Antimuscarinics for treatment of storage lower urinary tract symptoms in men: a systematic review

Efficacy and Safety of Mirabegron in Men with Overactive Bladder Symptoms and Benign Prostatic Hyperplasia

PURPOSE OF REVIEW

To review the efficacy and safety of mirabegron in men with overactive bladder (OAB) and benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Numerous studies have shown mirabegron to be efficacious and safe in treating symptoms of OAB. More recent studies evaluating the use of mirabegron in men with OAB and BPH have also shown the medication to be effective with few adverse side effects when used as monotherapy or in combination therapy. Mirabegron is an effective and safe treatment for men with OAB and BPH.

A retrospective analysis comparing persistence and adherence to treatment with free- vs fixed-dose combination of an alpha blocker and an antimuscarinic agent in men with LUTS in Spain

INTRODUCTION

Combination therapy with an alpha blocker (AB) plus an antimuscarinic (AM) is recommended for men with moderate-to-severe mixed lower urinary tract symptoms (LUTS) when monotherapy is not effective in relieving storage symptoms. This study compared treatment persistence and adherence with an AB plus AM fixed-dose combination (FDC) vs an AB plus AM free-dose combination in men with LUTS in Spain.

METHODS

Retrospective study using the Spanish IQVIA Cegedim Electronic Medical Records database. Men prescribed AB plus AM combination therapy were included in an FDC or free-dose combination cohort based on their index treatment. Treatment persistence was the time from index date to first discontinuation of ≥1 of the two index drugs over 12 months. Adherence was measured using the fixed medication possession ratio (MPR).

RESULTS

Of 3114 patients identified, 999 were included (FDC, n = 790; free-dose combination, n = 209). Median (95% CI) persistence was longer in the FDC (125 [109-151] days) than in the free-dose combination (31 [31-36] days) cohort (hazard ratio [HR], 2.9; 95% CI, 2.4-3.4; P < .0001). The 12-month persistence rates were 31.1% (FDC cohort) and 8.9% (free-dose cohort). The mean (SD) fixed MPR was higher in the FDC cohort (48.8 [37.2]) compared with the free-dose cohort (23.1 [28.4]); more patients in the FDC cohort (34.2%) than in the free-dose cohort (10.0%) were adherent (MPR ≥ 80%). The probability of treatment persistence and adherence increased with age (>80 vs <65 years, persistence HR, 0.7 [95% CI, 0.5-0.9]; MPR difference, 12.5), polypharmacy (persistence HR, 0.7 [95% CI, 0.6-0.9]; MPR difference, 10.7) and previous use of AB (persistence HR, 0.8 [95% CI, 0.7-1.0]; MPR difference, 5.7) or AB/AM combinations (persistence HR, 0.7 [95% CI, 0.5-0.9]; MPR difference, 11.1).

CONCLUSIONS

Treatment with an AB/AM FDC is associated with better persistence and adherence vs a free-dose combination in men with LUTS in Spain.

Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial

IMPORTANCE

First-line behavioral and drug therapies for overactive bladder (OAB) symptoms in men are effective but not usually curative.

OBJECTIVE

To determine whether combining behavioral and drug therapies improves outcomes compared with each therapy alone for OAB in men and to compare 3 sequences for implementing combined therapy.

DESIGN, SETTING, AND PARTICIPANTS

In this 3-site, 2-stage, 3-arm randomized clinical trial, participants were randomized to 6 weeks of behavioral therapy alone, drug therapy alone, or combined therapy followed by step-up to 6 weeks of combined therapy for all groups. Participants were recruited from 3 outpatient clinics and included community-dwelling men 40 years or older with urinary urgency and 9 or more voids per 24 hours. Data were collected from July 2010 to July 2015 and analyzed from April 2016 to September 2019.

INTERVENTIONS

Behavioral therapy consisted of pelvic floor muscle training with urge suppression strategies and delayed voiding. Drug therapy included an antimuscarinic (sustained-release tolterodine, 4 mg) plus an α-blocker (tamsulosin, 0.4 mg).

MAIN OUTCOMES AND MEASURES

Seven-day bladder diaries completed before and after each 6-week treatment stage were used to calculate reduction in frequency of urination (primary outcome) and other symptoms (ie, urgency, urgency incontinence, and nocturia). Other secondary outcomes included validated patient global ratings of improvement and satisfaction, Overactive Bladder Questionnaire score, and International Prostate Symptom Score.

RESULTS

Of the 204 included men, 133 (65.2%) were white, and the mean (SD) age was 64.1 (11.1) years. A total of 21 men discontinued treatment and 183 completed treatment. Mean (SD) voids per 24 hours decreased significantly in all 3 groups from baseline to 6-week follow-up (behavioral therapy: 11.7 [2.4] vs 8.8 [2.1]; change, 2.9 [2.4]; percentage change, 24.7%; P < .001; drug therapy: 11.8 [2.5] vs 10.3 [2.7]; change, 1.5 [2.3]; percentage change, 12.7%; P < .001; combined therapy: 11.8 [2.4] vs 8.2 [2.3]; change, 3.6 [2.1]; percentage change, 30.5%; P < .001). Intention-to-treat analyses indicated that posttreatment mean (SD) voiding frequencies were significantly lower in those receiving combined therapy compared with drug therapy alone (8.2 [2.3] vs 10.3 [2.7]; P < .001) but not significantly lower compared with those receiving behavioral therapy alone (8.2 [2.3] vs 8.8 [2.1]; P = .19) and were lower for behavioral therapy alone compared with drug therapy alone (8.8 [2.1] vs 10.3 [2.7]; P < .001). At 12-week follow-up, after all groups had received combined therapy, improvements in mean (SD) voids per 24 hours were also greatest for those receiving initial combined therapy compared with baseline (behavioral therapy: 11.7 [2.4] vs 8.0 [2.2]; change, 3.7 [2.3]; percentage change, 31.6%; P < .001; drug therapy: 11.8 [2.5] vs 8.6 [2.3]; change, 3.2 [2.5]; percentage change, 27.1%; P < .001; combined therapy: 11.8 [2.4] vs 8.0 [2.2]; change, 3.8 [2.1]; percentage change, 32.2%; P < .001), but there were no statistically significant group differences on primary or secondary measures.

CONCLUSIONS AND RELEVANCE

Combining behavioral and drug therapy yields greater improvements in OAB symptoms than drug therapy alone but not behavioral therapy alone. When using a stepped approach, it is reasonable to begin with behavioral therapy alone.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01175382.

