Long-term effects of doxazosin, finasteride and combination therapy on quality of life in men with benign prostatic hyperplasia. J Urol. 2013;190:187-193. [PMID: 23357210 DOI: 10.1016/j.juro.2013.01.061]

Lower urinary tract symptom severity, urinary bother, and incident life-space mobility restriction among older men

BACKGROUND

Life-space mobility represents the distance, frequency, and independence of mobility, ranging from one's bedroom to beyond their town. Older men with lower urinary tract symptoms (LUTS) may limit their life-space to stay close to a bathroom. However, it's unknown whether LUTS severity or urinary bother are associated with risk of life-space mobility restriction.

METHODS

We analyzed data from 3025 community-dwelling men age ≥71 years without life-space mobility restriction at analytic baseline (Year 7) of the Osteoporotic Fractures in Men (MrOS) study. The American Urologic Association Symptom Index (AUASI) was assessed at baseline and includes one question assessing urinary bother ("If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?"; score 0-1,2,3,4-6) and seven items to classify LUTS severity as none/mild (score 0-7), moderate (8-19), or severe (20-35). The University of Alabama Life-space Assessment was used to define life-space mobility restriction (≤60) at baseline and follow-up (Year 9). We used log-binomial regression with robust variance estimators to model adjusted risk ratios (ARR) for LUTS severity and urinary bother with incident life-space mobility restriction, controlling for age, site, health-related factors, and comorbidities. We then mutually adjusted for urinary bother and LUTS severity.

RESULTS

Overall, the 2-year risk of life-space mobility restrictions was 9.9%. Compared to men without urinary bother (scores 0-1), the risk of life-space mobility restriction was significantly higher among men with bother scores of 4-6 (ARR = 2.20, 95% CI: 1.52, 3.19), independent of LUTS severity and confounders. Conversely, LUTS severity was not independently associated with the risk of life-space mobility restriction.

CONCLUSIONS

Urinary bother, but not LUTS severity, is independently associated with incident life-space mobility restriction among older men. To maintain life-space mobility in older men with LUTS, future studies should identify shared mechanisms and interventions that minimize urinary bother.

Lower urinary tract symptoms and incident functional limitations among older community-dwelling men

BACKGROUND

Lower urinary tract symptoms (LUTS) are associated with frailty phenotype, a risk factor for functional decline. Our objective was to determine the association between baseline LUTS and 2-year risk of new functional limitation among older men.

METHODS

We analyzed data from the Osteoporotic Fractures in Men (MrOS) study with baseline at Year 7 and follow-up through Year 9. Participants included 2716 community-dwelling men age ≥ 71 years without any baseline self-reported functional limitation. LUTS severity (American Urologic Association Symptom Index) was classified as none/mild (score 0-7), moderate (8-19), and severe (20-35). At baseline and follow-up, men reported their ability to complete several mobility, activities of daily living (ADLs), and cognition-dependent tasks. Risk was estimated for 3 incident functional limitation outcomes: (1) mobility (any difficulty walking 2-3 blocks or climbing 10 steps), (2) ADL (any difficulty bathing, showering, or transferring), and (3) cognition-dependent (any difficulty managing money or medications). We used Poisson regression with a robust variance estimator to model adjusted risk ratios (ARR) and 95% CIs controlling for age, site, and comorbidities; other demographic/lifestyle factors did not meet criteria for inclusion.

RESULTS

Overall, the 2-year risk was 15% for mobility, 10% for ADLs, and 4% for cognition-dependent task limitations. Compared to none/mild LUTS, risk of incident mobility limitations was increased for moderate (ARR = 1.35, 95% CI: 1.12, 1.63) and severe LUTS (ARR = 1.98, 95% CI: 1.48, 2.64). Men were also at higher risk for incident ADL limitations if they reported moderate (ARR = 1.32, 95% CI: 1.05, 1.67) and severe LUTS (ARR = 1.62, 95% CI: 1.07,2.43). Results were somewhat attenuated after adjusting for the frailty phenotype but remained statistically significant. LUTS were not associated with incident cognition-dependent task limitations.

