First-line treatment for symptomatic benign prostatic hyperplasia: is there a particular patient profile for a particular treatment?

Racial Disparities in Diagnosis and Management of Benign Prostatic Hyperplasia: A Review

PURPOSE OF REVIEW

We sought to perform a contemporary literature review highlighting the racial disparities which exists in the evaluation and management of benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Current literature suggests that racial disparities exist in the diagnosis of BPH and treatment lower urinary tract symptoms (LUTS). This is seen in the presentation and diagnosis of the disease as well as a difference in preventative care with discordant incidences of medical and surgical management among racial groups. The racial disparities that exist in the diagnosis and management of BPH and LUTS require further investigation to better identify the underlying causes. This will ultimately allow for continued improvement in care delivery and a more personalized approach in patient management.

Factors influencing nonabsolute indications for surgery in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: analysis using causal bayesian networks

Purpose

To identify the factors affecting the surgical decisions of experienced physicians when treating patients with lower urinary tract symptoms that are suggestive of benign prostatic hyperplasia (LUTS/BPH).

Methods

Patients with LUTS/BPH treated by two physicians between October 2004 and August 2013 were included in this study. The causal Bayesian network (CBN) model was used to analyze factors influencing the surgical decisions of physicians and the actual performance of surgery. The accuracies of the established CBN models were verified using linear regression (LR) analysis.

Results

A total of 1,108 patients with LUTS/BPH were analyzed. The mean age and total prostate volume (TPV) were 66.2 (±7.3, standard deviation) years and 47.3 (±25.4) mL, respectively. Of the total 1,108 patients, 603 (54.4%) were treated by physician A and 505 (45.6%) were treated by physician B. Although surgery was recommended to 699 patients (63.1%), 589 (53.2%) actually underwent surgery. Our CBN model showed that the TPV (R=0.432), treating physician (R=0.370), bladder outlet obstruction (BOO) on urodynamic study (UDS) (R=0.324), and International Prostate Symptom Score (IPSS) question 3 (intermittency; R=0.141) were the factors directly influencing the surgical decision. The transition zone volume (R=0.396), treating physician (R=0.340), and BOO (R=0.300) directly affected the performance of surgery. Compared to the LR model, the area under the receiver operating characteristic curve of the CBN surgical decision model was slightly compromised (0.803 vs. 0.847, P<0.001), whereas that of the actual performance of surgery model was similar (0.801 vs. 0.820, P=0.063) to the LR model.

Conclusions

The TPV, treating physician, BOO on UDS, and the IPSS item of intermittency were factors that directly influenced decision-making in physicians treating patients with LUTS/BPH.

Does the endoscopic treatment of lower ureter stones affect uroflowmetric values? A prospective clinical trial

OBJECTIVES

The aim of this study was to document if stones at the lower ureter alter the micturition capability of the patients and to investigate whether endoscopic removal of these stones restores normal urinary flow rates or not in the 3 months of follow-up.

METHODS

Forty patients with lower ureteral stone (group 1) and 20 control subjects with proximal ureteral stone (group 2) were enrolled into the study. All patients underwent uroflowmetry testing before and 3 months after the treatment for endoscopic stone removal. The mean average and peak flow rates with a sufficient voided volume (≥150 ml) were evaluated before and after surgery and compared between the groups.

RESULTS

Mean values of the peak flow rates before and after surgery were 20.3 and 27.5 ml/s in group 1 and 22.5 and 23.6 ml/s in group 2, and the mean average flow rate values before and after surgery were 10.5 and 13.6 ml/s in group 1 and 11.4 and 12.1 ml/s in group 2. Statistically significant differences were determined between before and after ureteroscopy values were determined in terms of average (p < 0.05) and peak flow rates (p < 0.01) in group I; however, there no significant difference was seen in the control group.

CONCLUSION

We document for the first time in the literature that patients with lower ureteric stones have a reduction in their urinary stream which resolves with endoscopic removal of the stones.

