To examine the effects on erectile function of concomitant treatment with an alpha-blocker (tamsulosin) and an antimuscarinic agent (solifenacin) in patients with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH).
Materials and Methods
Fifty-seven male patients with LUTS/BPH were assessed for the degree of LUTS and erectile function. In group 1 (tamsulosin) and group 2 (tamsulosin and solifenacin), changes in the International Prostate Symptom Score [IPSS: total scores, storage symptoms (ST), voiding symptoms (VD), and quality of life (QoL)], prostate-specific antigen, trans-rectal ultrasonography, urine flowmetry, residual urine, and a 5-item version of the International Index of Erectile Function (IIEF-5) were assessed after a 3-month treatment period. In both groups, it was determined whether treatment was associated with changes in LUTS and erectile function and whether improvement in the IPSS was correlated with the IIEF-5. Comparative analysis was also done to examine the linear relationship between improved IPSS scores and IIEF-5 scores.
A comparison of the degree of improvement in all the parameters indicated that both groups showed significant improvement in total IPSS, IPSS-ST, IPSS-VD, and IPSS-QoL (p<0.05). A comparison of the degree of improved sexual function associated with improved LUTS in each patient showed significant improvement in the IIEF-5 score associated with the degree of improvement in the IPSS-ST domain in group 1, but no significant associations were found in group 2. In cases in which tamsulosin was administered, the IIEF-5 score significantly improved as the IPSS-ST domain score improved. In the group in which tamsulosin and solifenacin were concomitantly administered, improvement of the IPSS-ST domain score had no significant effect on the IIEF-5
In patients with LUTS/BPH, tamsulosin and solifenacin combination therapy was effective for LUTS, but erectile function was not significantly improved. Therefore, although effective for improving LUTS, combination therapy with an alpha-blocker and an antimuscarinic agent was not effective for improving erectile function.
Prostatic hyperplasia; Sexual dysfunction, physiological; Solifenacin; Tamsulosin
Objectives. To prospectively examine the efficacy and safety of propiverine hydrochloride in patients with overactive bladder (OAB) symptoms who poorly responded to previous treatment with solifenacin, tolterodine or imidafenacin. Methods. Patients aged ≥20 with persisting OAB symptoms (≥6 in OAB symptom score (OABSS)) even after at least 4-week treatment using solifenacin, tolterodine or imidafenacin were enrolled. Propiverine 20 mg/day was administered for 12 weeks to 70 patients who desired the further improvement of OAB symptoms and 3 who had intolerable adverse events of previous drugs. The OABSS and postvoid residual urine volume (PVR) were determined before and at 4 and 12 weeks of treatment. Results. Of 73 patients enrolled (29 males and 44 females, median age 71 years), 52 completed the protocol treatment. The OABSS was significantly improved by propiverine treatment (9.0 at baseline, 6.2 at 4 weeks, 6.3 at 12 weeks (P < 0.001)). The scores of OAB symptoms (nighttime frequency, urgency and urge incontinence) except daytime frequency also improved significantly. No increase in PVR was observed. The most frequent adverse event was dry mouth (13.7%), followed by constipation (6.8%). Conclusions. Propiverine is useful to improve OAB for patients who poorly respond to solifenacin, tolterodine or imidafenacin.
The overactive bladder (OAB) syndrome is characterized by urgency usually with frequency and nocturia. Tamsulosin, α1-adrenergic receptor antagonist, is widely used to reduce symptoms of urinary obstruction and prostatic hyperplasia. Tamsulosin can across the blood-brain barrier. We investigated the effects of tamsulosin on the symptoms of OAB in relation to neuronal activity using rats.
Adult female Sprague-Dawley rats, weighing 250±10 g (9 weeks old), were used in this study. The animals were divided into five groups (n=8 in each group): control group, OAB-induced group, OAB-induced and 0.01 mg/kg tamsulosin-treated group, OAB-induced and 0.1 mg/kg tamsulosin-treated group, and OAB-induced and 1 mg/kg tamsulosin-treated group. OAB was induced by intraperitoneal injection of cyclophosphamide (75 mg/kg) every third day for 10 days. The rats in the tamsulosin-treated groups orally received tamsulosin once a day for 14 consecutive days at the respective dose of the groups, starting 1 day after the induction of OAB. Cystometry for bladder pressure determination, immunohistochemistry for c-Fos, nicotinamide adenine dinucleotide phosphate-diaphorase histochemistry for nitric oxide synthase (NOS) in the neuronal voiding centers and western blot for inducible NOS in the bladder were conducted.
