Symptoms and signs of prostatism as risk factors for prostatectomy

Study of correlation of urodynamic profile with symptom scoring and ultrasonographic parameters in patients with benign prostatic hyperplasia

Context:

Urodynamic study (UDS) and ultrasonography (USG) both are established investigations to assess the patients of benign prostatic hyperplasia (BPH). It is known that the prostate mass (PM) and post-void residual urine volume (PVR) are not significantly related to the patients' symptoms and degree of obstruction; however, the relation between the UDS, USG and patient's International Prostate Symptom Scoring (IPSS) has not been defined.

Aims:

To correlate the urodynamic parameters with IPSS, PM and PVR in patients with lower urinary tract symptoms (LUTS) suggestive of BPH.

Settings and Design:

An observational study carried out as a thesis project.

Methods and Materials:

Thirty male patients aged more than 40 years with LUTS suggestive of BPH were selected and underwent USG, UDS and IPSS. In UDS, the parameters studied were the maximum flow rate (Q_max), detrusor pressure (P_det) and bladder compliance (BC). PM and PVR were studied in the USG.

Statistical Analysis Used:

IBM Statistical Package for the Social Sciences (SPSS) software version 16 (SPSS Inc., Chicago, USA). Pearson's correlation and two-sided significance levels were determined.

Results:

1. Significant negative correlation between Q_max and PVR_USG (r = −0.404, P = 0.027); PM_USG (r = −0.655, P = <0.001) and IPSS (r = −0.563, P = 0.001). 2. Significant positive correlation between P_det and PVR_USG (r = 0.535, P = 0.002); PM_USG (r = 0.719, P = <0.001) and IPSS (r = 0.649, P = <0.001). 3. Significant negative correlation between BC and PVR_USG (r = −0.490, P = 0.006); PM_USG (r = −0.654, P = <0.001) and IPSS (r = −0.667, P = <0.001).

Conclusions:

UDS has a significant correlation with IPSS and USG findings and urodynamic parameters give a more specific diagnosis in BPH patients when it is combined with USG and IPSS.

Lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction: from physiology to clinical aspects

Erectile dysfunction, prostatic hyperplasia and lower urinary tract symptoms hare important pathogenetic links. Endothelial dysfunction and hormonal alterations represent the main aspects. The present article examines the anatomical, physiological, and pathophysiological characteristics of this association, finalizing the text to an interpretation of the clinical management of these patients based on these functional considerations.

Effects of running distance and performance on incident benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia (BPH) is generally not considered a preventable condition. Our goal is to assess whether running (a vigorous physical activity) and 10-km race performance (an indicator of cardiorespiratory fitness) reduce BPH risk.

METHODS

Prospective cohort study of incident BPH in 28,612 nonsmoking, nonvegetarian, nondiabetic men.

RESULTS

The 1899 men (6.64%) reported physician-diagnosed incident BPH during (mean +/- SD) 7.74 +/- 1.84 yr of follow-up. Survival analyses showed significantly lower risk with both longer distance run (km x wk(-1); P < 0.0001) and faster 10-km performance (m x s(-1); P = 0.0004) independent of age, BMI, and meat, fish, fruit, and alcohol intake. When adjusted for age, the fastest men (> or =4.0 m x s(-1)) had 32% lower risk than the slowest men (<3 m x s(-1); P = 0.0006). The decline in incidence extended throughout the performance range, with even the fastest category (> or =4 m x s(-1)) having significantly lower risk than the penultimate fastest category (3.5-4.0 m x s(-1); P = 0.03). The decline in BPH risk with running distance was independent of performance. BPH incidence was more strongly related to the average of the baseline and the follow-up distance run than to concurrent changes in running distance between baseline and follow-up. Incident BPH was significantly lower in men who ran >16 than <16 km x wk(-1) (P = 0.05), >32 than 16-32 km x wk(-1) (P = 0.02), and >48 than 32-48 km x wk(-1) (P = 0.04).

CONCLUSIONS

Greater distances run per week may reduce BPH risk independent of BMI, 10-km performance, and diet. If the relationship is causal, then this health benefit accrues at greater exercise doses and intensities than the minimum guideline levels currently recommended.

Natural course of lower urinary tract symptoms following discontinuation of alpha-1-adrenergic blockers in patients with benign prostatic hyperplasia

OBJECTIVE

alpha1-adrenergic blockers (alphab) remain the first-line therapy in men with lower urinary tract symptoms (LUTS). The current published work advocates continued use of alphab for their effect to be maintained. However, some patients decide to discontinue use of the medication after their symptoms are relieved and can keep good conditions. In this study, we investigated the natural course of LUTS after the discontinuation of successful treatment of alphab.

METHODS

Among 75 patients with LUTS who stopped alphab medication once their symptoms improved, 60 patients (age, 50-87 years; median, 70) who could be followed for at least 12 months after discontinuation of alphab were analyzed in this study. Evaluations included a clinical determination of the International Prostate Symptom Score (IPSS), peak flow rate (Qmax) and postvoid residual urine volume (PVR). Upon patient request or in cases of PVR more than 100 mL, administration of alphab was resumed.