Precision medicine in the diagnosis and treatment of male lower urinary tract symptoms suggestive of benign prostatic hyperplasia

Male lower urinary tract symptoms (LUTSs) are highly prevalent in men and the incidence increases with aging. The pathophysiology of male LUTSs might be bladder outlet dysfunctions such as bladder neck (BN) dysfunction, benign prostatic obstruction, and poor relaxation of external sphincter and bladder dysfunctions such as detrusor overactivity (DO), detrusor underactivity, DO, and inadequate contractility. Male LUTSs include voiding and storage symptoms, and precision diagnosis should not be done based on the symptoms alone. Videourodynamic study provides a thorough look at the bladder and bladder outlet and can clearly demonstrate the underlying pathophysiology when the initial medication fails to relieve LUTS. Medical treatment should be given based on the underlying pathophysiology of LUTS, and surgical intervention to remove prostate should only be performed when a definite bladder outlet obstruction due to prostatic obstruction has been confirmed by invasive urodynamic study.

Efficacy of newer medications for lower urinary tract symptoms attributed to benign prostatic hyperplasia: a systematic review

We conducted a systematic review to evaluate the efficacy and adverse effects of newer drugs used to treat lower urinary tract symptoms (LUTS). The drugs were either Food and Drug Administration (FDA) approved for benign prostatic hyperplasia (BPH) or not FDA approved for BPH but have been evaluated for treatment of BPH since 2008. We searched bibliographic databases through September 2017. We included randomized controlled trials (RCTs) lasting one month or longer published in English. Outcomes of interest were LUTS assessed by validated measures. Efficacy was interpreted using established thresholds indicating clinical significance that identified the minimal detectable difference. Twenty-three unique, generally short-term, RCTs evaluating over 9000 participants were identified. Alpha-blocker silodosin and phosphodiesterase type 5 inhibitor tadalafil were more effective than placebo in improving LUTS (moderate strength evidence) but these drugs had more adverse effects, including abnormal ejaculation (silodosin). Anticholinergics were only effective versus placebo when combined with an alpha-blocker. Evidence was generally low strength or insufficient for other drugs. Evidence was insufficient to assess long-term efficacy, prevention of symptom progression, need for surgical intervention, or long-term adverse effects. Longer trials are needed to assess the effect of these therapies on response rates using established minimal detectable difference thresholds, disease progression, and harms.

Silodosin: An Update on Efficacy, Safety and Clinical Indications in Urology

INTRODUCTION

Silodosin determines smooth muscle relaxation in bladder and prostate tissues, increases bladder blood flow in conditions of chronic bladder ischemia and regulates the activity of transcriptional factors responsible for stromal growth and prostate hyperplasia. Phase III trials have already demonstrated the efficacy and safety of silodosin in the treatment of patients bothered by lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

OBJECTIVE

We aimed to describe the rationality for the use of silodosin and to summarize the current literature on the use of Silodosin for the treatment of LUTS.

METHODS

PubMed and Web of Science were queried with the terms: 'silodosin' in combination (AND) with the terms 'lower urinary tract symptoms', 'LUTS', 'pathophysiology', 'symptoms' OR 'therapy'. Studies published in the last 10 years (2007-2017) in adults and core clinical journals in English were included.

RESULTS

Silodosin 8 mg once-daily was superior to placebo in improving IPSS total score, voiding subscore, storage subscore and QoL score, and at least as effective as tamsulosin 0.4 mg once-daily in all the efficacy analyses. In addition, studies assessing the effect on urodynamic parameters showed that silodosin determined a higher improvement in the bladder outlet obstruction index compared to other alpha1 adrenergic receptor antagonists. Concerning the safety profile, long-term data (after 9 months of treatment) confirmed the limited effect of silodosin on the cardiovascular and gastrointestinal systems. Although ejaculatory disorders represented the main complaint of patients taking silodosin, the discontinuation rate due to this condition remained low even in a long-term follow-up study (7.5%). Encouraging findings showed that silodosin may be administered as a medical expulsive therapy for promoting spontaneous stone passage of distal ureteral stones < 10 mm, to relieve LUTS in patients who underwent prostate cancer brachytherapy and to increase the likelihood of successful trials without a catheter in patients experiencing acute urinary retention.

CONCLUSION

Silodosin is one of the drugs approved for the treatment of BPH, being highly effective in improving not only LUTS but also urodynamic parameter impairments secondary to BPH. Moreover, it has shown efficacy as medical expulsive therapy for distal ureteral stones in previous prospective randomized trials.

FUNDING

Sponsorship for this study and article processing charges were funded by Recordati.

Individualizing medical treatment of overactive bladder

Overactive bladder (OAB) syndrome is highly prevalent in both men and women and might have negative impact on quality of life. Clinical trials of OAB usually highly select participants that may not reflect the real-world practice of OAB patients. The spectrum of OAB includes patients with idiopathic, neuropathic, with bladder outlet obstruction, and patients in elderly and medical comorbidities. Patients might have poor response to OAB medication or have adverse events after treatment. Therefore, treatment of OAB should be individualized to obtain therapeutic efficacy and avoid unacceptable adverse events. This article reviews the recently published literature and provides a guide for physicians to choose the appropriate treatment for different OAB patients.

Cardiovascular Safety of the β3 -Adrenoceptor Agonist Mirabegron and the Antimuscarinic Agent Solifenacin in the SYNERGY Trial

There have been concerns that treatment of overactive bladder with β₃ -adrenoceptor agonists may potentially have detrimental cardiovascular (CV) side effects. We evaluated the CV safety of mirabegron, a β₃ -adrenoceptor agonist, alone and in combination therapy with the antimuscarinic agent solifenacin. The SYNERGY trial was a multinational, multicenter, randomized, double-blind, parallel-group, placebo and active-controlled phase 3 trial. Patients were randomized to receive solifenacin 5 mg + mirabegron 50 mg (combination 5 + 50 mg), solifenacin 5 mg + mirabegron 25 mg (combination 5 + 25 mg), solifenacin 5 mg monotherapy, mirabegron 25 mg monotherapy, mirabegron 50 mg monotherapy, or placebo for a 12-week double-blind treatment period. A total of 3398 patients were included in the study. Mean changes from baseline to the end of therapy in ECG parameters were similar across treatment groups, although there was an increase in heart rate of 1 beat/minute in the mirabegron treatment groups. There were no clinically meaningful differences in change from baseline in QTcF between monotherapies and placebo and between monotherapies and combination therapy. There were very few major CV events: 1 of 853 (0.1%) with a nonfatal myocardial infarction in the combination 5 + 25 mg group, 2 of 848 (0.2%) with a nonfatal stroke in the combination 5 + 50 mg group, and no events in the other groups. This CV safety analysis of the combination of mirabegron and solifenacin showed rates of CV events comparable with those for monotherapy treatments based on assessments of vital signs, electrocardiograms, and adjudicated CV events.