Cyclophosphamide injection enhanced contraction pressure and time, representing the induction of OAB. Contraction pressure and time were significantly suppressed by tamsulosin treatment. c-Fos and NOS expressions in the neuronal voiding centers were enhanced by induction of OAB. OAB-induced c-Fos and NOS expressions were suppressed by tamsulosin treatment.
Tamsulosin exerts inhibitory effect on neuronal activation in the neuronal voiding centers of OAB. The present results suggest the possibility that tamsulosin is effective therapeutic modality for ameliorating the symptoms of OAB.
Overactive bladder; Cyclophosphamide; Tamsulosin; Rats
There is little data evaluating the changes of severity of bladder outlet obstruction after 80 W-potassium-titanyl-phosphate (KTP) photoselective laser vaporization prostatectomy (PVP) by pressure-flow study. We evaluated the efficacy of PVP to relieve the obstruction in benign prostate hyperplasia (BPH) compared with transurethral resection of the prostate (TURP).
Materials and Methods
This is a prospective, non-randomized single center study. The inclusion criteria were as follows: Men suffering from lower urinary tract symptoms (LUTS) secondary to BPH, age ≥50 years, International Prostatic Symptom Score (IPSS) ≥13, maximum flow rate (Qmax) ≤15 ml/s, and ability to give fully informed consent. Patients with neurogenic cause or detrusor underactivity were excluded. The IPSS, bother score, Qmax, postvoid residual volume (PVR), detrusor pressure at maximum flow rate (PdetQmax), bladder outlet obstruction index (BOOI), and prostate volume were measured before and 6 months after surgery and compared between PVP and TURP.
Sixty-seven patients (53 in PVP, 14 in TURP) were evaluable. In both groups, the IPSS, bother score, Qmax, and PVR had significantly improved (p<0.05), and there were no differences between the changes in those parameters. PVP could effectively reduce the PdetQmax, prostate volume, and BOOI from baseline (from 68.7±23.3 to 40.6±11.2 cmH2O, 49.5±16.3 to 31.3±12.1 ml, 49.8±25.6 to 9.8±20.7), similar to TURP. There were no differences in postoperative PdetQmax, prostate volume, or BOOI between the two groups. The percentage of patients with BOOI ≥40 was decreased from 64% to 4% in the PVP group and from 86% to 14% in the TURP group.
PVP could reduce the prostate volume effectively and relieve bladder outlet obstruction similar to TURP by the 6-month follow up in men with BPH.
Prostatic hyperplasia; KTP lasers; Transurethral resection of prostate; Urinary bladder neck obstruction
Male overactive bladder (OAB) may be caused by prostatic pathologies such as bladder outlet obstruction (BOO). Intravesical prostatic protrusion (IPP) has been found to correlate with BOO and acute urinary retention. We investigated the interrelation between male OAB symptoms and IPP for estimating anatomical changes to the prostate.
Materials and Methods
We assessed 179 consecutive men aged >40 years who presented with lower urinary tract symptoms. The initial evaluation included International Prostate Symptom Score (IPSS) and quality of life assessments, transrectal ultrasonography (TRUS), uroflowmetry, and postvoid residual urine volume. The degree of IPP was determined by the distance from the tip of the protrusion to the circumference of the bladder at the base of the prostate gland. Patients with IPP <0.5 cm were defined as group A (n=114), and patients having 0.5 cm≤IPP<1 cm were defined as group B (n=38). The others were defined as group C (n=27).
A total of 51 patients complained of urgency in group A, 38 patients in group B, and 27 patients in group C. Likewise, 14 patients had a history of acute urinary retention in group A, 8 patients in group B, and 16 patients in group C. IPP grade had a statistically significant relation with both OAB and a history of acute urinary retention.
The results of our study have shown that male OAB is correlated with IPP. However, larger scale studies are needed to confirm these results.
Overactive bladder; Prostatic hyperplasia; Ultrasonography
Lower urinary tract symptoms (LUTS) can have multiple causes in men. Overactive bladder (OAB) is an empirical diagnosis used as the basis for initial management after assessing symptoms, physical findings, urinalysis and other indicated evaluations. In men, the diagnosis is complicated by the potential of benign prostatic hyperplasia (BPH), which is a histological diagnosis. Although storage symptoms (i.e., those associated with OAB) are the most bothersome group of LUTS in men with BPH, these patients are usually treated with BPH rather than OAB drugs. The standard pharmacologic treatment of patients with bothersome voiding and storage LUTS at low risk of progression should be an α1-AR antagonist. The combination α1-AR antagonist + antimuscarinic agent is an appropriate and valid option for male patients with voiding symptoms and persistent storage symptoms.