RESULTS

Eighteen out of the 60 patients (30%) asked for re-treatment within 12 months after discontinuation (re-treatment group). The other 42 patents were able to maintain good condition without medication (discontinuation group). The IPSS was 15.9, 8.7, 10.1, 10.2, 9.7, 8.8 and 9.0, on the first visit, just before discontinuation, and 1, 3, 6, 9 and 12 months after stopping treatment among the discontinuation group, respectively. Similarly, Qmax was 10.6, 14.8, 14.2, 14.3, 14.7, 13.2 and 13.6 mL/ s, respectively. Treatment periods, prostatic volume and peak flow rates just before discontinuation of medication differed significantly between the re-treatment and discontinuation group.

CONCLUSIONS

In spite of the short follow-up periods, these results suggest that selected patients with relatively small prostatic volume and good flow rates after therapy can discontinue alphab medication after their symptoms improve.

Managing the progression of lower urinary tract symptoms/benign prostatic hyperplasia: therapeutic options for the man at risk

There are two fairly divergent reviews in this month's issue. The first is a paper which concentrates on the progression of LUTS and BPH. Previous papers on LUTS and BPH were focused on changes in urinary flow rates and symptom scores, a rather static view of things. The first author in this review introduced the concept of dynamic variables in LUTS and BPH, and this, along with the idea of progression of the disease which the MTOPS study brought to our notice, has lead to a major change to our approach to trials of therapy in LUTS and BPH. The second review is really statement of a theory, an expression of a concept being proposed by the author, which hopefully will be of interest to the reader. In benign prostatic hyperplasia (BPH), increased prostate volume has been shown to be associated with future symptom deterioration and progression to acute urinary retention (AUR) or BPH-related surgery. Dihydrotestosterone (DHT) is the primary androgen responsible for prostate growth. Inhibition by 5alpha-reductase inhibitors (5-ARIs) of the enzyme responsible for the production of DHT decreases prostate volume. This translates to an overall improvement in symptoms and a reduction in the risk of AUR and/or BPH-related surgery. Selective blockage of alpha(1)-adrenoceptors, principally in the region of the prostate, results in rapid symptom relief for the patient but this does not translate into a long-term reduction in the risk of AUR or BPH-related surgery. Given their different modes of action the rationale has always existed for using 5ARIs and alpha-blockers together in men deemed to be both symptomatic and at risk of progression. The factors that predict this progression and the methods available to reduce the risk of it occurring are the subjects of this review.

Finasteride effects on hypoxia and angiogenetic markers in benign prostatic hyperplasia

OBJECTIVES

To assess the effects of finasteride on angiogenetic and hypoxia markers in benign prostatic hyperplasia.

METHODS

A total of 178 patients aged 51 to 85 years (mean 68.7) with benign prostatic hyperplasia and awaiting transurethral prostate resection were prospectively randomized into a group of patients receiving finasteride (group 1; 88 patients) and a group of patients who received no medication until transurethral prostate resection (group 2; 90 patients). Tissue specimens were immunohistochemically stained with monoclonal antibodies against CD34 for microvessel density (MVD), vascular endothelial growth factor (VEGF), and hypoxia inducible factor-1alpha (HIF-1alpha).

RESULTS

Blood loss during transurethral prostate resection was significantly higher in group 2 compared with group 1 (P <0.001). The distribution of CD34 immunostaining was mainly at the suburethral prostate. MVD, VEGF, and HIF-1alpha values were significantly lower statistically (P <0.001) in group 1 compared with group 2. In the finasteride group (group 1), the positive correlation of the immunoreactivity of CD34 and HIF-1alpha, VEGF and HIF-1alpha, and VEGF and CD34 was statistically significant (P <0.001). In the same group, MVD and VEGF and HIF-1alpha expression correlated statistically with the treatment duration.

CONCLUSIONS

Finasteride administration in benign prostatic hyperplasia results in statistically significant suppression of MVD, VEGF, and HIF-1alpha in a time-dependent manner.

How Do Patients with Familial Benign Prostatic Hyperplasia Differ Clinically from Those with Sporadic Benign Prostatic Hyperplasia?

INTRODUCTION

The aim of this study was to compare age, prostatic volume, International Prostate Symptom Score (IPSS), maximal flow rate, serum total prostate-specific antigen (PSA), serum free PSA, free/total PSA ratio and PSA density values of familial and sporadic benign prostatic hyperplasia (BPH) patients suffering moderate or severe lower urinary tract symptoms.

MATERIALS AND METHODS

Between September 1999 and August 2004, 511 patients with moderate or severe lower urinary tract symptoms (IPSS > or =8) due to BPH were included in the study. Patients with at least 2 first-degree relatives who had undergone surgery or received medication for BPH were classified as having the familial form of the disease, while the remaining patients were taken as sporadic cases. Mean age, prostatic volume, symptom score, maximal flow rate, PSA, free PSA, free/total PSA ratio and PSA density values of the familial and sporadic groups were compared using student's t test.

RESULTS

Thirty-eight patients had a positive family history and formed the familial group, while the remaining 473 made up the sporadic group. No significant difference was observed in the parameters studied, except that mean prostate volume of the familial group was found to be greater and the mean age to be lower than those of sporadic patients in accordance with the literature.

CONCLUSIONS

Patients with familial BPH need treatment significantly earlier and have larger prostates than those with sporadic BPH.

Fact or fiction: what do the benign prostatic hyperplasia data tell us?