A strategy utilizing ambulatory monitoring and home and clinic blood pressure measurements to optimize the safety evaluation of noncardiovascular drugs with potential for hemodynamic effects: a report from the SYNERGY trial

Supplemental Digital Content is available in the text.

Objective

The aim of this study was to perform a blood pressure (BP) safety evaluation in patients with an overactive bladder receiving solifenacin (an antimuscarinic agent), mirabegron (a β₃-adrenoceptor agonist), or both compared with placebo in the SYNERGY trial.

Patients and methods

Patients were randomized to receive solifenacin 5 mg+mirabegron 50 mg (combination 5+50 mg); solifenacin 5 mg+mirabegron 25 mg (combination 5+25 mg); solifenacin 5 mg; mirabegron 50 mg; mirabegron 25 mg; or placebo for a double-blind 12-week treatment period. Systolic BP, diastolic BP, and heart rate were measured by ambulatory BP monitoring, and in the clinic or home.

Results

A total of 715 patients were analyzed in an ambulatory BP monitoring substudy. At the end of treatment, ambulatory BP monitoring measurements showed no consistent increases from baseline in the mean 24-h systolic BP or diastolic BP for combination versus monotherapy groups or for monotherapy groups versus placebo. Analysis of 1-h BP averages during the 6 h range that included the T_max values of both study drugs showed no significant BP effects. Shift analysis (switch between different normotension/hypertension stages) did not show differences among the active and placebo groups, nor did outlier analysis of major BP changes differ between placebo and active treatment. Similarly, there were no significant signals in the 24-h heart rate. Office and home measurements were consistent with ambulatory BP monitoring findings.

Conclusions

A paradigm of ambulatory BP monitoring analysis designed to test BP safety of noncardiovascular drugs showed that solifenacin plus mirabegron combination therapy during 12 weeks produced no meaningful changes in BP or heart rate.

Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, and Urinary Retention

Lower urinary tract symptoms (LUTS) consist of a common set of urologic symptoms that can affect the elderly. The prevalence of LUTS is expected to rise owing to the continued increase of numbers of the elderly. Although benign prostatic hyperplasia is considered a common cause of LUTS, the broader potential causes of LUTS are myriad. A wide range of diagnostic modalities and treatments are available to manage patients with LUTS and their utilization should not be limited to the urologist.

Pharmacotherapy in overactive bladder

Overactive bladder syndrome (OAB) has a high prevalence within the population and has a negative effect on quality of life. Although the precise pathophysiology has yet to be fully elucidated, pharmacotherapeutic agents have been developed targeting two main pathways, antimuscarinic drugs and β3-adrenoreceptor agonists. Conservative management strategies, for example, bladder training, should be used as first-line treatment, with pharmacotherapy used as an adjunct if this is insufficiently effective. Antimuscarinics have a moderate effect on treating the symptoms of OAB, are associated with side effects, particularly dry mouth, and have low adherence rates in the long term. No single agent has consistently shown superiority over another. Antimuscarinics can affect cognition and may contribute to the anticholinergic burden in elderly patients. Mirabegron, a β3-agonist, appears to be as effective as antimuscarinics in improving symptoms of OAB with fewer side effects and improved adherence, and is currently recommended if treatment with antimuscarinics has failed. A combination of an antimuscarinic and β3-agonist may be worth considering if symptoms remain refractory or to reduce the side-effect profile associated with higher doses of antimuscarinics.

Level of evidence: Not applicable.

Targeting phenotypic heterogeneity in benign prostatic hyperplasia

Benign prostatic hyperplasia and associated lower urinary tract symptoms remain difficult to treat medically, resulting in hundreds of thousands of surgeries performed annually in elderly males. New therapies have not improved clinical outcomes since alpha blockers and 5 alpha reductase inhibitors were introduced in the 1990s. An underappreciated confounder to identifying novel targets is pathological heterogeneity. Individual patients display unique phenotypes, composed of distinct cell types. We have yet to develop a cellular or molecular understanding of these unique phenotypes, which has led to failure in developing targeted therapies for personalized medicine. This review covers the strategic experimental approach to unraveling the cellular pathogenesis of discrete BPH phenotypes and discusses how to incorporate these findings into the clinic to improve outcomes.

Efficacy and Safety of Medium-to-long-term Use of Tolterodine Extended Release with or without Tamsulosin in Patients with Benign Prostate Hyperplasia and Larger Prostate Size: A Double-blind, Placebo-controlled, Randomized Clinical Trial

Background:

The medium-to-long-term use of antimuscarinics alone or in combination with an α-blocker in men with an enlarged prostate is still controversial. This double-blind, placebo-controlled, randomized clinical trial aimed to investigate the efficacy and safety of medium-to-long-term use of tolterodine extended release (ER) with or without tamsulosin in patients with benign prostate hyperplasia (BPH) and larger prostate size.

Methods:

Totally, 152 patients (age ≥50 years) with BPH, International Prostate Symptom Score (IPSS) ≥12, quality-of-life (QoL) score ≥3, and total prostate volume ≥25 ml were enrolled in this study. The patients were randomized into four groups (n = 38 in each) to receive tolterodine ER placebo plus tamsulosin placebo, 0.2 mg tamsulosin plus tolterodine ER placebo, 4 mg tolterodine ER plus tamsulosin placebo, or tolterodine ER plus tamsulosin once daily for 24 weeks. IPSS (total, storage, and voiding subscales), QoL, maximum urinary flow rate (Q_max), and postvoid residual volume (PVR) were collected at baseline, and at weeks 4, 12, and 24.

Results:

Compared with placebo, tolterodine ER plus tamsulosin significantly improved total IPSS (−7.15, −12.20, and −14.66 vs. −3.51, −5.78, and −7.23), storage IPSS (−3.56, −5.63, and −6.66 vs. −1.52, −1.21, and −2.43), voiding IPSS (−2.88, −5.10, and −6.48 vs. −1.52, −3.03, and −2.97), QoL (−1.21, −2.40, and −3.21 vs. −0.39, −1.41, and −1.60), Q_max (2.21, 7.97, and 9.72 ml/s vs. 2.15, 2.44, and 2.73 ml/s), and PVR (−17.88, −26.97, and −27.89 ml vs. −12.03, −11.16, and −16.73 ml) at weeks 4, 12, and 24, respectively; the differences were all statistically significant (P < 0.05). Adverse events (AEs) were not increased with treatment progression. Tolterodine ER alone did not improve total IPSS (−4.61, −6.79, and −5.70), voiding IPSS (−0.64, −1.83, and −1.45), QoL (−0.69, −1.21, and −1.41), or Q_max (−0.79, 2.83, and 1.11 ml/s), compared with placebo (all P > 0.05). However, a gradual increase in PVR (10.03, 10.41, and 12.89 ml) and more urinary AEs suggestive of urinary retention (11/38 vs. 4/38) were observed.

