall and by baseline subgroups; and nocturnal voiding frequency <2 at study end in patients with baseline score ≥ 2.

RESULTS

In total, 4,321 patients with a mean age of 66 years were evaluated. From month 12 onwards, mean nocturia improvements were significantly superior with dutasteride than with placebo (p ≤ 0.05). Reduction in nocturia was significantly better with dutasteride than with placebo across all baseline subgroups tested (p ≤ 0.05). Also at month 24, dutasteride therapy resulted in a greater proportion of subjects with nocturia improvement compared with placebo (p ≤ 0.05), with the largest treatment group differences in subjects with a baseline nocturia score of 2 or 3. Among patients with significant nocturia at baseline (score ≥ 2), significantly more subjects with dutasteride versus placebo had a score <2 at month 24 (26 vs. 19 %, p < 0.001).

CONCLUSIONS

After 24 months of treatment, dutasteride treatment provided significantly greater improvements in nocturia, and less worsening, compared with placebo, primarily in subjects with two or three nocturia episodes per night. Studies specifically designed to assess nocturia are required to prospectively confirm these findings.

Nocturia improvement in the combination of Avodart(®) and tamsulosin (CombAT) study

PURPOSE

The purpose of the study was to assess the impact of dutasteride plus tamsulosin combination therapy, compared with dutasteride or tamsulosin monotherapy, on nocturia in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) using data from the 4-year CombAT study.

METHODS

Nocturia was assessed using Question 7 of the International Prostate Symptom Score questionnaire. Efficacy measures included as follows: mean change in nocturia at 3-month intervals up to 48 months; proportion of patients with improvement/worsening in nocturia; nocturnal voiding frequency at baseline and study end, overall and by baseline subgroups; and nocturnal voiding frequency <2 at study end in patients with a baseline score ≥ 2.

RESULTS

In total, 4,722 patients with a mean age of 66 years were included. Mean nocturia improvements were significantly superior (p ≤ 0.01) with combination therapy than with either monotherapy (adjusted mean change from baseline in IPSS Question 7 score at month 48: combination therapy -0.5, dutasteride -0.4, tamsulosin -0.3). Reduction in nocturia score with combination therapy was significantly (p ≤ 0.01) better than tamsulosin monotherapy across all baseline subgroups tested, except for men with previous 5ARI use. Among those with a baseline IPSS Q7 score ≥ 2, more patients with combination therapy had a score <2 at month 48 (34 %) compared with dutasteride (30 %, p = 0.018) or tamsulosin (26 %, p < 0.0001).

CONCLUSIONS

Combination therapy provided greater improvements and less worsening of nocturia compared with both dutasteride and tamsulosin monotherapies. These analyses are the first to show greater improvement with a 5ARI/α-blocker combination versus either agent alone for the management of nocturia in patients with LUTS/BPH.

Efficacy of Additional Dutasteride on Lower Urinary Tract Symptoms in Patients with Alpha-1 Blocker-Resistant Benign Prostatic Hyperplasia

OBJECTIVE

We investigated the effects of dutasteride on urination and quality of life (QOL) in patients diagnosed with benign prostatic hyperplasia (BPH) who showed poor improvement in lower urinary tract symptoms (LUTS) with alpha-1 blockers.

METHODS

We retrospectively analyzed 108 patients with BPH who took dutasteride for more than 3 months from October 2009 to October 2011. The patients showed poor improvement in LUTS despite administration of alpha-1 blockers for more than 3 months; all had an International Prostate Symptom Score (IPSS) of eight or greater. We investigated changes in prostate-specific antigen and prostate volume and performed uroflowmetry and medical interviews to assess IPSS-QOL score and BPH impact index (BII).

RESULTS

Mean prostate volume was 52.8 ± 22.2 mL, and the mean period of dutasteride administration was 284 ± 118 days. Prostate volume decreased 24.1% from baseline to 6 months after administration. Voiding symptoms and storage symptoms showed improvements with longer administration periods, but only nocturia showed no clear improvement. There was a 0.9-point decrease in BII after 6 months. There was no statistically significant association between the rate of prostate volume reduction and improvement in voiding and storage symptoms.

CONCLUSION

Additional administration of dutasteride to patients with alpha-1 blocker-resistant BPH led to improvements in all voiding and storage symptoms except nocturia, and showed no correlation between the prostate volume reduction rates and improvement in LUTS.

The New England Research Institutes, Inc. (NERI) Nocturia Advisory Conference 2012: focus on outcomes of therapy

A consensus statement published in 2011 summarised current research, clinical approaches, and treatment options for nocturia. Since that time, new research has refined our understanding of nocturia in clinically important ways and new evidence has been presented on the efficacy and outcomes of several treatment methods for this underreported, infrequently recognised, and undertreated problem in adults. This paper provides updated guidance to clinicians in light of recent advances in the field.

Nocturia: current concepts and future perspectives

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

Are polymorphisms of the β(3)-adrenoceptor gene associated with an altered bladder function?

AIMS

As the presence of a Trp64Arg polymorphism of the gene encoding the β(3)-adrenoceptor (B3AR) has been linked to the presence of overactive bladder, we investigated whether additional polymorphisms are detectable in this gene and explore their relationships parameters related to lower urinary tract function.

METHODS

The coding region and adjacent stretches of the B3AR gene was sequenced in 91 patients. In total, 1015 patients from a single academic hospital were genotyped for the presence of two single nucleotide polymorphisms. Symptom scores and parameters from pressure-flow studies were analyzed relative to genotype in the B3AR gene.

RESULTS

No frequent novel polymorphisms were detected in the coding region. Five polymorphisms were found in the non-coding region of the gene but were in complete linkage with the 64Arg allele. Out of 32 parameters including bladder compliance, only prostate size was weakly (44 vs. 39 mL) but significantly associated with the 64Arg allele, but was not mirrored by an association with prostate-specific antigen levels.

CONCLUSIONS

Our data do not support the hypothesis that polymorphisms in the B3AR gene are associated with alterations of bladder function.

Excessive nocturnal urine production is a major contributing factor to the etiology of nocturia

PURPOSE

Nocturnal polyuria is a common but often overlooked cause of nocturia. We investigated the proportion of adults with 2 or greater voids nightly who had nocturnal polyuria in 2 cohorts from the United States and Europe.

MATERIALS AND METHODS

Data on nocturnal polyuria were obtained from 3 or 7-day frequency-volume charts completed by patients as part of screening for inclusion in subsequent trials of nocturia therapy. Patients recorded the time and volume of each void. Nocturnal polyuria was defined as nocturnal urine volume greater than 33% of 24-hour volume, including the first morning void.

RESULTS

In the first cohort 1,003 patients were screened, of whom 846 provided evaluable diary data, including 641 (76%) with nocturnal polyuria. Of the total screened population of 1,003 patients 641 (64%) had confirmed nocturnal polyuria. The prevalence of nocturnal polyuria increased with age but was high in all age groups. In the second cohort 1,412 patients were screened, of whom 917 provided evaluable diary data, including 806 (88%) with nocturnal polyuria. Of the total screened population of 1,412 patients 806 (57%) had confirmed nocturnal polyuria. The prevalence of nocturnal polyuria increased with age but was high in all age groups. Of 158 patients receiving benign prostatic hyperplasia and/or overactive bladder medication 141 (89%) had nocturnal polyuria. In each cohort the nocturnal polyuria prevalence was high in all ethnic groups (63% or greater).

CONCLUSIONS

In this large study nocturnal polyuria was present in most patients with nocturia regardless of gender, age, ethnicity, country and concomitant benign prostatic hyperplasia/overactive bladder therapy.