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men. Our understanding of this condition has improved greatly over the years and recent advances have changed our approach to management. At the end of the 19th century, prostatic enlargement was treated effectively by bilateral orchidectomy. Unsurprisingly, this treatment option never gained widespread popularity. Less than 10 years ago, surgery and watchful waiting were the only considered treatment options for BPH. We now have a number of medical therapies and minimally invasive treatment options available that can effectively manage lower urinary tract symptoms secondary to benign prostatic obstruction. However, with increased choice comes the increased need for clarity in selection and application of these various treatment options. In the current environment of evidence-based clinical practice, awareness and interpretation of data from the numerous studies is paramount. The lessons learned from these trials should be reflected clearly in our practice, with clinical management based on fact, not fiction. In this review, we critically assess the available data and understanding of the management of BPH.

CAN A BASELINE PROSTATE SPECIFIC ANTIGEN LEVEL IDENTIFY MEN WHO WILL HAVE LOWER URINARY TRACT SYMPTOMS LATER IN LIFE?

PURPOSE

We evaluated the relationship between baseline prostate specific antigen (PSA) and subsequent lower urinary tract symptom development during 3 decades in unselected men in the Baltimore Longitudinal Study of Aging.

MATERIALS AND METHODS

Urinary questionnaires were used to evaluate lower urinary tract symptoms in 704 men during 3 decades. The number of repeat evaluations was 1 to 18. We divided subjects into age groups of younger than 50 and 50 to 69.9 years at the time of the first PSA evaluation. Subjects were divided into 3 PSA groups based on initial PSA below the 25th, 25th to 75th and above the 75th percentile. A mixed effects Poisson model was used to test whether there was a significant relationship between PSA grouping and symptom score with time.

RESULTS

There was no statistically significant difference in symptom score distribution across PSA percentiles in men younger than 50 years (p = 0.87) or 50 to 69.9 years old (p = 0.59). When age was used as an independent variable in the model, there was no statistically significant relationship between baseline PSA and symptom score (p = 0.38).

CONCLUSIONS

These data suggest that PSA is not a useful predictor of the development of lower urinary tract symptoms in unselected, asymptomatic men.

Change in parameters before and after alpha-1-blocker therapy for men with lower urinary tract symptoms using color doppler ultrasound urodynamics: possible application for prediction of clinical outcome

INTRODUCTION

We previously developed a noninvasive video urodynamic study using color Doppler ultrasonography. We sought the best flow velocity-related parameter which would allow prediction of an improvement in lower urinary tract symptoms (LUTS) after alpha 1-blocker treatment.

METHODS

Twenty-two men with benign prostatic hyperplasia who were treated with a nonselective alpha 1-blocker (urapidil) were included. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) before and after alpha 1-blocker treatment. We measured the flow velocities using a transperineal ultrasound technique in the distal prostatic urethra just proximal to the external urethral sphincter (V1) and in the sphincteric urethra (V2), and used them to obtain the velocity ratio (VR=V1/V2). The corresponding functional cross-sectional areas of the urethra at these two sites (A1 and A2) were calculated as Q(max)/V. All these parameters obtained by the velocity-flow urodynamics were compared before treatment and after 4 weeks.

RESULTS

After treatment, V1 and VR were decreased, and A1 was increased. V2 correlated best with the change in IPSS before and after alpha 1-blocker therapy, with Spearman's rho of 0.584. All men with V2 exceeding 50 cm/s did not show an improvement in the LUTS.

CONCLUSIONS

The maximum flow velocity at the sphincteric urethra (V2) can predict the subjective outcome of alpha 1-blocker treatment. The velocity-flow parameters changed after alpha 1-blocker treatment. We confirmed that the transperineal ultrasound urodynamic study is not only noninvasive but also informative.

The relationship between erectile dysfunction and lower urinary tract symptoms: epidemiological, clinical, and basic science evidence

Lower urinary tract symptoms (LUTS) and sexual dysfunction are highly prevalent in aging men. Both conditions also are significant contributors to overall quality of life. New data have emerged to indicate potential links in epidemiological, physiologic, pathophysiologic, and treatment aspects of these two entities. There are numerous publications based on sophisticated community and clinical-based data, suggesting a strong and consistent association between LUTS and erectile dysfunction (ED). The association is supported by the consistent linear relationship of more severe LUTS with more severe ED. The link between ED and LUTS has biologic plausibility given the four leading theories of how these diseases inter-relate.

Benign prostatic hyperplasia progression and its impact on treatment

PURPOSE OF REVIEW

Management of men with benign prostatic hyperplasia should reduce the lifetime risk of acute urinary retention and the need for benign prostatic hyperplasia-related surgery. A number of recent studies demonstrate that 5alpha-reductase inhibitors are unique in providing a long-term combination of improvements in symptoms and flow, and reductions in the risks of acute urinary retention and surgical intervention.

RECENT FINDINGS

The 5alpha-reductase inhibitor finasteride was shown to reduce the risk of retention and surgery in men with large prostate volumes and/or high PSA. Recent studies have examined the role of adding an alpha1-blocker to 5alpha-reductase inhibitor in short- or long-term combination. The Medical Therapy of Prostatic Symptoms study randomised 3,047 men with benign prostatic hyperplasia to treatment with a 5alpha-reductase inhibitor (finasteride), an alpha1 blocker (doxazosin), a combination of both, or placebo. Only treatment arms containing 5alpha-reductase inhibitor therapy were associated with longer-term significant reductions in the risk of acute urinary retention and invasive therapy for benign prostatic hyperplasia. Three randomised, two-year, placebo-controlled studies have assessed the clinical relevance of the >93% DHT suppression provided by dutasteride. Dutasteride was also associated with a reduction in the risk of acute urinary retention of 57%, and a reduction of 48% in the risk of surgical intervention compared with placebo after 2 years.