Conclusion:

Medium-to-long-term use of tolterodine ER plus tamsulosin should be recommended in patients with BPH and an enlarged prostate volume.

Trial Registration:

www.chictr.org.cn, ChiCTR-TRC-09000596; http://www.chictr.org.cn/showproj.aspx?proj=8939.

Incidence of urinary retention during treatment with single tablet combinations of solifenacin+tamsulosin OCAS™ for up to 1 year in adult men with both storage and voiding LUTS: A subanalysis of the NEPTUNE/NEPTUNE II randomized controlled studies

INTRODUCTION

The emergence of urinary retention (UR), specifically acute urinary retention (AUR), has been a concern when treating men with lower urinary tract symptoms (LUTS) with antimuscarinic drugs.

MATERIALS AND METHODS

In NEPTUNE (12-week, double-blind), men (≥45 years) with LUTS were randomized to receive tamsulosin oral-controlled absorption system (TOCAS) 0.4 mg, fixed-dose combination (FDC) of solifenacin (Soli) 6 mg + TOCAS 0.4 mg, FDC Soli 9 mg + TOCAS 0.4 mg, or placebo. In NEPTUNE II (40-week, open-label extension of NEPTUNE), continuing patients received 4-week FDC Soli 6 mg + TOCAS, then FDC Soli 6 mg or 9 mg + TOCAS for the remainder of the study, switchable every 3 months.

RESULTS

Across both studies, 1208 men received ≥1 dose of FDC Soli 6 mg or 9 mg + TOCAS for up to 52 weeks; 1199 men completed NEPTUNE and 1066 received ≥1 dose in NEPTUNE II. In total, 13 men (1.1%; 95% CI, 0.6%-1.8%) reported a UR event while receiving FDC, eight of which were AUR (0.7%; 95% CI, 0.3%-1.3%, incidence 7/1000 man-years). Six men reported UR events while taking Soli 6 mg + TOCAS (three AUR), and seven men reported a UR event while taking Soli 9 mg + TOCAS (five AUR). One man developed AUR while taking TOCAS alone and four reported UR (three AUR) during placebo run-in. Most AUR/UR events occurred within 4 months of treatment initiation.

CONCLUSIONS

FDC Soli and TOCAS was associated with a low rate of UR and AUR in men with LUTS.

[S2e guideline of the German urologists: Conservative and pharmacologic treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

Treatment Patterns for Patients on Overactive Bladder Therapy: A Retrospective Statistical Analysis Using Canadian Claims Data

Background: Overactive bladder (OAB) is a chronic condition which may be associated with a significant negative impact on quality of life. Antimuscarinic drugs are currently the mainstay of medical therapy, but persistence and adherence are generally poor. Treatment switching may be considered in order to maximise benefits from pharmacological therapy, but there are relatively few data on OAB therapy switching to second and third-lines of medication. There are also few formal analyses on the impact of age, gender and choice of initial OAB drug on discontinuation rates. Objectives: To investigate discontinuation rates with antimuscarinics in patients newly starting OAB therapy, with regard to patterns of switching to alternative medication, and the potential impact of age, gender and choice of initial drug. Methods: Data on prescription drug use in Canada were retrieved from the IMS Brogan public and private prescription claims databases. Medication usage was tracked for four years following an index claim. The primary endpoint was the number of days from index claim to discontinuation of medication. Secondary endpoints were the number of days on first-line therapy before switching. Descriptive results were evaluated using univariate (Kaplan-Meier) and multivariate (Cox proportional hazards) models. Results: Data were available for 31,754 patients. Approximately 91% discontinued OAB medication within the four-year follow-up period. The discontinuation rate was similar between men and women. The risk of discontinuation in patients ≥75 years was only slightly higher than that in patients aged 40-64 years (hazard ratio of 1.08) and was lower than in those aged 65-74 years. Retention when oxybutynin was the initial drug was lower than with most of the other antimuscarinics. Only 12.5% of patients changed OAB medication during the 4-year period. Women were more likely than men to switch from first-line or second-line treatment. Conclusions: Discontinuation of initial antimuscarinic therapy was high. Compared with oxybutynin, several alternative antimuscarinics offered lower risks of discontinuation. The majority of patients had no trial of second-line treatment.

Efficacy and safety of tamsulosin hydrochloride 0.2 mg and combination of tamsulosin hydrochloride 0.2 mg plus solifenacin succinate 5 mg after transurethral resection of the prostate: a prospective, randomized controlled trial

Objective

The objective of this study was to evaluate the safety and efficacy of tamsulosin hydrochloride 0.2 mg (TAM) and its combination with solifenacin succinate 5 mg (SOL) after transurethral resection of the prostate (TURP).

Patients and methods

The patients were randomized into three groups: TURP (group 1), TURP plus TAM (group 2), and TURP plus TAM + SOL (group 3). Patients in group 2 and group 3 received medication for 4 weeks. The primary efficacy end points were the mean change in total International Prostate Symptom Score (IPSS) and IPSS subscores. The secondary end points included quality-of-life score, Overactive Bladder Symptom Score, and short-form voiding and storage score of International Continence Society.

Results

In total, 37 men (31.8%) in group 1, 37 men (31.8%) in group 2, and 42 men (36.2%) in group 3 completed the study. In total IPSS, no significant improvement was seen from baseline to the end of treatment in groups 2 and 3 compared with group 1. However, in group 2, the decrement in the IPSS storage score was smaller than group 1 (P=0.02), and in group 3, the decrement in the IPSS voiding score was smaller than group 1 (P=0.05). In groups 2 and 3 compared with group 1, improvements in the quality of life score, total score of Overactive Bladder Symptom Score, and short-form voiding score and storage score of International Continence Society were not statistically significant.

Conclusion

Treatment with TAM and combination of TAM and SOL did not have significant additional benefits for lower urinary tract symptoms during the early recovery period after TURP.

Development of a predictive model for urgency urinary incontinence

The ability to set realistic expectations of treatment response in patients with overactive bladder (OAB) can have an impact on patient engagement and adherence to study medication. In order to help set treatment expectations for OAB, a Physician Predictive Tool has been developed based on predictive modelling. Models have been developed utilizing data from eight Phase 3 and 4 fesoterodine clinical trials and these models enable the prediction of individual treatment response in subjects with OAB, based on various baseline characteristics. The data utilized and covariates that were hypothesized to influence treatment response are described. The model selection and development process are also outlined, and the final model and some example results utilizing this model are presented. Finally, we discuss the potential benefits and limitations of such a predictive tool.