To assess the measurement properties of the Benign Prostatic Hyperplasia Impact Index (BII) for use in men with Lower Urinary Tract Symptoms (LUTS) secondary to Benign Prostatic Hyperplasia (BPH) treated with tadalafil.
Data from a dose-titration (Study 1) and a dose-finding placebo-controlled (Study 2) tadalafil studies of men 45 years of age or older with moderate to severe LUTS (N = 281; N = 1053) were included in this post-hoc analysis. Measures included the BII, International Prostate Symptom Score (IPSS), IPSS Quality of Life Index (IPSS-QoL), LUTS Global Assessment Question, uroflowmetry measure peak flow rate (Qmax) and postvoid residual volume (PVR). Spearman rank and Pearson correlation coefficients were computed between the BII score and the other measures at each visit. Wilcoxin two-sample tests, t-tests and general linear modeling compared BII scores of subjects with global ratings of improvement versus no improvement, and subjects taking tadalafil versus placebo. Effect size, standardized response mean and Guyatt's responsiveness statistic were calculated for BII and IPSS change scores.
There were high correlations between BII and IPSS & IPSS-QoL and low correlations between BII and Qmax & PVR at each visit. There were significant differences in BII at the End-of-Study Visit between subjects reporting improvement versus subjects reporting no improvement (Studies 1 and 2, P < .0001) and subjects taking tadalafil versus subjects taking placebo (Study 1, P = .0045; Study 2, P = .0064). The BII and IPSS were both responsive to change.
Results show that the BII is reliable, shows responsiveness to change in patients with BPH-LUTS, and demonstrates construct validity.
In order to gain insight into the physicians' awareness of and attitude towards management of overactive bladder (OAB) in males, we performed a nationwide survey of the current strategies that urologists use to diagnose and manage OAB in male patients.
Materials and Methods
A probability sample was taken from the Korean Urological Association Registry of Physicians, and a random sample of 289 Korean urologists were mailed a structured questionnaire that explored how they manage benign prostatic hyperplasia (BPH).
A total of 185 completed questionnaires were returned. The consent rate in the survey was 64.5%. Eighty-one (44%) urologists believed that of all males with lower urinary tract symptoms (LUTS), 20% or more had OAB and 72 (39%) believed that 10-20% had OAB. Half of the urologists surveyed believed that the most bothersome symptom in male OAB patients was nocturia. Seventy-three percent of respondents reported that they prescribed alpha blockers with anticholinergics for first line management, while 19% of urologists prescribed alpha blocker monotherapy but not anticholinergics for OAB patients. Though acute urinary retention (AUR) was considered the anticholinergic adverse event of most concern, the most frequently observed adverse event was dry mouth (95%).
The present study provides insights into urologist views of male OAB. There is a discrepancy between the awareness of urologists and actual patterns of diagnosis and treatment of male OAB. This finding indicates the need to develop further practical guidelines based on solid clinical data.
Overactive bladder; physician's practice patterns; bladder outlet obstruction; benign prostatic hyperplasia; anticholinergics
The aim of this study was to evaluate whether low-dose anticholinergics combined with an α1-receptor antagonist would continue the effect of an alpha-blocker, decrease the side effects of anticholinergics, and improve the symptoms of lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH).
Materials and Methods
Two hundred nine men with LUTS/BPH with storage symptoms (International Prostate Symptom Score [IPSS] ≥12; storage symptoms ≥4) were randomly assigned in a prospective, multicentered, and single-blind fashion to either the control group (alfuzosin 10 mg, once daily) or the combined group (alfuzosin 10 mg, once daily, and propiverine 10 mg, once daily) for 2 months. IPSS, maximal urinary flow rate (Qmax), and postvoid residual volume (PVR) were used to grade symptoms, side effects, and the impact on quality of life (QoL) at the start of the study and after 1 and 2 months.
There were no significant differences in patient background, including age, prostate size, Qmax, and PVR, between the control group and the combined group. In the combined group, the IPSS total score and the IPSS storage symptom score were significantly improved compared with the control group. The IPSS voiding symptom score, QoL, Qmax, and PVR did not differ significantly. There were no serious side effects in either group.
