Lower urinary tract symptoms, benign prostatic hyperplasia, erectile dysfunction, and phosphodiesterase-5 inhibitors

Many patients who present to their healthcare provider with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) will also have erectile dysfunction (ED), and vice versa. Although alpha-adrenergic receptor blockers and 5-alpha-reductase inhibitors are highly effective in treating BPH-associated LUTS, these agents have sexual adverse effects that cause many men to discontinue therapy. The discovery of nitric oxide as a major factor in the mechanism of erection has led to the development of new drugs for ED, including the phosphodiesterase (PDE) inhibitors. Preliminary data support the theory that inhibition of PDE isoenzymes in the prostate may improve LUTS due to BPH through relaxation of prostatic smooth muscle. Further studies of PDE inhibitors in men with ED and BPH-associated LUTS are indicated.     

Phosphodiesterase type 5 inhibitors for the treatment of male lower urinary tract symptoms

Both lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) and erectile dysfunction have a very high prevalence among aging men, and there is some clinical evidence that they may share a common pathophysiology. Consequently, several preliminary studies of phosphodiesterase type 5 inhibitors-sildenafil and tadalafil-have recently been conducted in men with concomitant erectile dysfunction and lower urinary tract symptoms to determine whether these agents are effective for the treatment of symptomatic BPH. These studies have demonstrated efficacy, both alone and in combination with an alpha-blocker, in treating lower urinary tract symptoms along with sexual dysfunction. However, larger-scale randomized studies are necessary to determine long-term safety, efficacy, and cost effectiveness.     

Landmark studies impacting the medical management of benign prostatic hyperplasia

The treatment of benign prostatic hyperplasia (BPH) has changed dramatically over the past 10 years. Phase 3 studies of the safety and effectiveness of alpha-blockers (eg, terazosin and doxazosin) and 5-alpha-reductase inhibitors (eg, finasteride) for the treatment of BPH began to appear in the literature in 1992. This article reviews the results of landmark studies of these agents, either separately as monotherapy or as combined therapy, for the treatment of BPH. The relationship between prostate size and lower urinary tract symptoms (LUTS) is discussed. Although prostate volume is not as strongly correlated with these symptoms as was once believed, it has been shown to be an important predictor of risk for developing acute urinary retention. alpha-Blockers represent an effective treatment for LUTS independent of prostate volume; the clinical benefit of finasteride for LUTS is limited primarily to men with large prostates. Finasteride decreases the risk of progression to acute urinary retention and the requirement for surgical intervention; this benefit is greatest in men with enlarged prostates.     

Interstitial cystitis and lower urinary tract symptoms in males and females-the combined role of potassium and epithelial dysfunction

Evidence of a lower urinary tract dysfunctional epithelium has been detected in women and men with interstitial cystitis and other complexes of lower urinary tract symptoms. Lower urinary tract dysfunctional epithelium can affect the bladder, the urethra, the labia or vaginal introitus in women, and the prostatic ducts and urethra in men. Because an individual with lower urinary tract dysfunctional epithelium may experience pain in one or more locations throughout the pelvis in any combination, the clinician cannot reliably establish a diagnosis based on "where it hurts." A useful diagnostic tool is the intravesical potassium sensitivity test, which detects the abnormal epithelial permeability of lower urinary tract dysfunctional epithelium. In most cases, lower urinary tract dysfunctional epithelium can be treated successfully.     

Medical therapy for benign prostatic hyperplasia: new terminology, new concepts, better choices

This article discusses 3 areas of medical therapy for benign prostatic hyperplasia (BPH) that are undergoing extensive research and evaluation: 1) the use of muscarinic receptor antagonists to treat lower urinary tract symptoms (LUTS) in men with BPH; 2) the definition of an "enlarged prostate"; and 3) sexual function and LUTS. Fears of worsening obstructive symptoms or causing acute urinary retention often keep practitioners from prescribing muscarinic receptor antagonists to men who might have concomitant bladder outlet obstruction; a multicenter, multinational, double-blind study showed that tolterodine is safe for men with low postvoid residual volumes. Most urologists accept that a prostate volume of more than 40 mL is consistent with an enlarged prostate; there is more debate regarding prostate volumes of 30 to 40 mL. Recently presented data suggest that combination medical therapy might be effective for men having prostates with volumes of more than 25 mL. The association between voiding and sexual function has been increasingly recognized and investigated, and there seem to be common pathophysiologic mechanisms governing both conditions. Targeted treatment algorithms addressing both conditions seem warranted.     