Various treatment options for benign prostatic hyperplasia: A current update

In benign prostatic hyperplasia (BPH) there will be a sudden impact on overall quality of life of patient. This disease occurs normally at the age of 40 or above and also is associated with sexual dysfunction. Thus, there is a need of update on current medications of this disease. The presented review provides information on medications available for BPH. Phytotherapies with some improvements in BPH are also included. Relevant articles were identified through a search of the English-language literature indexed on MEDLINE, PUBMED, Sciencedirect and the proceedings of scientific meetings. The search terms were BPH, medications for BPH, drugs for BPH, combination therapies for BPH, Phytotherapies for BPH, Ayurveda and BPH, BPH treatments in Ayurveda. Medications including watchful waitings, Alpha one adrenoreceptor blockers, 5-alpha reductase inhibitors, combination therapies including tamsulosin-dutasteride, doxazosin-finasteride, terazosin-finasteride, tolterodine-tamsulosin and rofecoxib-finasteride were found. Herbal remedies such as Cernilton, Saxifraga stolonifera, Zi-Shen Pill (ZSP), Orbignya speciosa, Phellodendron amurense, Ganoderma lucidum, Serenoa Repens, pumpkin extract and Lepidium meyenii (Red Maca) have some improvements on BPH are included. Other than these discussions on Ayurvedic medications, TURP and minimally invasive therapies (MITs) are also included. Recent advancements in terms of newly synthesized molecules are also discussed. Specific alpha one adrenoreceptor blockers such as tamsulosin and alfuzosin will remain preferred choice of urologists for symptom relief. Medications with combination therapies are still needs more investigation to establish as preference in initial stage for fast symptom relief reduced prostate growth and obviously reduce need for BPH-related surgery. Due to lack of proper evidence Phytotherapies are not gaining much advantage. MITs and TURP are expensive and are rarely supported by healthcare systems.

National-wide data on the treatment of BPH in Korea

The healthcare system in Korea provides coverage to all the people who are residing in Korea, so the data of the Korea healthcare system are national-wide and relatively accurate. We obtained the recent 5-year data (2004-2008) on the treatment of BPH from the national health insurance system. We tried to determine the trends or changes of BPH treatments in Korea. Over 3.8 million men visited clinics and were prescribed one or more BPH medications, and more than 44 000 men underwent surgical treatment during 2004-2008. Compared with the year 2004, two times the patients were prescribed BPH medications in 2008. With respect to the surgical treatment, the number of cases was increased 1.6 times in 2006 compared with the previous years. The most commonly used surgical option was TURP before 2006, but laser therapy was carried out as much as TURP in 2006 and in the following years. The relative risk of laser therapy in the 50 s is 1.53 (95% CI is 1.47-1.59). In conclusion, our national-wide data for the Korean BPH patients show that these patients' medical treatment increased during the 5 years from 2004 to 2008. Laser treatment had increased and it might replace TURP in several years.

Clinical efficacy of a loading dose of naftopidil for patients with benign prostate hyperplasia

PURPOSE

The efficacy of a loading dose of α(1)-adrenoreceptor antagonist for patients with benign prostate hyperplasia who did not improve at a low dose has not been determined. We performed a prospective study to estimate the efficacy of incremental naftopidil administration.

METHODS

The efficacy of naftopidil was examined based on changes in the International Prostate Symptom Score (IPSS). We defined a "responder" as a patient who improved by ≥5 points in IPSS total score. All patients were administered naftopidil at 50 mg/day for 12 weeks, and nonresponders at 50 mg/day were increased to 75 mg/day. Efficacy was finally evaluated after an additional 12 weeks of administration at 75 mg/day.