Management with an α1-receptor antagonist combined with a low-dose anticholinergic improved the total score and storage symptom score of the IPSS compared with α1-receptor antagonist only group without causing serious side effects. This initial combination medication can be considered an effective and safe treatment modality for LUTS/BPH patients with storage symptoms.
Cholinergic antagonists; Propiverine; Prostatic hyperplasia
Nocturia is defined as waking one or more times during the night due to the urge to void. Recently, the effectiveness of several sedatives and analgesics for nocturia has been reported. We herein investigated the effects of ramelteon, an antioxidant and sleep inducer, on nocturia unresponsive to α1-blocker monotherapy in males with lower urinary tract symptoms (LUTS) as a pilot study.
Subjects were 19 patients who had LUTS suggestive of benign prostate hyperplasia, received α1-blockers (tamsulosin, silodosin, or naftopidil), and continued to have two or more episodes of nocturia per night before starting ramelteon. Ramelteon at 8 mg once daily for one month was added to the α1-blocker. A self-administered questionnaire including the International Prostate Symptom Score (IPSS), quality of life (QoL) index, Overactive Bladder Symptom Score (OABSS), and Nocturia Quality-of-Life Questionnaire (N-QOL) were assessed before and one month after starting ramelteon.
The mean score on IPSS question 7 (nocturia) decreased significantly from 2.88 before starting ramelteon to 2.41 one month after starting the medication (P = 0.03). The mean total OABSS decreased significantly from 6.31 to 5.38 (P = 0.03), and the mean for OABSS question 2 (nighttime frequency of nocturia) also significantly decreased from 2.63 to 2.13 (P = 0.01). The mean total N-QOL score did not change significantly. Two patients had dizziness; the remaining patients had no adverse drug-related events.
Ramelteon in combination with an α1-blocker could be a treatment option for reducing nocturia in men with BPH.
Ramelteon; Melatonin; Nocturia; Benign prostate hyperplasia; α1-blocker
Most men with benign prostatic hyperplasia (BPH) have bothersome lower urinary tract symptoms (LUTS). This study aimed to investigate the safety and efficacy of high-performance system (HPS) laser photoselective vaporization of the prostate (PVP) for the treatment of BPH in men with detrusor underactivity (DU).
Materials and Methods
From March 2009, 371 patients with BPH were divided into 2 groups according to the findings of preoperative urodynamic study: 239 (64.4%) patients with bladder outlet obstruction (BOO) and 132 (35.6%) patients with bladder outlet obstruction with detrusor underactivity (BOO+DU). 120 W HPS laser PVP was performed to resolve the BOO. The perioperative data and postoperative results at 1 month and 12 months, including the International Prostate Symptom Score (IPSS), maximum urinary flow (Qmax), and postvoid residual urine (PVR) values, were evaluated.
Compared with the preoperative parameters, significant improvements in IPSS, Qmax, and PVR were observed in each group at 1 and 12 months after the operation. In addition, IPSS, Qmax, and PVR were not significantly different between the BOO and BOO+DU groups at 1 and 12 months after the operation.
Surgery to relieve BOO in the patients with BPH seems to be an appropriate treatment modality regardless of the existence of DU.
Bladder dysfunction; Laser therapy; Prostatic hyperplasia
To investigate the relationship of improvement in erectile function (EF) with improvement in lower urinary tract symptoms (LUTS) and to assess the contribution of tamsulosin dose to the improvement of EF apart from the indirect influence of LUTS improvement in men with LUTS and erectile dysfunction (ED).
Materials and Methods
Fifty patients received tamsulosin 0.2 mg/d for the first 4 weeks and were subsequently divided into two groups by patient-reported outcomes. Nonescalators were maintained starting dose and escalators increased to 0.4 mg for the remaining 8 weeks. International Prostatic Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5), and underwent uroflowmetry were evaluated at baseline, and weeks 4 and 12.
LUTS parameters were significantly improved in both groups but insignificant between the 2 groups. The degree of the improvement in the total IPSS and in the voiding, storage, and quality of life (QoL) subscores were significantly correlated with the degree of the improvement in EF; this was especially prominent in patients successfully treated LUTS. The escalators experienced a significantly greater increase in IIEF-5 scores than did the nonescalators (3.3 vs. 1.5).
Dose escalation provided similar LUTS improvement in patients with refractory to starting dose. The improvements of LUTS were correlated with the improvement of EF. The increase in the IIEF-5 score was significantly higher in escalators. These findings imply that tamsulosin may contribute to the improvement in EF through the improvement of LUTS and QoL and direct relaxation of the corpus cavernosum in a dose-dependent fashion.