Medical treatment of benign prostatic hyperplasia

Medical therapy for the treatment of benign prostatic hyperplasia (BPH) became an accepted standard of care in the 1990s following the reports of randomized, double-blind, placebo-controlled studies showing that finasteride, a 5-α reductase inhibitor, and terazosin, an α-blocker, significantly improved lower urinary tract symptoms and increased peak urinary flow rates in men with BPH. This article reviews novel approaches to the pharmacological treatment of BPH.     

Evaluating men with benign prostatic hyperplasia

The clinical manifestations of benign prostatic hyperplasia (BPH) include lower urinary tract symptoms (LUTS), poor bladder emptying, urinary retention, detrusor instability, urinary tract infection, hematuria, and renal insufficiency. However, the majority of men with BPH present with LUTS only. Because LUTS can indicate a variety of conditions, evaluation of symptomatic men must first aim to identify or exclude BPH and, if present, assess its severity. It is important to assess symptom severity at baseline and during follow-up, using the American Urological Association Symptom Index or the International Prostate Symptom Score. Further testing can then be tailored to narrow the diagnosis and guide treatment decisions. Factors such as patient age and concomitant malignancy will also affect management, but the main goal of treatment remains the improvement of quality of life for the patient.     

Is There a Role for alpha-Blockers for the Treatment of Voiding Dysfunction Unrelated to Benign Prostatic Hyperplasia?

alpha-Adrenoreceptor antagonists have become the primary medical treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). It was presumed that the primary mechanism by which alpha-blockers reduced lower urinary tract symptoms (LUTS) was by relaxation of smooth muscle in the prostate through a sympathetic response. Reduction of outlet resistance leads to changes in bladder function, thus improving both storage and voiding symptoms. However, it was observed that many patients with BPH-associated LUTS had significant improvement in storage symptoms without subjective or objective improvement in voiding. Storage symptoms associated with detrusor overactivity (frequency, urgency, and urge incontinence) are typically thought of as being parasympathetically mediated, and therefore anticholinergic medications have been the mainstay of pharmacological treatment, but recent work has suggested that several nonparasympathetic-mediated mechanisms may cause detrusor overactivity. Because alpha receptors appear to play a role in lower urinary tract function at multiple sites and levels, alpha-blockers could be used to treat voiding dysfunction not related to BPH. In addition, these nonprostate effects should be gender-independent, making the use of alpha-blockers plausible in women with specific types of voiding dysfunction.     

Epidemiology of urinary tract diseases in general practice

During a one-year morbidity survey of urinary tract diseases in general practice 741 cases were diagnosed. Only about half of all the patients with symptoms of urinary tract infection had significant bacteriuria. In young women urinary tract infections and symptoms from the urinary tract without bacteriuria—in particular urethritis—were found to predominate. In middle-aged women, the urinary tract symptoms were ascribed increasingly to genital prolapse, while incidence of urolithiasis was the highest in any group, and urinary tract infections became less frequent. The prevalence of urinary tract infection showed another increase in elderly women, and recurrent/chronic pyelonephritis, which occurs with a steadily increasing prevalence throughout all age groups, became common.In younger male urological patients diseases with symptoms of urinary tract infection without bacteriuria were predominant, whereas prostatitis and urinary tract infections were less frequent. In middle-aged men, urolithiasis was especially frequent, while an increasing proportion of elderly men had prostatic hypertrophy, urinary tract infections, and recurrent/chronic pyelonephritis.     

Clinical results of the treatment of bacterial infections in children with ceftazidime

Ceftazidime (Fortum-Glaxo) was administrated to 19 children with urinary tract infections and to 21 children with pneumonia. Clinical symptoms of the infections resolved in 17 children (89%) with the urinary tract infections treated with ceftazidime within 4 days. The remaining children (11%) recovered after 7 days of therapy. Clinical symptoms of pneumonia resolved in 19 children (90%) within 7 days of the treatment. A significant improvement was achieved in the remaining 2 children after 10 days of the treatment.     