Safety and tolerability of β3-adrenoceptor agonists in the treatment of overactive bladder syndrome - insight from transcriptosome and experimental studies

INTRODUCTION

We have reviewed the safety and tolerability of β3-adrenoceptor agonists, specifically mirabegron and solabegron, a newly emerging drug class for the treatment of the overactive bladder syndrome. We discuss them mechanistically in the context of expression and other preclinical data.

AREAS COVERED

Based on a systematic PubMed search, incidence of overall adverse events, hypertension, dry mouth, and constipation are comparable between mirabegron or solabegron and placebo. Hypertension is the most frequently observed adverse event, but has a similar incidence with mirabegron and placebo. Nevertheless, severe uncontrolled hypertension has become a contraindication for use of mirabegron based on observation of severe hypertension in association with mirabegron exposure. The overall incidence of adverse events is also similar between mirabegron and the muscarinic receptor antagonist tolterodine, but the incidence of dry mouth is much lower with mirabegron.

EXPERT OPINION

The high β3-adrenoceptor mRNA expression in the human ovaries is not associated with reproductive side effects. Generally, β3-adrenoceptors exhibit a rather restricted expression in human tissues, which may explain the overall good tolerability of agonists acting on this receptor. We propose that expression profiles and functional preclinical studies can be important tools in the prediction of adverse event profiles in first-in-class drugs.

Practical points in the medical treatment of overactive bladder and nocturia in the elderly

The prevalence of overactive bladder (OAB) increases with age. Degeneration of the central nervous system in the elderly has been proposed as one of the pathogenic factors of OAB. Antimuscarinic therapy is effective in the treatment of OAB; however, intolerable systemic adverse events and cognitive dysfunction during treatment with nonselective antimuscarinic agents is of growing concern in elderly patients. The newly developed beta-3 adrenoceptor agonist mirabegron does not adversely affect flow rate and detrusor pressure, and its therapeutic efficacy and tolerability are similar in patients aged > 65 years and > 75 years, suggesting it might be the therapeutic choice in older patients with OAB. Nocturia can cause sleep deprivation at night and increase daytime sleepiness and loss of energy in the elderly. Desmopressin add-on therapy is effective in improving nocturia and storage symptoms. However, elderly patients with a baseline serum sodium level below the normal range are at high risk of developing significant hyponatremia.

Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics

OBJECTIVE

Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice.

METHODS

Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described.

RESULTS

Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years.

CONCLUSIONS

Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.

Overactive bladder

Overactive bladder syndrome is highly prevalent, and increasingly so with aging. It is characterized by the presence of urinary urgency, and can be associated with incontinence, increased voiding frequency, and nocturia. Assessment needs to exclude serious medical disorders that might present with similar symptoms, and a bladder diary is an invaluable part of understanding the presentation. Initial management is conservative, comprising education, bladder training, and advice on fluid intake. Drug therapy options include antimuscarinic medications and beta-3 adrenergic receptor agonists. Persistent overactive bladder syndrome, despite initial therapy, requires a review of the patient’s understanding of conservative management and compliance, and adjustment of medications. For refractory cases, specialist review and urodynamic testing should be considered; this may identify detrusor overactivity or increased filling sensation, and needs to exclude additional factors, such as stress incontinence and voiding dysfunction. Botulinum neurotoxin-A bladder injections can be used in severe overactivity, provided the patient is able and willing to do intermittent self-catheterisation, which is necessary in about 5% of treated patients. Sacral nerve stimulation and tibial nerve stimulation are other approaches. Major reconstructive surgery, such as augmentation cystoplasty, is rarely undertaken in modern practice but remains a possibility in extreme cases.

Clinical use of the β3 adrenoceptor agonist mirabegron in patients with overactive bladder syndrome

Mirabegron is a β3 adrenoceptor agonist licensed for the treatment of overactive bladder symptoms, such as urinary urgency or urgency incontinence. β3 adrenoceptor activation causes detrusor muscle relaxation, but mirabegron may also act by binding other targets in the bladder, and it may also reduce activity in sensory nerves. Phase III clinical trials (SCORPIO, ARIES, and CAPRICORN) evaluated mirabegron at various doses, demonstrating reduction from baseline to endpoint in mean incontinence episodes and mean number of micturitions per 24 h (coprimary endpoints), along with health-related quality of life and a range of secondary measures. Efficacy was seen in many patients who had previously discontinued antimuscarinic therapy on the grounds of lack of efficacy or poor tolerability. Treatment emergent adverse effects were documented in a long-term study (TAURUS), mostly being of mild or moderate severity. The most frequent adverse effects were hypertension, dry mouth, constipation, and headache, with a lower incidence of dry mouth than for the antimuscarinic active comparator. Efficacy and safety are not substantially different in older patients. A urodynamic safety study in men showed no consistent effect on voiding function, but a small increase in postvoid residual. Use of mirabegron in combination with α-adrenergic blockers does not appear to increase adverse effects. Dose reduction is needed in people with severe renal failure, or moderate hepatic failure. Dose adjustment is not needed in relation to food intake. Ongoing research is evaluating the potential for combination therapy with antimuscarinics.

Fesoterodine clinical efficacy and safety for the treatment of overactive bladder in relation to patient profiles: a systematic review

OBJECTIVE

To summarize published evidence on the pharmacology, efficacy, and safety of fesoterodine for the treatment of overactive bladder (OAB) symptoms in relation to patient clinical and demographic profiles.

METHODS

A systematic review of published articles on fesoterodine was conducted via a PubMed search. Articles were identified using the search term fesoterodine, with limits of human species and abstract available. Review and meta-analysis articles, validation studies, articles focused on treatment compliance/adherence, meeting abstracts, and articles not focused on oral fesoterodine administration in human subjects were excluded. Data from retained articles were summarized descriptively.

RESULTS

Of 137 articles identified, 61 (15 articles on the pharmacology and 46 articles on the efficacy and/or safety of fesoterodine) met inclusion criteria. Superiority trials demonstrated the additional efficacy of fesoterodine 8 mg versus fesoterodine 4 mg and tolterodine extended release 4 mg in treating OAB. Prospective trials in specific patient populations indicated beneficial effects of fesoterodine in elderly patients, vulnerable elderly patients, patients dissatisfied with or with a suboptimal response to previous antimuscarinic therapy, patients with urge urinary incontinence (UUI) or nocturnal urgency, and men with persistent LUTS during alpha-blocker treatment. With two effective doses, the fesoterodine dose can be adjusted to achieve optimal efficacy and tolerability in individual patients. The most common adverse events during fesoterodine treatment are dry mouth and constipation.