Erectile dysfunction; Prostatic hyperplasia; Tamsulosin
We evaluated the therapeutic effects of tamsulosin for women with non-neurogenic voiding dysfunction. Women who had voiding dysfunctions for at least 3 months were included. Inclusion criteria were age ≥18 yr, International Prostate Symptom Score (IPSS) of ≥15, and maximum flow rate (Qmax) of ≥12 mL/sec and/or postvoid residuals (PVR) of ≥150 mL. Patients with neurogenic voiding dysfunction or anatomical bladder outlet obstruction were excluded. All patients were classified according to the Blaivas-Groutz nomogram as having no or mild obstruction (group A) or moderate or severe obstruction (group B). After 8 weeks of treatment, treatment outcomes and adverse effects were evaluated. One hundred and six patients were evaluable (70 in group A, 36 in group B). After treatments, mean IPSS, bother scores, Qmax, PVR, diurnal and nocturnal micturition frequencies and scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTS-SF) were changed significantly. Eighty-nine patients (84%) reported that the treatment was beneficial. The proportion of patients reported that their bladder symptoms caused "moderate to many severe problems" were significantly decreased. No significant difference were observed between the groups in terms of IPSS, bother score, Qmax, PVR, micturition frequency, and BFLUTS-SF changes. Adverse effects related to medication were dizziness (n=3), de novo stress urinary incontinence (SUI) (n=3), aggravation of underlying SUI (n=1), fatigue (n=1). Tamsulosin was found to be effective in female patients with voiding dysfunction regardless of obstruction grade.
Urination Disorders; Female; Adrenergic alpha-Antagonists; Outcomes Assessment
Transurethral resection of the prostate (TURP) is a gold treatment method in older men who develop lower urinary tract symptoms (LUTS) which are caused by benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO). The objective of the study was to assess the impact of BPH surgical treatment with TURP method on the quality of life, as a consequence of urinary symptoms.
Material and methods
The research material was based on 40 patients who, due to BPH, were treated with the method of transurethral resection. International Prostate Symptom Score (IPSS) was used in the research i.e. question Nº 8 that relates to the quality of life, as a consequence of the urinary symptoms. The criteria for the patients to be selected for this type of BPH surgical treatment were good general status of the patient, age under 80, the weight of benign prostatic gland hyperplasia tissue 30–80 grams, postvoid residual urine (PVR) higher than 150 ml, IPSS value >19 points, and Index of Quality of Life (IQL) values > 3 points. All patients, first preoperatively, and then postoperatively, gave answers to IPSS IQL in time intervals of 4, 8 and 12 weeks.
Difference testing of IQL arithmetic means (AM) between results before the operation, then during the first, second and third checkup was performed with the t-test and Wilcoxon test of equivalent pairs, and has shown that there is a highly statistically significant difference between preoperative values and the values during all the postoperative checkups. Taking into consideration the age subgroups (20 patients between 59 and 69 years and 20 patients between 70 and 80 years), difference testing of arithmetic means between results before the operation and first, second and third checkup, isolated, for each age subgroup, was carried out. It has demonstrated that there is a statistically significant difference between preoperative values and values during all postoperative checkups. Difference testing of arithmetic means between the stated age groups has also been conducted. The t-test and Mann-Whitney test have been used for this purpose and have shown that there is no statistically significant difference between preoperative test results and the results during all postoperative checkups.
The quality of life, as a consequence of urinary symptoms, has significantly improved after the BPH treatment with TURP method. The impact of TURP on the quality of life is not related to age i.e. TURP is equally efficient regardless of patient’s age.
benign prostatic hyperplasia (BPH); transurethral resection of the prostate (TURP); index of quality of life (IQL).
Overactive bladder (OAB) is a prevalent and costly condition that can affect any age group. Typical symptoms include urinary urgency, frequency, incontinence and nocturia. OAB occurs as a result of abnormal contractions of the bladder detrusor muscle caused by the stimulation of certain muscarinic receptors. Therefore, antimuscarinic agents have long been considered the mainstay of pharmacologic treatment for OAB. Currently, there are five such agents approved for the management of OAB in the United States: oxybutynin, tolterodine, trospium, solifenacin and darifenacin. This article summarizes the efficacy, contraindications, precautions, dosing and common side effects of these agents. All available clinical trials on trospium, solifenacin and darifenacin were reviewed to determine its place in therapy.