SUMMARY

Short-term combination of 5alpha-reductase inhibitor and alpha-blockade are optimal in providing symptomatic improvement among patients who require symptom relief, while enabling the initiation of 5alpha-reductase inhibitor therapy to reduce the risk of subsequent acute urinary retention or benign prostatic hyperplasia-related surgery in men who are at greater risk of disease progression.

Improvements in benign prostatic hyperplasia-specific quality of life with dutasteride, the novel dual 5alpha-reductase inhibitor

OBJECTIVES

To examine the effect of the dual-action 5alpha-reductase inhibitor dutasteride on benign prostatic hyperplasia (BPH)-specific health status, as measured by the BPH Impact Index (BII), and to identify baseline and treatment risk factors for those most bothered by their BPH symptoms at the end of the protocol.

PATIENTS AND METHODS

Data were derived from three randomized, double-blind, placebo-controlled, 2-year studies conducted in 4325 men with lower urinary tract symptoms caused by benign prostatic enlargement. Each study comprised a 1-month single-blind placebo run-in period, followed by randomization to oral dutasteride 0.5 mg once daily or placebo for 2 years. Patients eligible for inclusion were consenting men aged >/= 50 years with moderate to severe symptoms (American Urological Symptom Index, AUA-SI, score >/= 12), a prostate volume of >/= 30 mL, a serum prostate-specific antigen (PSA) level of >/= 1.5 or < 10 ng/mL, and a maximum urinary flow rate (Qmax) of </= 15 mL/s. BII scores were recorded at baseline and each study visit. Clinically and statistically significant changes in BII scores from baseline were investigated for each study visit. Logistical regression analysis was used to assess the significance of baseline prostate volume, symptoms, BII item 3, baseline Qmax, serum dihydrotestosterone, testosterone, PSA, age and weight in predicting the BII score at 2 years.

RESULTS

Dutasteride, but not placebo, resulted in clinically and statistically significant improvements in mean BII score from 6 months. Of patients with a baseline BII score of >/= 5 (greatest symptomatic burden) treatment with dutasteride improved the scores by 2.41, while the scores in placebo-treated patients only improved by 1.64. Dutasteride-treated patients with a baseline BII score of < 5 (least symptom burden) had a clinically significant improvement in health status, while placebo-treated patients deteriorated. Regression analysis showed that men with a combination of a baseline BII item-3 score of 3 (bothered a lot) and a high symptom score (AUA-SI >/= 20) were more likely to be bothered by their symptoms at the end of the study. Men receiving placebo were also more likely to be bothered at the end of the study than were those receiving dutasteride.

CONCLUSIONS

Dutasteride treatment is associated with clinically significant improvements in BII score, reflecting improvements in the quality of life of men with BPH. Taken together with previously reported improvements in prostate volume, lower urinary tract symptoms and urinary flow, and diminution of the risk of acute urinary retention and the need for BPH-related surgery, dutasteride offers demonstrable efficacy in the management of BPH.

Lower urinary tract symptoms of men seeking medical care--comparison of symptoms found in the clinical setting and in a community study

OBJECTIVES

To investigate which lower urinary tract symptoms were most influential in causing men to seek medical care.

METHODS

We evaluated the International Prostate Symptom Score (IPSS) and quality-of-life (QOL) score of 235 outpatients having lower urinary tract symptoms and 242 participants in a community-based study of Japanese men aged 50 to 79 years old.

RESULTS

Although the proportion of outpatients in the severe IPSS category (IPSS 20 to 35) was greater than that in the participants of the community-based study in each age decade, the proportion in the moderate IPSS category (IPSS 8 to 19) in both groups overlapped each other. On the other hand, the distribution of QOL scores was considerably different, with only a small portion of overlap in each age decade. Although scores for both voiding symptoms (incomplete emptying, intermittency, weak stream, and hesitancy) and storage symptoms (increased frequency, urgency, and nocturia) were significantly greater in outpatients than in study participants in each age decade, the difference was more obvious for voiding symptoms than for storage symptoms.

CONCLUSIONS

The QOL score appeared to show more pronounced differences between men in a clinic setting and those in a community setting than the IPSS category. Voiding symptoms may affect medical care-seeking behavior through QOL impairment in Japanese men.

Medical therapy for benign prostatic hyperplasia progression

The vast majority of patients presenting to their physicians with concerns about voiding are seeking quick resolution of a disturbed urination pattern. The primacy of their concern over symptoms is appropriate, given the current focus on amelioration of voiding complaints in the treatment of lower urinary tract symptoms. Patients also ask about the risks of symptom progression and how this should impact their decision to choose either medical or surgical intervention. The concept of benign prostatic hyperplasia (BPH) progression has recently become a growing area of interest as new information emerges concerning the natural history of BPH and the identification of risk factors for progression. The impact of medical treatment on the prevention of BPH progression is slowly becoming apparent. The Proscar Long-Term Efficacy and Safety Study trial (Proscar; Merck & Co., Whitehouse Station, NJ) revealed a reduced risk of acute urinary retention and the requirement for invasive treatment with the long-term use of finasteride. More recent data from the Medical Therapy of Prostate Symptoms trial revealed that symptomatic men with BPH who were treated with a combination of an a-blocker and a 5-a reductase inhibitor showed significantly delayed clinical progression of their symptoms compared with treatment with each drug individually. Combination therapy appears to be more effective than doxazosin or finasteride alone in producing significant improvements in American Urological Association Symptom Index and flow rate changes. Interestingly, finasteride and combination therapy reduced the long-term risk of acute urinary retention.

Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related outcomes

OBJECTIVES

To assess the utility of voiding and filling symptom subscores in predicting features of benign prostatic hyperplasia (BPH) progression, including acute urinary retention (AUR) and prostate surgery.

METHODS

The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year study designed to evaluate the effects of finasteride versus placebo in men with lower urinary tract symptoms (LUTS), clinical evidence of BPH, and no evidence of prostate cancer. A self-administered questionnaire was employed to quantify LUTS at baseline. Receiver operating characteristics (ROC) curves were used to assess baseline characteristics from patients treated with placebo as predictors of outcomes. The characteristics assessed included the overall symptom score (Quasi-AUA SI), separate voiding and filling subscores, prostate volume (PV) and serum prostate-specific antigen (PSA) levels.

RESULTS

PV and PSA were superior to the symptom scores at predicting episodes of spontaneous AUR and all types of AUR. The Quasi-AUA SI and the filling and voiding subscores were effective at predicting progression to surgery; however, PSA was more effective at predicting this outcome. To better evaluate symptoms as predictors of surgery, patients who experienced a preceding episode of AUR were excluded from the surgery analysis. In the absence of preceding AUR, the best predictors of future surgery were the Quasi-AUA SI and the filling subscore.

CONCLUSIONS

Among men with LUTS, clinical BPH and no history of AUR, the overall symptom score and storage subscore are useful parameters to aid clinicians in identifying patients at risk for future prostate surgery. PV and PSA were the best predictors of AUR, while PSA was the best predictor of prostate surgery (for all indications).

Benign prostatic hypertrophy which nonoperative strategies are best?

Benign prostatic hypertrophy is one of the common complaints of older men who visit their primary care physicians. Nonoperative therapy, such as drug therapy or lifestyle modification, is aimed primarily at reducing bothersome lower urinary tract symptoms and preventing serious morbidity such as urinary retention and renal function impairment. As more men reach advanced age, it becomes crucial for the primary care physician to be aware of the epidemiology, pathophysiology, natural history, clinical presentation, and therapeutic modalities available for the treatment of clinically significant cases.

Office-based transurethral microwave thermotherapy using the TherMatrx TMx-2000

BACKGROUND AND PURPOSE

Transurethral microwave thermotherapy (TUMT) is an effective therapy for symptomatic benign prostatic hyperplasia (BPH), but the trade-off between the magnitude of clinical improvement and side effects and patient tolerance has limited its appeal to patients and urologists. This study, using the TherMatrx TMx-2000, a TUMT device that directly heats the transition zone to greater than 50 degrees C, has been focused on resolving these issues and developing a truly office-based therapy that is well tolerated with a benign post-treatment course.

PATIENTS AND METHODS

This study was multi-institutional and designed as a blinded, randomized, and sham-controlled trial. A series of 200 patients with an AUA Symptom Index (AUASI) of >12, a peak flow rate of <12 mL/sec, and cystoscopic evidence of BPH were randomized 2:1 (active to sham) and treated in seven physician offices under a Food and Drug Administration-supervised and audited premarket approval protocol. No intravenous sedation was used in any patient. Follow-up for the sham-treatment group was 3 months, at which time, patients could cross over to an active treatment. A total of 119 patients have completed 1-year follow-up.

RESULTS

The active and sham groups were statistically identical at baseline. The 1-hour total treatment was extremely well tolerated using urethral lidocaine and oral medications; not a single prostate block or parental dose of medication was required. The active-treatment group demonstrated a statistically significant reduction (p < 0.05) in AUASI at 3 months compared with sham treatment, with an AUASI decrease from 22.4 to 12.4 (n = 124) for active v 22.9 to 17 for sham (n = 62). For the 119 patients in the active arm who have reached 12 months, the AUASI has fallen to 10.6 points (47.1% decrease), and the peak flow rate has increased 5.0 mL/sec (58.1%). Postprocedure catheterization was typically 2 or 3 days, and the 16.8% of patients who failed their first voiding trial all voided within 1 week. No major adverse events such as stricture, rectal findings, or ejaculatory changes have been reported.

CONCLUSIONS

This study demonstrates that the TherMatrx TMx-2000 TUMT effectively treats symptomatic BPH in the physician office with minimal morbidity.

Prostate volume and prostate-specific antigen in the absence of prostate cancer: a review of the relationship and prediction of long-term outcomes

BACKGROUND

The risk for long-term outcomes associated with benign prostatic hyperplasia (BPH) has not been well characterized. Untreated, BPH can lead to complications and negative outcomes, such as deterioration of bladder function, urinary tract infection, acute urinary retention (AUR), and surgery.

METHODS

A literature review was conducted to summarize the results of studies investigating the relationship of prostate volume and PSA with prediction of long-term outcomes in the absence of prostate cancer.