CONCLUSIONS

LUTS severity is associated with incident mobility and ADL limitations among older men. Increased clinical attention to risk of functional limitations among older men with LUTS is likely warranted.

Predictive value of preoperative comprehensive evaluation on the efficacy of HoLEP

Background

With the aging of the population, prostate hyperplasia is more and more perplexing to the old men. This study aimed to evaluate the predictive value of international prostatic symptom score-voiding/storage score ratio (IPSS-V/S), urodynamic examination, intravesical prostatic protrusion (IPP) and residual urine volume (RUV) on the efficacy of holmium laser enucleation of the prostate (HoLEP) before operation.

Methods

Ninety-six patients with benign prostatic hyperplasia (BPH) were enrolled in this study. Each patient was diagnosed as BPH and completed all the evaluations as described above before the same urologist surgeon performed HoLEP. Three months later, another IPSS questionnaire would be finished by each patient to assess the efficacy of the operation. According to the results of IPSS after operation, the group with significant effect and the group with poor effect were divided. Then compare the difference of preoperative examination results between the two groups.

Results

In single factor analysis, the differences of the age, voiding symptom score, V/S, RUV, Qmax and IPP between the two groups were statistically significant (P<0.05). While there was no significant difference in IPSS score and score of urine storage period. In the logistic regression analysis, the age of patients, V/S, RUV, IPP and Qmax can establish a good prediction model. In this model, the younger the patients are, the less the RUV is, the larger the V/S and IPP are, the more likely they are to achieve good efficacy of HoLEP.

Conclusions

In conclusion, HoLEP was more effective in BPH patients with younger age, more IPP, less RUV, less Qmax and those whose IPSS score was mainly based on voiding symptoms.

Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes

This study was aimed to compare serial long-term postoperative changes in quality-of-life (QoL) between photoselective-vaporization (PVP) using 120W-High-Performance-System and holmium-laser-enucleation (HoLEP) in benign-prostatic-hyperplasia (BPH) patients and to identify factors influencing the QoL improvement at the short-term, mid-term and long-term follow-up visits after surgery. We analyzed 1,193 patients with a baseline QoL-index ≥2 who underwent PVP (n = 439) or HoLEP (n = 754). Surgical outcomes were serially compared between the two groups at up to 60-months using the International-Prostatic-Symptom-Score (I-PSS), uroflowmetry, and serum PSA. We used logistic regression analysis to identify predictors of QoL improvement (a reduction in the QoL-index ≥50% compared with baseline) at the short-term (12-months), mid-term (36-months), and long term (60-months) follow-up after surgery. In both groups, the QoL-index was decreased throughout the entire follow-up period compared with that at baseline. There were no significant differences in postoperative changes from the baseline QoL-index between the two groups during the 48-month follow-up, except at 60-months. The degree of improvement in QoL at 60-months after HoLEP was greater than that after PVP. A lower baseline storage-symptom-subscore and a higher bladder-outlet-obstruction-index (BOOI) were independent factors influencing QoL improvement at the short-term. No independent factor influences QoL improvement at the mid- or long-term.

Genetic variants in 5p13.2 and 7q21.1 are associated with treatment for benign prostatic hyperplasia with the α-adrenergic receptor antagonist

BACKGROUND

The etiology of benign prostatic hyperplasia (BPH) has not been well established. The preferred medical treatment for many men with symptomatic benign prostatic hyperplasia is either an α-adrenergic receptor antagonist (α-blocker), or a 5α-reductase inhibitor. Single nucleotide polymorphism (SNP) is a powerful tool for successful implementation of individualized treatment.