overactive bladder; urinary incontinence; pharmacologic management; antimuscarinic agents; anticholinergics
Objectives. Overactive bladder (OAB) is a chronic disease, but comparative trials of anticholinergics, which are commonly used for treatment of OAB, have generally been performed for up to 12 weeks only. There is no comparative study of a long-term intervention. Methods. We conducted a 52-week prospective randomized comparative study to evaluate the efficacy and tolerability of two anticholinergics. Results. Forty-one Japanese patients with untreated OAB were randomly assigned to imidafenacin and solifenacin groups. There was no difference in OABSS and KHQ scores between the two groups, but the severity and incidence of adverse events caused by the anticholinergics showed increased differences between the groups with time. The severity of dry mouth and the incidence of constipation were significantly lower in the imidafenacin group (P = 0.0092 and P = 0.0013, resp.). Conclusions. This study is the first long-term trial to show differences in the properties of anticholinergics that were not detected in short-term studies. Since OAB is a chronic disease, we conclude that imidafenacin is preferable to solifenacin from a perspective of safety.
To evaluate whether intravesical protrusion of the prostate (IPP) is related to the treatment effect of alpha-1 receptor antagonist in patients with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH) with a prostate size of less than 40 g.
A total of 77 BPH patients over 50 years of age treated with alfuzosin (alpha blocker) were enrolled prospectively. The study included only patients with BPH of 40 g or less. The patients were classified into two groups depending on the presence of IPP at baseline: the IPP group (41 patients) and the non-IPP group (36 patients). Prostate volume, prostate-specific antigen (PSA), International Prostate Symptom Score and quality of life (IPSS/QoL), maximum flow rate (Qmax), and postvoid residual (PVR) volume were compared between the groups. The clinical significance of IPP was evaluated after the patients had been taking alfuzosin for 8 weeks.
PSA and IPSS (total and voiding subscore) showed significant correlations with IPP (P<0.05). Comparison of parameters before and after 8 weeks showed that alfuzosin improved the total IPSS and all subscores (P<0.001), QoL (P<0.001), Qmax (P<0.001), and PVR (P=0.030) in the non-IPP group.
Alfuzosin may be less effective in improving symptom scores, PVR, and Qmax in the treatment of LUTS/BPH in the presence of IPP.
Prostate; Lower urinary tract symptoms; Prostatic hyperplsia; Urinary bladder neck obstruction; Adrenergic alpha-1 receptor antagonists
A number of aspects of neural control are potentially important in the control of bladder function, including both sensory and motor and peripheral and central pathways. It is likely that a combination of disorders of both central and peripheral neural mechanisms is important in the genesis of urgency and the other symptoms of the overactive bladder (OAB). Given the number of potential pathways involved, potential pharmacologic targets for OAB exist in the CNS (central nervous system; cerebral cortex, midbrain, spinal cord) and periphery (LUT; lower urinary tract). Antimuscarinics are still the mainstay of OAB treatment, but there are also a number of other potentially efficacious drugs that may also provide benefit against the neurologic components of OAB. This review discusses the impact of neurological abnormalities on lower urinary tract symptoms and the potential for treatments targeting these pathways to improve symptoms.
The prevalence of overactive bladder (OAB) symptoms is considerable in both men and women and the impact on quality of life (QOL) is equally substantial. Ironically, despite nearly equal prevalence, OAB symptoms in men are infrequently treated, and often with medical therapies aimed at bladder outlet obstruction (BOO). In this review, we examine the pathophysiology of OAB and its evaluation in the context of benign prostatic hypertrophy and concomitant BOO. We then consider the efficacy and safety of individual therapeutic options for lower urinary tract symptoms in men, focusing on the mainstays of medical therapy: α-adrenergic blockers, 5-α reductase inhibitors, and antimuscarinic agents. Finally, we aim to comment on new therapeutic strategies and targets that may one day be available for the treatment of male OAB.
anticholinergic; benign prostatic hypertrophy; overactive bladder
Intravesical protrusion of the prostate (IPP) can affect voiding. We evaluated the improvement in lower urinary tract symptoms and patient satisfaction after laser prostate photovaporization in benign prostatic hyperplasia (BPH) patients with or without IPP.