RESULTS

Among 122 patients whose data could be analyzed, the efficacy rate after administration at 50 mg/day was 52.5%. In all IPSS items except urgency score, the responders had significantly higher (poorer) values than nonresponders before the start of treatment. Of 40 patients whose dose was increased to 75 mg/day and whose data could be analyzed, prostate volume in the responder group (9 patients) was significantly smaller than that in the nonresponder group (31 patients). Multivariate analysis showed that patients with improved IPSS total score, voiding symptoms, urgency, and weak stream after administration of 50 mg/day naftopidil were more likely to improve after a dose increase.

CONCLUSIONS

A dose increment of naftopidil to 75 mg/day may be useful in patients with BPH who did not improve at 50 mg/day.

Epidemiology of benign prostatic hyperplasia and comorbidities in racial and ethnic minority populations

In the United States, research into the etiology of benign prostatic hyperplasia (BPH) and the incidence and treatment of lower urinary tract symptoms (LUTS) in racial/ethnic minority patients is just beginning, despite a high incidence of both conditions in these populations. The relative risks for the development of BPH and commonly comorbid conditions in African Americans and Latinos may be increased compared with the white majority population. This heightened risk may be attributable to factors such as autonomic hyperactivity and metabolic abnormalities, which appear at a higher rate in African Americans and Latinos. Differences in genetic factors related to androgen receptor CAG repeats, the androgen signaling pathway, and in the cellular composition of the prostate also contribute to racial/ethnic differences in the incidence of clinical BPH and LUTS. Despite the disproportionately high rates of BPH-associated risk factors and comorbidities associated with the condition, a large proportion of minority patients with BPH and LUTS are undiagnosed and untreated. Expanding the information base on BPH and LUTS in minority patients may help to narrow existing ethnic/racial disparities in treatment and to reduce the impact of LUTS on the quality of life of these patients.

Benign prostatic hyperplasia and lower urinary tract symptoms in African Americans and Latinos: treatment in the context of common comorbidities

Benign prostatic hyperplasia (BPH), with accompanying lower urinary tract symptoms (LUTS), is a common age-related condition associated with a variety of cardiovascular, metabolic, and sexual comorbidities. While there is debate, in the United States race and ethnicity, particularly among Latinos and African American men, may confer an elevated risk for BPH and LUTS. Hypertension and deficits in sexual health are more common among African American men, while both Latino and African American men experience more metabolic-related disorders, including diabetes mellitus, insulin resistance, and end-stage renal disease. Although socioeconomic factors may play a significant role in these disparities, pathological and genetic variations between patients of different races and ethnicities are additional factors in the development of BPH. The proliferation of available treatments for BPH demands greater discernment in treatment selection, and comorbidities represent a central criterion upon which choice of appropriate BPH therapy should be based. This article reviews common comorbidities in minority populations, describes challenges to BPH management, and discusses medical, surgical, and phytotherapeutic treatment options.

LUTS treatment: Future treatment options

Lower urinary tract symptoms (LUTS) are commonly divided into storage, voiding, and postmicturition symptoms, and may occur in both men and women. Male LUTS have historically been linked to benign prostatic hyperplasia (BPH), but are not necessarily prostate related. The focus of treatment for LUTS has thus shifted from the prostate to the bladder and other extraprostatic sites. LUTS include symptoms of the overactive bladder (OAB), which are often associated with detrusor overactivity. Treatment for LUTS suggestive of BPH has traditionally involved the use of alpha(1)-adrenoceptor (AR) antagonists; 5alpha-reductase inhibitors; and phytotherapy-however, several new therapeutic principles have shown promise. Selective beta(3)-adrenoceptor agonists and antimuscarinics are potentially useful agents for treating LUTS, particularly for storage symptoms secondary to outflow obstruction. Other agents of potential or actual importance are antagonists of P2X(3) receptors, botulinum toxin type A, endothelin (ET)-converting enzyme inhibitors, and drugs acting at vanilloid, angiotensin, and vitamin D(3) receptor sites. Drugs interfering with the nitric oxide/cGMP-cAMP pathway, Rho-kinase and COX inhibitors, as well as drugs targeting receptors and mechanisms within the CNS, are also of interest and deserving of further study for the treatment of LUTS.