Prazosin as cause of urinary incontinence

Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults

BACKGROUND

Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. Alpha-blockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain.  OBJECTIVES: To assess the effects of alpha-blockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020.

SELECTION CRITERIA

We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an alpha-blocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE.

MAIN RESULTS

We included 40 studies with 4793 participants randomized to usual care and an alpha-blocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used alpha-blocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin.  Alpha-blockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an alpha-blocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. Alpha-blockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, alpha-blockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. Alpha-blockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; alpha-blockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with alpha-blocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. Alpha-blockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of alpha-blocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session.

AUTHORS' CONCLUSIONS

Based on low certainty evidence, adjuvant alpha-blocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

The relationship between comprehensive functional assessment and optimal pharmacotherapy in the older patient

Older patients hospitalized for treatment of an acute medical illness will have improved outcomes when approached in a comprehensive fashion focusing on the physical, social, and emotional aspects of life. When used by an interdisciplinary team, comprehensive functional assessment can address social, biomedical, nutrition, continence, mobility, pharmacotherapy, and psychological issues to enhance patient care. Although the appropriate use of medications is often cited as an important part of medical care for the older person, it has not been defined for this group of patients. This article outlines steps pharmacists can take to achieve optimal pharmacotherapy in older patients. Prior to attending a team conference, the pharmacist should interview the patient and review the chart. During the team conference, a comprehensive patient database will be generated that allows medications to be linked to diagnoses. To aid in selecting appropriate medications, the potential for drug-induced functional impairment of mobility, continence, and mental state is reviewed. Recommendations for therapy and establishment of therapeutic endpoints will conclude the patient conference. The pharmacist can contribute much in the process of comprehensive functional assessment and to the goal of achieving optimal pharmacotherapy in older patients.

Drug-induced illness in the elderly

The elderly are predisposed to adverse drug reactions because of age-related physiologic changes, interaction of one drug with another, and interaction between a drug and a coexisting medical condition. Recognition of such adverse reactions is essential, because many are reversible and many are even preventable. Assessment of clinical disorders in the elderly should include evaluation of drugs as a causal or aggravating factor. Careful choice and dosage of drugs in the elderly will minimize the likelihood of drug-induced illness.

Effect of adrenergic agents on urethral pressure and urethral compliance measurements in dog proximal urethra

The effects of adrenergic drugs on urethral compliance and urethral closure pressure at the proximal urethra of dogs were investigated using a new probe. The probe, with a balloon at the tip, was equipped with two generating and two detecting electrodes. The probe was inserted into the proximal urethra, and saline was then infused at a constant rate into the balloon with an infusion pump. The pressure and cross-sectional area of the urethra were recorded and a correlation curve of these parameters was drawn. The regression (of the form y = ax + b) was determined from the curve. Urethral compliance and closure pressures were obtained from the values of "a" and "-b/a" respectively, and the maximum cross-sectional area was measured when no further distension of the urethra was obtained. Urethral compliance decreased after the administration of phenylephrine, but increased after the administration of prazosin and labetalol. The urethral closure pressure decreased after the administration of dopamine and haloperidol. There was no change in either urethral compliance or closure pressure after the administration of clonidine, yohimbine, isoproterenol, or propranolol. The results indicate that adrenergic drugs work on urethral compliance, and that the alpha-adrenergic receptor of the proximal urethra is of the alpha-1 type. The changes in the urethral pressure after dopamine administration seems to be a response mediated by dopamine receptors.

Urinary incontinence in the elderly: etiology and treatment

Urinary incontinence is a common, though often hidden, medical problem among the elderly. Urinary continence requires integrity of the neural, muscular, and hormonal systems. Five distinct types of urinary incontinence can be distinguished based on patient symptoms. A variety of factors can impair continence, including aging, environmental barriers, and medications. Both pharmacological and nonpharmacological measures are useful in the treatment of incontinence.

Nicergoline in the treatment of neuropathic bladder dysfunction: a preliminary report

We have employed the alpha blocking drug Nicergoline in 14 patients with neuropathic bladder dysfunction of the upper motor neurone type. The oral administration of 15-30 mgrs/day of this drug over a period of 9.5 months significantly improved the urodynamic parameters, with an increase of bladder capacity, a disappearance or amelioration of uninhibited bladder contractions and a decrease in urethral pressure, profile urethral length and residual urine. Two patients with vesico-ureteral reflux present before treatment showed radiological improvement after Nicergoline administration. Tolerance of Nicergoline had been excellent without appreciable side effects. In conclusion, Nicergoline seems to be active and well tolerated in the pharmacological treatment of neuropathic bladder dysfunction.

Urinary incontinence secondary to drugs

With the current rapid introduction of new drugs on the market, drug toxicity and side effects have received increasing publicity in the literature. Bladder dysfunction, however, rarely has been reported as an adverse effect. The possible mechanisms in the induction of urinary incontinence by three main groups of drugs, the neuroleptics, the antihypertensive agents, and the drugs used in the treatment of neurogenic bladder obstruction, are reviewed. These drugs are thought to act peripherally at sympathetic neurons or through a centrally-mediated effect.