Materials and Methods
This prospective study included 134 patients who underwent GreenLight HPS laser photoselective vaporization prostatectomy (PVP) between January 2010 and July 2011 patient. Preoperative IPP was evaluated by using the retroflexed view from flexible cystoscopy. evaluation included complete medical history, International Prostate Symptom Scores (IPSS), maximum flow rate (Qmax), postvoid residual (PVR), serum prostate-specific antigen (PSA), and transrectal ultrasonogram. Changes from baseline in Qmax, PVR, total IPSS, and IPSS subscores (voiding and storage) were analyzed at postoperative months 1, 3, and 6.
The patients' mean age was 66.6±7.8 years. Mean serum PSA and prostate volume were 1.7±1.5 ng/mL and 42.9±16.7 g, respectively. No significant differences existed between the IPP and no IPP groups in preoperative prostate volume, total IPSS, PSA, or lasing time and energy. The mean follow-up duration was 6.2±1.9 months. IPP patients showed significant improvements in total IPSS and voiding subscores at months 1 and 3. Improvements in the quality of life score and storage subscore were not significantly different between the groups. Qmax was significantly improved at 6 months postoperatively in the IPP group versus the no IPP group.
Among patients who underwent PVP for BPH, the IPP group showed more symptom improvement, especially in voiding symptoms, than did the no IPP group. Preoperative cystoscopy is helpful for evaluating IPP and for anticipating postoperative outcome.
Lasers; Prostate; Prostatic hyperplasia; Transurethral resection of prostate; Urinary bladder neck obstruction
To find the association of trial without catheter (TWOC) outcome for first spontaneous acute urinary retention (AUR) in benign prostatic obstruction with age, prior lower urinary tract symptoms (LUTS), retention volume at catheterization (RV), and size of prostate.
Our prospective observational analytical (interventional) study enrolled 77 cases of spontaneous AUR over 24 months. After clinical evaluation, digital rectal examination, and transabdominal ultrasonography, all patients were catheterized per urethra and their RV was recorded. TWOC was administered after 2 or 3 doses of 0.4 mg tamsulosin-oral absorption control system and after 48-72 hours had passed. A successful endpoint was defined as a maximum flow-rate, >5 mL/sec; voided volume, >100 mL; postvoid residue, <200 mL; and voiding within 6 hours of catheter removal. Data obtained from 58 patients were analyzed after excluding the cases lost to follow-up and secondary exclusion. Age, RV, duration of LUTS, and prostate volume on examination and ultrasonography (PUSG) were recorded and statistically analyzed. Prostate-specific antigen levels were obtained on follow-up and cases of cancer, as seen on transrectal ultrasound-guided biopsy, were secondarily excluded.
The patients had a mean age of 65.89±8.67 years. Prior LUTS was seen in 35 patients (2.07±2.91 months). The mean PUSG and RV were 46.81±20.58 mL and 854.8±36.26 mL, respectively. Thirty patients underwent a successful TWOC; a mean age of 63.13±8.58 years (mean±standard deviation; unpaired t-test; P=0.0053) and a PUSG of ≤45 mL (Pearson chi-square test; P=0.0427) were significantly associated with a successful outcome.
There is a significant association between TWOC outcome, age (P=0.0053), and PUSG (P=0.0427).
Urinary retention; Tamsulosin; Urination disorders
To evaluate the clinical factors that impact ureteral stent-related lower urinary tract symptoms (LUTS) after ureteroscopic ureterolithotomy, including the stent position and medication.
Materials and Methods
Fifty-three patients who underwent ureteroscopic ureterolithotomy with indwelling a stent were distributed into three groups. On demand analgesics were given to the group 1 (n=18). Daily tamsulosin 0.2 mg was added for group 2 (n=15) and daily tamsulosin 0.2 mg and tolterodine 4 mg was added for group 3 (n=20). The patients were also subclassified into appropriate or inappropriate group according to stent position. All the patients completed a visual analogue scale (VAS) and International Prostate Symptom Score (IPSS) on the 1st and 7th postoperative days. The VAS and IPSS were analyzed according to the medication groups and the stent position.
In the appropriate stent potion group, only the storage symptom scores of groups 2 and 3 on the 1st postoperative day were significantly lower than those of the group 1 (p=0.001). This medication effect on LUTS was not observed in the inappropriate stent position group. In this group, total IPSS (p=0.015) and storage symptom scores (p=0.002) were higher than in the appropriate stent position group on the 7th postoperative day.
Correct placement of the stent was more important than medication for lessening stent-related storage symptoms.