RESULTS

In the studies reviewed, men with moderate to severe symptoms, depressed uroflow, prostatic enlargement and elevated PSA were at greater risk for developing subsequent AUR or surgery. Men with prostatic enlargement had a 3-fold higher risk for acute urinary retention and were 4 times more likely to have had any treatment for BPH.

CONCLUSIONS

The results of these studies may assist physicians in discussing treatment options as well as long-term complications with patients.

Lower urinary tract symptoms after renal transplantation

PURPOSE

We investigated the prevalence and nature of lower urinary tract symptoms after renal transplantation. In addition, we studied how these symptoms affect the quality of life and whether function of the lower urinary tract before transplantation was related to postoperative occurrence of lower urinary tract symptoms.

MATERIALS AND METHODS

Data were gathered by a written questionnaire. The research group consisted of 63 patients who underwent renal transplantation in 1998 at the University Medical Center St Radboud Nijmegen. The control group consisted of 74 patients with nonurological complaints who visited an outpatient clinic at the same university.

RESULTS

The most important finding was that patients who underwent renal transplantation needed to void more often than controls, both during the day and at night. After renal transplantation, almost 50% of the patients complained of frequency and 62% nocturia. Patients with a transplant had tended to perceive frequency and nocturia less as problems than those in the control group.

CONCLUSIONS

No relation was found between the functioning of the lower urinary tract before transplantation, and occurrence of frequency and nocturia after. The amount of fluid intake at the interview was not related to the occurrence of frequency and nocturia. No abnormalities were found regarding bladder evacuation.

Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men

We defined risk factors for a clinical diagnosis of benign prostatic hyperplasia (BPH) among subjects of the population-based Massachusetts Male Aging Study. In 1987-89 1709 men aged 40-70 provided baseline risk factor data and were followed for a mean of 9 years; 1019 men without prostate cancer provided follow-up data. We classified men with clinical BPH at follow-up if they reported (1) frequent or difficulty urinating and were told by a health professional that they had an enlarged or swollen prostate or (2) if they reported having surgery for BPH. At follow-up the prevalence of clinical BPH was 19.4%, increasing from 8.4% of men aged 38-49 years to 33.5% of men aged 60-70 years (P < 0.001 for trend). Elevated free PSA levels (age- and total PSA-adjusted OR, top vs. bottom quartile ng/mL 4.4, 95% CI 1.9-10.5), heart disease (age-adjusted OR 2.1, CI 1.3-3.3), and use of beta-blocker medications (OR 1.8, CI 1.1-3.0) increased odds for BPH, while current cigarette smoking (OR 0.5, CI 0.3-0.8) and high levels of physical activity (top vs. bottom quartile kcals/day OR 0.5, CI 0.3-0.9) decreased odds of BPH. All but the medication effects persisted in fully adjusted multivariable models. Total or fat calorie intake, sexual activity level, alcohol intake, body mass index, waist-hip ratio, diastolic blood pressure, a history of diabetes, hypertension, vasectomy, or serum levels of androgens or estrogens did not individually predict clinical BPH. We conclude that physical exercise and cigarette smoking appear to protect against development of clinical BPH. Elevated free PSA levels predict clinical BPH independent of total PSA levels. Risk associated with heart disease does not appear to be due solely to detection bias or to effects of heart disease medications. A wide variety of other characteristics appear to have no influence on risk for clinical BPH.

Use of prostatic stents for the treatment of benign prostatic hyperplasia in high-risk patients

Benign prostatic hyperplasia (BPH) is a frequent disease in men and a major cause of lower urinary tract symptoms (LUTS). Transurethral resection of the prostate (TURP) or open surgery remains the gold standard of treatment for symptomatic BPH. However, 10% to 15% of patients with BPH cannot undergo surgery due to grave concomitant diseases. For patients presenting with contraindications to surgery or anesthesia, several minimally invasive alternative treatment modalities are available. One such therapeutic alternative is prostatic stenting, which can serve as a temporary or permanent solution for bladder outlet obstruction caused by BPH. Although not a new concept, this is a relatively new treatment modality in the United States, primarily because of the strict regulatory forces governing the use of these devices. Prostatic urethral stents have been widely demonstrated to be safe and effective for the treatment of symptomatic BPH. In addition to being minimally invasive, prostatic stenting is generally rapid, easy to perform, immediately effective, and has a low cost compared with conventional surgical treatment. Prostatic stents are therefore well suited to treat the frail elderly patient who would not be able to withstand the stress of undergoing surgery. This report reviews the current use of prostatic urethral stents in the treatment of high-risk surgical patients with BPH.

The natural history of benign prostatic hyperplasia: what have we learned in the last decade?

Benign prostatic hyperplasia (BPH) frequently has a significant detrimental impact on a patient's quality of life. If the disease is left untreated, it may progress in severity, leading to recurrent bladder infections, bladder calculi, and acute urinary retention (AUR), necessitating surgical treatment. The Forth Valley, Scotland, study reported that 14% of men aged 40 to 50 years have BPH. This increases to 43% of men >60 years old. BPH has been shown to be nearly as prevalent as hypertension and diabetes among patients seeking treatment for erectile dysfunction. The effects of BPH on quality of life include lack of sleep, anxiety, reduced mobility, interference with leisure activities and usual daily activities, and a compromised sense of well-being. Three symptoms are associated with an increased risk of AUR in men with BPH: a reduction in the force of the urinary stream, a sensation of incomplete bladder emptying, and an enlarged prostate gland on digital rectal examination. Age is a strong independent risk factor for the development of AUR. Transurethral resection of the prostate was more effective than watchful waiting in preventing AUR, as shown in the Veteran's Affairs Cooperative Study. Data from the Olmsted County study revealed that urinary flow decreases and prostate size increases with advanced age. This study also showed that lower urinary tract symptoms have a negative impact on parameters of physical and mental aspects of health. More recently, studies have shown that medical treatment with 5alpha-reductase inhibitors and possibly also alpha-blockers may alter the natural history and progression of BPH.