CONCLUSIONS

Extensive evidence demonstrates the efficacy and safety of fesoterodine in relieving OAB symptoms, including urgency, urinary frequency, UUI, and nocturnal urgency, in patients with various clinical and demographic profiles. Trial results provide valuable information on fesoterodine treatment in specific patient populations, including both elderly and vulnerable elderly patients. Potential limitations of this review are that only English language articles in PubMed were searched and included.

How to choose first-line treatment for men with predominant storage lower urinary tract symptoms: a prospective randomised comparative study

AIMS

To compare the therapeutic effects and identify predictors of successful treatment of first-line antimuscarinic and α-blocker monotherapy for men with predominant storage lower urinary tract symptoms (LUTS).

METHODS

This prospective randomised comparative study included men aged ≥ 40 years with a total IPSS ≥ 8, IPSS storage subscore (IPSS-S) ≥ voiding subscore (IPSS-V) and PVR ≤ 250 ml. Subjects were randomised to receive tolterodine 4 mg or doxazosin 4 mg daily for 12 weeks. The primary end-point included changes of total IPSS, IPSS subscore and global response assessment (GRA) after treatment. The secondary end-points included comparisons of baseline parameters between patients with a GRA ≥ 1 and GRA < 1. All adverse events were also recorded.

RESULTS

This study was completed by 163 patients. The IPSS-T, IPSS-S and quality of life index decreased significantly in both groups. An improved outcome (GRA ≥ 1) at 4 weeks was reported in 51/74 patients (68.9%) receiving doxazosin and 69/89 patients (77.5%) receiving tolterodine. The rate of improved outcome in patients with a TPV < 40 ml was significantly higher in tolterodine group (73.3% vs. 57.6%, p = 0.040). Patients with tolterodine treatment failure (GRA < 1) had higher baseline IPSS-V and IPSS intermittency domain, whereas patients with doxazosin treatment failure had a higher baseline IPSS urgency domain.

CONCLUSIONS

The rate of improved outcome was comparable between first-line tolterodine and doxazosin monotherapy for male storage LUTS. Antimuscarinic monotherapy was suggested for men with smaller prostate volume and higher urgency symptom scores, whereas α-blocker monotherapy was suggested for those with higher voiding symptom scores.

Long-term safety and efficacy of single-tablet combinations of solifenacin and tamsulosin oral controlled absorption system in men with storage and voiding lower urinary tract symptoms: results from the NEPTUNE Study and NEPTUNE II open-label extension

BACKGROUND

Short-term trials have demonstrated the efficacy and safety of combination therapy using antimuscarinics and α-blockers in men with lower urinary tract symptoms (LUTS). The Study of Solifenacin Succinate and Tamsulosin Hydrochloride OCAS (oral controlled absorption system) in Males with Lower Urinary Tract Symptoms (NEPTUNE) II is the first long-term study using solifenacin (Soli) and the oral controlled absorption system formulation of tamsulosin (TOCAS).

OBJECTIVE

To evaluate long-term (up to 52 wk) safety and efficacy of flexible dosing of two fixed-dose combinations (FDC) of Soli plus TOCAS in men with moderate to severe storage symptoms and voiding symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Patients with both storage and voiding LUTS, maximum urinary flow rate of 4.0-12.0 ml/s, prostate size <75 ml, and postvoid residuals ≤ 150 ml, who completed the 12-wk, double-blind NEPTUNE study could continue in the 40-wk, open-label NEPTUNE II study.

INTERVENTION

FDC of Soli 6 mg plus TOCAS 0.4 mg, or Soli 9 mg plus TOCAS 0.4mg; patients could switch between doses in NEPTUNE II.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Safety and efficacy data from NEPTUNE and NEPTUNE II were combined to cover a 52-wk period. Primary efficacy end points were total International Prostate Symptom Score (IPSS) and total urgency and frequency score (TUFS); secondary end points included IPSS storage and voiding subscores, micturition diary variables, and quality of life parameters.

RESULTS

In all, 1066 men completed NEPTUNE and received one dose or more of study medication in NEPTUNE II. Treatment-emergent adverse events were reported in 499 (46.8%) patients who participated in NEPTUNE II; most were mild or moderate. Urinary retention occurred in 13 of 1208 (1.1%) patients receiving one or more FDCs in NEPTUNE and/or NEPTUNE II; 8 (0.7%) required catheterisation (acute urinary retention [AUR]). Reductions in total IPSS and TUFS during NEPTUNE were maintained for up to 52 wk of FDC treatment, with mean reductions of 9.0 (standard deviation [SD]: 5.7) and 10.1 (SD: 9.2), respectively, from baseline to end of treatment. Clinically relevant improvements were also observed for secondary efficacy end points.

CONCLUSIONS

Long-term treatment with FDC Soli plus TOCAS was well tolerated and efficacious in men with storage and voiding LUTS, with a low incidence of AUR.

PATIENT SUMMARY

Treatment with solifenacin plus tamsulosin in a fixed-dose combination tablet was well tolerated by men with lower urinary tract symptoms. Improvements in symptoms were achieved after 4 wk of treatment, with further improvements at week 16 maintained for up to 52 wk throughout the study.

Comparison of alfuzosin 10 mg with or without propiverine 10 mg, 20 mg in men with lower urinary tract symptom and an overactive bladder: randomised, single-blind, prospective study

PURPOSE

The efficacy and safety of treatment with alfuzosin 10 mg plus propiverine 10 or 20 mg in men with lower urinary tract symptoms (LUTS) and an overactive bladder were investigated.

MATERIALS AND METHODS

In this parallel-arm, prospective, multicentre, single-blind study, men who were ≥ 40 years old, had an International Prostate Symptom Score (IPSS) of ≥ 8, an Overactive Bladder Symptom Score (OABSS) of ≥ 3 and an OABSS urgency item score of ≥ 2 were randomised in a 1 : 1 :1 ratio to receive alfuzosin 10 mg alone (Group A) or with propiverine 10 mg (Group B) or 20 mg (Group C) for 8 weeks. Four and 8 weeks after commencing treatment, OABSS was measured along with IPSS, maximal urinary flow rate (Qmax ) and postvoid residual volume (PVR). Adverse events were recorded.

RESULTS

A total of 135 men, including 43 in Group A, 48 in Group B and 44 in Group C, completed the study. Relative to baseline, all groups demonstrated significant reductions in OABSS and the IPSS after eight treatment weeks (p < 0.005). The improvement of OABSS in Group C was significantly greater than Group A and B (Group A: 0.70 ± 1.94; Group B: 2.50 ± 2.98; Group C: 4.30 ± 3.40; p < 0.005). An observed improvement of Qmax and PVR in the three groups did not achieve statistical significance. Overall adverse event rates were higher in Group C but not significant compared with others.