Current medical therapies for men with lower urinary tract symptoms and benign prostatic hyperplasia: achievements and limitations

Over the last 20 years, our understanding of the pathophysiology and symptomatology of men with lower urinary tract symptoms (LUTS) has become increasingly more sophisticated. With this increase in sophistication, our utilization of various medical therapies, either alone or in combination, has also increased the understanding of the roles of individual medications, combinations of medications, and the benefits of different types of intervention. The rapid decline of the use of transurethral resection of the prostate (TURP) and other surgical procedures for benign prostatic hyperplasia (BPH) in the 1990s is due in part to the introduction of medical therapy. This article reviews the current state of medical therapy for men with LUTS and highlights its promises and its current limitations.     

Quality of life and sexual function in patients with benign prostatic hyperplasia

Incidence of benign prostatic hyperplasia (BPH), one of the most common conditions affecting adult men, increases dramatically after the age of 50. The various symptoms of BPH, which include lower urinary tract symptoms (LUTS), can adversely affect quality of life (QOL). Many men with BPH and LUTS wait until symptoms become significantly bothersome before seeking medical attention. Evaluating the exact severity and significance of symptoms has been difficult with previous methodology. Over the last decade, assessment tools have become available to quantify the symptoms of BPH and LUTS. This article addresses the impact of BPH, its management, and the overall effects it has on QOL.     

Results of ciprofloxacin therapy in urinary and respiratory tract infections

Ciprofloxacin was administered to 218 patients with various urinary and respiratory tracts infections, including 142 patients with urinary tract infections and 76 patients with respiratory tract infections. Bacteriological tests and routine laboratory tests were performed thrice (before, during and after therapy) in all patients. Ciprofloxacin was administered orally in daily dose of 500 mg for 10 days. Daily dose was increased to 1000 mg in 23 patients with severe respiratory tract infections. Satisfactory results (recovery or regression of the symptoms of exacerbated chronic disease) were achieved in 185 patients (84.9%) and no effect in 10 patients (4.6%). Significant improvement or transient improvement were noted in 23 patients (10.5%).     

Steroid 5 α-reductase inhibitors targeting BPH and prostate cancer

Steroid 5 alpha-reductase inhibitors (5ARIs) have been approved for use clinically in treatment of benign prostate hyperplasia (BPH) and accompanying lower urinary tract symptoms (LUTS) and have also been evaluated in clinical trials for prevention and treatment of prostate cancer. There are currently two steroidal inhibitors in use, finasteride and dutasteride, both with distinct pharmacokinetic properties. This review will examine the evidence presented by various studies supporting the use of these steroidal inhibitors in the prevention and treatment of prostate disease. Article from the Special issue on Targeted Inhibitors.     

Preventing progression in men with mild symptoms of benign prostatic hyperplasia: a potential role for phytotherapy

Prevalence of benign prostate hyperplasia (BPH) is increasing with the aging population worldwide. Throughout the 20th century, men with minimally symptomatic BPH were generally advised to defer treatment. Treatment deferral or watchful waiting has always appeared reasonable because mild lower urinary tract symptoms suggestive of bladder outlet obstruction are not bothersome and are often regarded as part of the aging process, progression is usually slow, and symptoms often regress spontaneously. This review examines the evidence of the natural history of BPH, highlighting the group of patients with mild symptoms, the risk factors for progression, and the potential role of phytotherapy in this group of men.     

The controversies regarding the role of estrogens in urogynecology

Estrogens are crucial for the proper functioning of genitourinary tract. Hypoestrogenism related to menopause could be linked to numerous disturbances of lower urinary tract. However, the results of most well designed clinical studies do not support use of estrogen or hormone replacement therapy for the treatment of genitourinary symptoms. According to evidence base medicine stress urinary incontinence, overactive bladder syndrome or pelvic organ prolapse are best treated by the surgery or non-hormonal drug therapy.     

Prevalence of spina bifida occulta in patients with functional disorders of the lower urinary tract and its relation to urodynamic and neurophysiological measurements.