Epidemiology and classification of urinary incontinence

Urinary incontinence is a common symptom affecting the physical, psychological, social and economic well-being of individuals and their families. It also poses a considerable economic burden on health and social services. The literature reports widely varying prevalence rates for incontinence that are partially explained by methodological differences between studies. However, community-based studies indicate that approximately 6% of the population, particularly women and older people, will have urinary incontinence of sufficient severity to interfere with their quality of life. This represents a significant demand for health care. Although further research on prevalence is unlikely to add anything new to current knowledge on the size of the problem, more information is needed on the onset, progression and risk factors of urinary incontinence to inform methods of effective treatment and preventive strategies. In addition, there has been little investigation of the triggers to seeking professional help or of the response of health professionals to patients' demands for treatment, either for incontinence or other lower urinary tract symptoms. The aetiology of incontinence is multifactorial; incontinence is caused by pathophysiological impairments to the lower urinary tract and neurological system, as well as a range of external factors. The key to effective management, therefore, is a comprehensive assessment of the patient, including other lower urinary tract symptoms, so that appropriate intervention is tailored on a diagnosis and not on symptoms.

Effect of finasteride on bother and other health-related quality of life aspects associated with benign prostatic hyperplasia. PLESS Study Group. Proscar Long-term Efficacy and Safety Study

OBJECTIVES

To investigate the long-term effects of finasteride on bother and health-related quality of life (HRQOL) in men with symptomatic benign prostatic hyperplasia.

METHODS

A large prospective 4-year placebo-controlled trial (PLESS) of 3040 men with moderate to severe lower urinary tract symptoms and an enlarged prostate was performed that included self-administered questionnaires assessing HRQOL.

RESULTS

Significantly greater reductions in bother score were seen for finasteride compared with placebo at every time point after 4 months. Analysis of bother scores by baseline serum prostate-specific antigen (PSA), as it is highly correlated with prostate volume, suggested greater differences from placebo for men with PSA 1.4 ng/mL or greater, primarily due to worsening after the first-year improvement in the placebo group. An activity interference domain score was significantly improved for finasteride over placebo at each time point (P<0.01), with greater treatment differences in men with higher baseline PSA levels. Comparable results were seen for worry at each time point and embarrassment due to urinary symptoms in the last 2 years of the trial. Mean changes in sexual interest and satisfaction were somewhat better for the placebo group overall, as has been previously reported, but little difference between treatments was found in sexual satisfaction measures for men with PSA 1.4 ng/mL or greater.

CONCLUSIONS

Compared with placebo, men receiving finasteride had significantly less bother, activity interference, and worry due to urinary symptoms, with more pronounced differences for men with baseline PSA 1.4 ng/mL or greater. As expected, sexual satisfaction and sexual drive were slightly worse for finasteride overall, but little difference in sexual satisfaction measures was found for men with a higher baseline PSA. Thus, HRQOL was improved for finasteride compared with placebo, especially for men with a baseline PSA 1.4 ng/mL or greater.

Benign prostatic hyperplasia (the aging prostate)

BPH is a common phenomenon of the aging process. Clinical manifestations may range from minimally bothersome symptoms to urinary retention and renal failure. Tailoring of treatment based on the individual patient is required for successful management. For mild symptoms, watchful waiting is a valid option. For severe symptoms, surgical therapy is most appropriate. For men complaining of moderate symptoms, medical therapy has become front-line therapy, with other less invasive treatment modalities being available or in development.

Limitations of epidemiologically based needs assessment. The case of prostatectomy

OBJECTIVES

The aim of this study was to make epidemiologically based estimates of the prevalent and incident "need" for prostatectomy for lower urinary tract symptoms, defined as the numbers of men who would both benefit from and want the operation.

METHODS

The methods involved a consensus panel, a two-stage postal survey of 1,480 men aged 55 years or older from eight general practices to the northwest of London, United Kingdom, and a multistate life table.

RESULTS

The overall response rate was 69% (initial survey: 78%, follow-up survey: 88%). A trial-based estimate of number of candidates for prostatectomy (men with symptoms that were at least moderately severe and bothersome and who would probably or definitely want surgery) was 610 men in a population of 250,000. The corresponding incidence estimate (including men with symptoms recurring after spontaneous remission or surgery) was approximately 200 per year, including approximately 110 new cases. Consensus-based estimation, including categories of patients who have not yet been subject to a trial, gave much higher figures of approximately 3,000, 650, and 200 candidates, respectively. Adding the number of men who said they were "inclined to" choose surgery would almost double these figures.

CONCLUSIONS

Estimates of need were highly sensitive to choice of indications and assumptions about patients' attitudes toward surgery. Population needs assessment for specific procedures will always involve judgment as well as epidemiological data and modeling.