CONCLUSION

In patients with LUTS and overactive bladder, combined therapy with alfuzosin 10 mg plus propiverine 20 mg was significantly more effective than alfuzosin monotherapy and propiverine 10 mg combined therapy in terms of improving OABSS while not significantly affecting Qmax or PVR.

Non-Hormonal treatment of BPH/BOO

OBJECTIVES

To review the use of non-hormonal pharmacotherapies in the treatment of lower urinary tract symptoms (LUTS) due to presumed benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A search of the PUBMED database was conducted for the terms BPH, LUTS, bladder outlet obstruction, alpha-adrenoceptor blockers, anti-muscarinics, and phosphodiesterase-5-inhibitors.

RESULTS

Medical therapy has long been established as the accepted standard of care in the treatment of male LUTS. The aim of treatment is improvement in symptoms and quality of life whilst minimizing adverse effects. The agents most widely used as 1(st) line therapy are alpha-blockers (AB), as a standalone or in combination with 2 other classes of drug; 5-α reductase inhibitors and anti-muscarinics. AB have rapid efficacy, improving symptoms and flow rate in a matter of days, these effects are then maintained over time. AB do not impact on prostate size and do not prevent acute urinary retention or the need for surgery. Anti-mucarinics, alone or in combination with an AB are safe and efficacious in the treatment of bothersome storage symptoms associated with LUTS/BPH. Phosphodiesterase-5 inhibitors are an emerging treatment option that improve LUTS without improving flow rates.

CONCLUSIONS

AB are the most well-established pharmacotherapy in the management of men with LUTS/BPH. The emergence of different classes of agent offers the opportunity to target underlying pathophysiologies driving symptoms and better individualize treatment.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Neurogenic detrusor overactivity in adults: a review on efficacy, tolerability and safety of oral antimuscarinics

OBJECTIVES

This review analyzed efficacy, tolerability and safety of oral antimuscarinic (AM) drugs in adults suffering from neurogenic detrusor overactivity (NDO).

METHODS

A comprehensive search of major literature bases was conducted to identify all references.

RESULTS

Thirty studies, thereof 16 randomized controlled trials (RCT), enrolling 1479 patients were identified and included in the review. Results were grouped in dose-finding, placebo- and active-controlled, flexible dose and combined high-dose AM drugs, and various studies. Key urodynamic outcome parameters, such as maximum detrusor pressure and maximum cystometric bladder capacity, demonstrated the efficacy of AM in NDO, following 2-3 weeks of treatment. Contrary to idiopathic detrusor overactivity (IDO), no placebo effects manifested. Other important parameters, such as impact on the upper urinary tract function and morphology, issues of continence, post-void residual urine, catheterisation, urinary tract infections and quality of life, were investigated to a limited extent only. Incidence rates of adverse events were comparable for NDO and IDO. Most of the studies, especially RCT, were undertaken with oxybutynin immediate release (IR), trospium chloride IR, propiverine IR and propiverine extended release. In NDO, these drugs are best investigated.

CONCLUSIONS

AM drugs are effective in NDO, they normalize the intravesical pressure and increase cystometric bladder capacity. However, other important parameters are not adequately investigated so far and should be recognized in future studies.

Effectiveness of oxybutynin for treatment of hyperhidrosis in overweight and obese patients

OBJECTIVE

Until the present moment, the lack of efficient therapeutic options available for hyperhidrosis treatment in obese patients has left this population without prospect of clinical or quality of life (QOL) improvements. Outcomes of oxybutynin treatment for overweight and obese patients with hyperhidrosis are unknown. This study aims to investigate the results related to clinical and QOL improvements in this specific population, submitted to a 12-week protocol treatment with oxybutynin.

METHODS

559 patients with palmar and axillary hyperhidrosis, routinely followed in this service, were divided into the groups, according to their body mass index (BMI) (<25kg/m(2); 25 < BMI < 30kg/m(2), > 30kg/m(2)). Improvements in QOL and in the level of hyperhidrosis were analyzed after 12 weeks of protocol treatment with oxybutynin. These parameters were investigated using a scoring system based on a scientifically validated clinical questionnaire, applied before and after treatment.

RESULTS

67.8% of the overweight sample group and 63% of the obese patients presented "partial" or "great" improvement in the level of hyperhidrosis. Over 65% of patients demonstrated improvement in QOL ("much better" or "slightly better") for all three groups, with no statistical difference between them. The only adverse event associated with oxybutynin was dry mouth, observed in 63.0% of the patients.

CONCLUSION

Overweight and obese patients with palmar or axillary hyperhidrosis present significant improvement in QOL after treatment with oxybutynin, and the results are comparable to those of normal weight individuals.

TRK-380, a novel selective human β3-adrenoceptor agonist, ameliorates formalin-induced pollakiuria in rats and carbachol-induced bladder contraction in dogs

OBJECTIVE

To investigate the effects of TRK-380, a selective β3-adrenoceptor (β3-AR) agonist, on voiding behavior in rats with pollakiuria and on carbachol (CCh)-induced bladder contraction in dogs.

METHODS

The voiding behavior of female Sprague Dawley rats was recorded continuously with a balance. Rats were intravesically pretreated with 2.5% formalin under isoflurane anesthesia. The next day, the effect of TRK-380 (7.5-30 mg/kg, orally) or tolterodine, an antimuscarinic drug (3.75-15 mg/kg, orally), on the voiding frequency was evaluated. In another experiment, male beagle dogs were anesthetized with pentobarbital, CCh (3 μg/kg, intravenously) was administered to them, and the effect of TRK-380 (0.1 or 0.3 μg/kg/minute, intravenously infusion) on CCh-induced bladder contraction was evaluated.

RESULTS

Rats treated with formalin showed a significant increase in the voiding frequency compared with the sham group, and the increase in it was significantly and dose-dependently suppressed by TRK-380 at doses of ≥15 mg/kg. In contrast, tolterodine did not lead to a significant change in the voiding frequency even at the highest dose. In dogs, CCh-induced bladder contraction was dose-dependently suppressed by TRK-380; the plasma concentration required for 30% suppression of the CCh-induced bladder contraction (30% relaxation) was 4.90 ng/mL.

CONCLUSION

This study indicated that TRK-380 ameliorated pollakiuria, which was resistant to an antimuscarinic drug, and that it also suppressed the bladder contraction induced by cholinergic stimulation in dogs, whose bladder relaxation is known to be predominantly mediated by β3-ARs, as in humans. These data strengthen the therapeutic potential of β3-AR for the treatment of overactive bladder.

Urodynamics and safety of the β₃-adrenoceptor agonist mirabegron in males with lower urinary tract symptoms and bladder outlet obstruction

PURPOSE

Bladder outlet obstruction often presents as storage and voiding symptoms. We investigated urodynamic parameters in men with lower urinary tract symptoms and bladder outlet obstruction treated with the β₃ agonist mirabegron, a new therapy for overactive bladder symptoms.