Adrenergic alpha-antagonists; Cholinergic antagonists; Ureteroscopy; Urinary catheterization; Urological manifestations
To evaluate the efficacy and tolerability of tamsulosin 0.4 mg once daily in Korean patients with symptomatic benign prostatic hyperplasia (BPH) and investigate whether tamsulosin 0.4 mg can improve symptoms in patients with refractory lower urinary tract symptoms (LUTS) who were previously receiving tamsulosin 0.2 mg once daily.
Materials and Methods
A total of 116 patients from 3 urology centers participated. All study subjects entered a nonblind phase consisting of 8 weeks of tamsulosin 0.2 mg monotherapy followed by an additional 8 weeks of tamsulosin 0.2 mg (0.2 mg group) or 8 weeks of tamsulosin 0.4 mg (0.4 mg group). At week 8, we chose the 0.4 mg group on the basis of International Prostate Symptom Score (IPSS), quality of life (QoL), maximal urinary flow rate (Qmax), and adverse effects. At week 16, we compared the efficacy and tolerability of tamsulosin between the 0.2 and 0.4 mg groups.
A total of 26 patients (22.4%) were escalated to tamsulosin 0.4 mg at week 8. There were significant differences in IPSS, QoL, and Qmax at week 8 in both groups. There were significant differences in improvement in IPSS, QoL, Qmax, and postvoid residual urine volume from baseline to week 16 in both groups. There were no significant differences in efficacy or tolerability between the groups at week 16.
Our trial demonstrated that tamsulosin 0.4 mg has favorable efficacy and tolerability in Korean patients with symptomatic BPH refractory to tamsulosin 0.2 mg. No patients experienced any serious adverse effects when we escalated the dose of tamsulosin to 0.4 mg.
Prostatic hyperplasia; Tamsulosin
Comparison of efficacy of propiverine extended release (ER) 30 mg o.d. in the treatment of male OAB administered as monotherapy (MT) or add-on to α-blockers (combination treatment, CT) in relation to maximum urinary flow (Qmax) in a non-interventional study.
Men ≥40 years with OAB symptoms, Qmax ≥10 ml/s, prostate volume <40 ml, post-void residuals (PVR) <100 ml, and IPSS <20 were included. OAB symptoms, IPSS, and PVR were recorded before and after 12 weeks of treatment. Participants were stratified by Qmax (group A ≥15 ml/s, group B <15 ml/s) and CT vs. MT. Safety parameters were monitored.
A total of 2,219 men participated and were involved in safety analysis; 1,849 men (mean age 66 years) fulfilled the inclusion criteria and were involved in efficacy analysis. In group A, 291 men received MT and 479 CT; in group B, 184 men received MT and 895 CT. OAB symptoms improved significantly in all groups throughout the study without differences between MT and CT. IPSS improvement in group B was less with MT than with CT (−3.9 vs. −5.2; P < 0.001), whereas IPSS improvement was similar in group A (−4.6 vs. −5.1). Mean PVR change was not clinically relevant, but two men (0.1%) experienced urinary retention.
Under real-life conditions, treatment of OAB symptoms with propiverine ER is equally effective in men with MT or CT regardless of baseline Qmax. In men with reduced Qmax, IPSS improvement is significantly smaller with MT. The incidence of urinary retention during propiverine ER treatment is low.
Lower urinary tract symptoms; Overactive bladder syndrome; Cholinergic antagonists; Adrenergic α-antagonists; Urinary retention; Propiverine hydrochloride
Purpose. To evaluate the effects of chlormadinone acetate (CMA), progesterone-derived antiandrogen, on lower urinary tract symptoms (LUTS) and erectile functions of benign prostatic hyperplasia (BPH). Methods. A multicenter, single-cohort prospective study was conducted. A total of 114 patients received CMA for 16 weeks. The endpoints were changes in International Prostate Symptom Scores (IPSS), IPSS-QOL, International Index of Erectile Function-5, Qmax prostate volume, and residual urine volume. Results. Significant improvements were observed in IPSS from week 8 to week 48 (32 weeks after treatment). IPSS-QOL improvements were also significant from week 8 to week 48. Qmax increased to a maximum at Week 16 and remained elevated throughout the study. Moreover, a decrease of 25% in prostate volume was observed at Week 16. IPSS, QOL, and Qmax changes during the study were not different between the previously treated and untreated patients. IPSS storage subscore changes differed between the age groups. Few severe adverse reactions were observed, except for erectile dysfunction. Conclusions. CMA rapidly and significantly reduced prostate volume and improved voiding and storage symptoms and QOL. Our results suggest that CMA is safe and beneficial, especially for elderly patients with LUTS associated with BPH.