Epidemiologic survey of lower urinary tract symptoms in Asia and Australia using the international prostate symptom score

BACKGROUND

The prevalence of lower urinary tract symptoms was determined by survey as an initial step in estimating the significance of benign prostatic hyperplasia (BPH) in Asia and Australia.

METHODS

The symptom index (0 to 35) and quality-of-life (QOL) index (0 to 6) of the international prostate symptom score were measured in 7588 men in 9 Asian countries and 146 men in Australia.

RESULTS

The percentages of Asian men considered to be symptomatic (symptom index > or = 8) were 18%, 29%, 40%, and 56% in the age groups of 40 to 49, 50 to 59, 60 to 69, and 70 to 79 years, respectively. For Australian men, these figures were 36%, 33%, and 37% in the 50 to 59, 60 to 69, and 70 to 79 year age groups, respectively.

CONCLUSIONS

Our estimates indicate that the prevalences of symptomatic men in Asia and Australia are similar to or greater than those in Europe and America, and suggest BPH is similarly common in these areas.

Underdetection of clinical benign prostatic hyperplasia in a general medical practice

OBJECTIVE

To measure detection of clinical benign prostatic hyperplasia (BPH) in a general medicine practice.

DESIGN

Self-administered questionnaire and retrospective ambulatory medical record review.

SETTING

Hospital-based general medicine practice.

PATIENTS

Two hundred and four men aged 50 years and older.

MEASUREMENTS AND MAIN RESULTS

Clinical information was obtained from a self-administered questionnaire containing the American Urological Association symptom index and the BPH Impact Index bother scale, and from retrospective review of ambulatory medical records for the previous 24 months. Thirty percent of patients had moderate to severe urinary tract symptoms, and 67% of these individuals were bothered by the symptoms. Only 52% with moderate to severe symptoms recalled any discussion with their primary care physician about their symptoms. There was medical record documentation of a review of urinary tract symptoms in only 18% and a prostate examination in only 64%. Patients with more symptoms and bother tended to recall a discussion of urinary tract symptoms with their physician. However, moderate to severe symptoms and bother were not associated with increased documentation of a history of urinary tract symptoms or prostate examination.

CONCLUSIONS

Clinical BPH was underdetected in a general medicine practice. Because many men do not complain to their physicians about urinary tract symptoms and reduced quality of life, perhaps primary care physicians should pay more attention to recognizing this common condition of older men.

Prostates and profits: the social construction of benign prostatic hyperplasia in American men

Benign prostatic hyperplasia (BPH) is clinically diagnosed in approximately three-fourths of American men, a prevalence two to three times higher than that currently reported in Scotland and Japan. Prostatectomy is the most common operation performed on American men over 65. A critical medical anthropological analysis reveals that American urologists rely on prostatectomy to maintain their practices, and the growth of urology as a specialty is significantly related to the 50% increase in the rate of surgery since 1965. Marketing campaigns and studies funded by pharmaceutical companies promote the perception of urinary difficulties as problematic, encourage men to medicalize their symptoms, and create demand for drug therapy and urologist treatment. The social construction of BPH as a progressive age-related disorder and the profit orientation of American medicine account for the elevated prevalence of BPH.

Primary care practitioners: an analysis of their perceptions of voiding dysfunction and prostate cancer

PURPOSE

We analyzed practice and referral patterns of primary care practitioners regarding the diagnosis of prostate cancer, and the evaluation and treatment of voiding dysfunction.

MATERIALS AND METHODS

An anonymous multiple-choice questionnaire was mailed to all primary care practitioners in Brooklyn, New York who were registered with the Medical Society of the State of New York.

RESULTS

More than 25% of primary care practitioners begin performing digital rectal examination after patient age 55 years. Compared to prostate specific antigen (PSA) 59% of practitioners believe that digital rectal examination is more sensitive or that the tests are equal, or they do not know. In regard to PSA 11% of respondents begin testing after patient age 60 years, 11% evaluate PSA only if digital rectal examination is abnormal and greater than 3% never evaluate PSA. Approximately 45% of primary care practitioners indicated that PSA of greater than 4.0 ng./ml. signifies prostate cancer regardless of patient age, prostate size or prostatis and 50% think that digital rectal examination elevates PSA in a clinically significant way. Although 93.2% of respondents refer a patient to a urologist after palpating a prostatic nodule, only 51.1% refer for an area of induration. Of the 47.2% of respondents who attempt pharmacotherapy for voiding dysfunction with finasteride, terazosin or both 15% do not know the agent mechanisms of action. Of those prescribing finasteride 68.6% are not aware of its effects on serum PSA. Overall 66.5% of primary care practitioners are not familiar with the American Urological Association Symptom Index while only 15% of those attempting pharmacotherapy use the index as a diagnostic tool.

CONCLUSIONS

Primary care practitioners might require further education in regard to the use of PSA, digital rectal examination and pharmacotherapy in voiding dysfunction. Consideration should be given to the establishment of guidelines for urological referral.

Prostatism: benign prostatic hyperplasia

This article is devoted to the most common cause of outlet obstruction in the male geriatric population, benign prostate hyperplasia (BPH). The prevalence, pathophysiology, and natural history of BPH is discussed, along with the work-up and indications for medical or surgical intervention. The authors also focus on medical and surgical options now available for management of BPH.