OBJECTIVE--To determine the relation between neurophysiological abnormalities and the radiological detection of spina bifida occulta in patients with dysfunction of the lower urinary tract. DESIGN--Blind assessment and subsequent decoding of mixed batch of abdominal radiographs from patients with and without urological symptoms for evidence of spina bifida occulta and comparison of results with those of previous control series. SETTING--Review study among tertiary referrals to an incontinence clinic of a city hospital. PATIENTS--One hundred and thirty eight adults with proved urodynamic abnormalities in whom neurophysiological measurements were available. INTERVENTIONS--None. END POINT--Correlation of neurophysiological abnormalities in lower urinary tract dysfunction with presence and type of spina bifida occulta and level of opening of posterior sacral arcs. MEASUREMENTS AND MAIN RESULTS--On decoding radiographs those from patients without urological symptoms showed a similar prevalence of spina bifida occulta to that in the control series (631/2707 controls; 23%). By contrast, patients with urological symptoms had a significantly increased prevalence of spina bifida occulta at S1 and S2 and a higher level of opening of posterior sacral arcs. The increased prevalence of the bony defect was particularly striking in men with urgency and instability and in women with stress incontinence. No significant correlation was found between any particular neurophysiological abnormality and the presence of spina bifida. CONCLUSIONS--In patients with dysfunction of the lower urinary tract neurophysiological abnormalities may be associated with congenital dysraphic lesions in the lower lumbar spine and sacrum. There appears to be no direct causal relation between the radiological and neurophysiological abnormalities but the findings suggest a common aetiological factor.     

Optimizing Diagnostic Accuracy and Treatment Decisions in Men With Testosterone Deficiency

ObjectiveThis narrative review offers a guideline-based approach for optimizing diagnostic evaluation and treatment decision making in men being evaluated for testosterone deficiency.MethodsA narrative review.ResultsTestosterone deficiency is a clinical syndrome that results from the inability of the testes to produce normal amounts of testosterone and is characterized by a constellation of symptoms and signs associated with consistently low testosterone concentrations. The diagnosis of testosterone deficiency is made by the ascertainment of symptoms and signs; the measurement of total and, if indicated, free testosterone levels in early-morning fasting samples on ≥2 days; the measurement of luteinizing hormone and follicular-stimulating hormone levels to distinguish primary from secondary hypogonadism; and an additional evaluation to ascertain the cause of testosterone deficiency. Nonspecificity of symptoms and signs, variations in testosterone levels over time, inaccuracy in the measurement of total and free testosterone levels, variations in binding protein concentrations, and suboptimal reference ranges contribute to diagnostic inaccuracy. Testosterone treatment is indicated for men with symptomatic testosterone deficiency. Testosterone treatment should be avoided in men with prostate or breast cancer, erythrocytosis, thrombophilia, increased risk of prostate cancer or severe lower urinary tract symptoms without prior urologic evaluation, a recent major adverse cardiovascular event, uncontrolled heart failure, or severe untreated sleep apnea. Testosterone replacement therapy should be accompanied by a standardized monitoring plan.ConclusionA shared decision of the patient and physician to treat should be guided by the consideration of the burden of symptoms, potential benefits and risks, patient’s values, and the cost and burden of long-term treatment and monitoring.     

Ciprofloxacin and therapy of urinary tract infections, including those due to Staphylococcus saprophyticus]

Staphylococcus saprophyticus is one of the main pathogens of cystitis in young women. The human biotopes are contaminated by the staphylococcus on direct contacts with domestic animals or after using not properly cooked food of animal origin. Young women are more susceptible to colonization of the urinary tract by S. saprophyticus vs. the other contingents. Sexual intercourse is conducive to the colonization and infection. Shifts in the urinary tract microflora due to the use of spermicide, as well as candidiasis promote colonization of the urinary tract by S. saprophyticus. At present fluoroquinolones are considered as a significant independent group of chemotherapeutics within the class of quinolones, inhibitors of DNA gyrase, characterized by high clinical efficacy in the treatment of urinary tract infections. Especially significant clinical experience with ciprofloxacin in the therapy of urinary tract infections is available.     

Investigation of interaction phenomena between lower urinary tract and artificial urinary sphincter in consideration of urethral tissues degeneration

Biomechanics and Modeling in Mechanobiology - Lower urinary tract dysfunction pertains to symptoms related to the lower urinary tract (LUT), with consequent incontinence. Artificial urinary...