MATERIALS AND METHODS

A total of 200 men 45 years old or older with lower urinary tract symptoms and bladder outlet obstruction were randomized to receive once daily mirabegron 50 mg (70) or 100 mg (65), or placebo (65) for 12 weeks. The primary urodynamic parameters assessed were change from baseline to end of treatment in maximum urinary flow and detrusor pressure at maximum urinary flow (noninferiority margins -3 ml per second and 15 cm H2O, respectively). We evaluated adverse events and vital signs.

RESULTS

Treatment with mirabegron 50 and 100 mg was noninferior to placebo based on the lower and upper limits of the 95% CI, respectively, for maximum urinary flow and detrusor pressure at maximum urinary flow. The adjusted mean difference vs placebo was 0.40 (95% CI -0.63, 1.42) and 0.62 ml per second (95% CI -0.43, 1.68) for maximum urinary flow, and -5.94 (95% CI -13.98, 2.09) and -1.39 cm H2O (95% CI -9.73, 6.96), respectively, for detrusor pressure at maximum urinary flow. The incidence of adverse events was similar for mirabegron and placebo.

CONCLUSIONS

Mirabegron did not adversely affect voiding urodynamics (maximum urinary flow and detrusor pressure at maximum urinary flow) compared with placebo after 12 weeks of treatment.

Future direction in pharmacotherapy for non-neurogenic male lower urinary tract symptoms

BACKGROUND

The pathophysiology of male lower urinary tract symptoms (LUTS) is highly complex and multifactorial. The shift in perception that LUTS are not sex or organ specific has not been followed by significant innovations regarding the available drug classes.

OBJECTIVE

To review pathophysiologic mechanisms and clinical and experimental data related to the development of new pharmacologic treatments for male LUTS.

EVIDENCE ACQUISITION

The PubMed database was used to identify articles describing experimental and clinical studies of pathophysiologic mechanisms contributing to male LUTS and, supported by them, new pharmacotherapies with clinical or experimental evidence in the field.

EVIDENCE SYNTHESIS

Several pathologic processes (eg, androgen signaling, inflammation, and metabolic factors) and targets (eg, the urothelium, prostate, interstitial cells, detrusor, neurotransmitters, neuromodulators, and receptors) have been implicated in male LUTS. Some newly introduced drugs, such as phosphodiesterase type 5 inhibitors and β3-adrenergic agonists, have just started broad use in clinical practice. Drugs with potential benefit, such as vitamin D3 receptor analogs, gonadotropin-releasing hormone antagonists, cannabinoids, and drugs injected into the prostate, have been evaluated in experimental studies and have progressed to clinical trials. However, safety and efficacy data for these drugs are still scarce. Some compounds with interesting profiles have only been tested in experimental settings (eg, transient receptor potential channel blockers, Rho-kinase inhibitors, purinergic receptor blockers, and endothelin-converting enzyme inhibitors).

CONCLUSIONS

New pathophysiologic mechanisms of male LUTS are described that lead to the continuous development of new pharmacotherapies. To date, few drugs have been added to the current armamentarium, and several are in various phases of clinical or experimental investigation.

Update on the sexual impact of treatment for benign prostatic hyperplasia

There is an established link between lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) and erectile dysfunction (ED). The medical and surgical management of LUTS can affect erectile function (EF), cause ejaculatory dysfunction (EjD) or affect libido. This article will review the effects of these therapies on sexual function.

Bladder health across the life course

Influences on bladder health begin during infancy and continue throughout the lifespan. Bladder anatomy and physiology change as individuals age, and the risk and propensity for bladder conditions, including lower urinary tract symptoms, throughout life are related to factors specific to age, sex, and life events. Bladder habits and dysfunctions at one stage of life may affect bladder health in subsequent stages. However, bladder problems are neither a normal part of aging nor inevitable at any stage of life. Many of the factors that negatively impact bladder health at all ages may be modifiable, and healthy bladder habits may prevent or reverse bladder dysfunctions that can occur naturally or in response to life events. There are opportunities to further define and promote healthy bladder habits through focused research and heightened public awareness of the importance of bladder health, which may lead to improvements in overall health and quality of life. It is our hope that this paper will inform and encourage public health initiatives and research programs aimed at this goal.

International Prostatic Symptom Score-voiding/storage subscore ratio in association with total prostatic volume and maximum flow rate is diagnostic of bladder outlet-related lower urinary tract dysfunction in men with lower urinary tract symptoms

OBJECTIVES

The aim of this study was to investigate the predictive values of the total International Prostate Symptom Score (IPSS-T) and voiding to storage subscore ratio (IPSS-V/S) in association with total prostate volume (TPV) and maximum urinary flow rate (Qmax) in the diagnosis of bladder outlet-related lower urinary tract dysfunction (LUTD) in men with lower urinary tract symptoms (LUTS).

METHODS

A total of 298 men with LUTS were enrolled. Video-urodynamic studies were used to determine the causes of LUTS. Differences in IPSS-T, IPSS-V/S ratio, TPV and Qmax between patients with bladder outlet-related LUTD and bladder-related LUTD were analyzed. The positive and negative predictive values (PPV and NPV) for bladder outlet-related LUTD were calculated using these parameters.

RESULTS

Of the 298 men, bladder outlet-related LUTD was diagnosed in 167 (56%). We found that IPSS-V/S ratio was significantly higher among those patients with bladder outlet-related LUTD than patients with bladder-related LUTD (2.28±2.25 vs. 0.90±0.88, p<0.001). TPV was similar between the two groups; however, in contrast to patients with bladder-related LUTD, patients with bladder outlet-related LUTD had higher detrusor voiding pressure, lower Qmax values, and greater postvoid residual volumes. The combination of TPV≥30 ml and Qmax≤10 ml/sec had a PPV of 68.8% and a NPV of 53.5% for bladder outlet-related LUTD. When IPSS-T≥12 or IPSS-T≥15 was considered as an additional criterion, PPV increased to 75.0% and 78.5%, respectively, and the NPV decreased to 50.9% and 50.2%, respectively. When IPSS-V/S>1 or >2 was factored into the equation instead of IPSS-T, PPV were 91.4% and 97.3%, respectively, and NPV were 54.8% and 49.8%, respectively.

CONCLUSIONS

Combination of IPSS-T with TPV and Qmax increases the PPV of bladder outlet-related LUTD. Furthermore, including IPSS-V/S>1 or >2 into the equation results in a higher PPV than IPSS-T. IPSS-V/S>1 is a stronger predictor of bladder outlet-related LUTD than IPSS-T.