METHODS

Eighteen SNPs associated with drug efficacy in a Chinese population were genotyped in 790 BPH cases (330 aggressive and 460 non-aggressive BPH cases) and 1008 controls. All BPH patients were treated with α-adrenergic blockers for at least 9 months. We tested the associations between tagging single nucleotide polymorphism and BPH risk/aggressiveness, clinical characteristics at baseline, including the International Prostate Symptom Score (IPSS) and total prostate volume, and changes in clinical characteristics after treatment.

RESULTS

There were nine SNPs associated with BPH risk, clinical progression and therapeutic effect. (1) There were nine tSNPs been chosen in CYP3A4, CYP3A5 and RANBP3L genes. (2) The SNP, rs16902947 in RANBP3L at 5p13.2 (p = .01), was significantly associated with BPH. (3) We found two SNPs, rs16902947 in RANBP3L at 5p13.2 (p = .0388) and rs4646437 in CYP3A4 at 7q21.1 (p = .0325), associated with drug effect. (4) Allele "G" for rs16902947 was found to be risk alleles for BPH risk (OR= 2.357, 95%CI 1.01-1.48). The "A" allele of rs4646437 was associated with lower IPSS at baseline (β= -0.4232, p= .03255).

CONCLUSIONS

rs16902947, rs16902947 and rs4646437 single nucleotide polymorphisms are significantly associated with the clinical characteristics of benign prostatic hyperplasia and the efficacy of benign prostatic hyperplasia treatment.

Long-term dutasteride therapy in men with benign prostatic hyperplasia alters glucose and lipid profiles and increases severity of erectile dysfunction

Background Dutasteride has been successfully used in treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). However, dutasteride inhibits 5α-reductase type 1 and type 2 enzymes and may compromises glucocorticoids and androgen metabolism and alters metabolic function resulting in undesirable metabolic and sexual adverse side effects. Aim The aim of this study was to investigate the long-term adverse effects of dutasteride therapy in men with BPH on: i) blood glucose, ii) glycated hemoglobin (HbA1c), iii) low density lipoprotein-cholesterol (LDL-C); high density lipoprotein-cholesterol (HDL-C) and total cholesterol (TC), iv) testosterone (T), v) liver alanine and aspartate aminotransferases (ALT and AST) and vi) erectile dysfunction (ED). Methods A retrospective registry study, with a cohort of 230 men aged between 47 and 68 years (mean 57.78 ± 4.81) were treated with dutasteride (0.5 mg/day) for LUTS, secondary to BPH. A second cohort of 230 men aged between 52 and 72 years (mean 62.62 ± 4.65) were treated with tamsulosin (0.4 mg). All men were followed up for 36-42 months. At intervals of 3-6 months, and at each visit, plasma glucose, HbA1c, TC, LDL-cholesterol, T levels and liver alanine amino transferase (ALT) and aspartate aminotransferase (AST) were determined. Further patient assessment was made by the International Index of Erectile Function (IIEF-EF) questionnaire, the Aging Male Symptom (AMS) and International Prostate Symptom Scores (IPSS). Results Long-term treatment with dutasteride therapy is associated with significant improvements in LUTS, as assessed by reduction in prostate volume, IPSS and prostate specific antigen (PSA). Long-term dutasteride therapy, however, resulted in increased blood glucose, HbA1c, TC and LDL levels, ALT and AST activities, AMS Score and reduced T levels and worsened ED as assessed by the IIEF-EF scores. No worsening of ED, glucose, HbA1c, ALT, AST, AMS were observed in men treated with tamsulosin. Most importantly, long-term dutasteride therapy resulted in reduction in total T levels, contributing to a state of hypogonadism. Conclusion Our findings suggest that long-term dutasteride therapy produces worsening of ED, reduced T levels and increased glucose, HbA1c and alters lipid profiles, suggesting induced imbalance in metabolic function. We strongly recommend that physicians discuss with their patients these potential serious adverse effects of long-term dutasteride therapy prior to instituting this form of treatment.

Finasteride-loaded biodegradable nanoparticles: Near-infrared quantification of plasma and prostate levels

Finasteride is an orally active testosterone 5-alpha-reductase inhibitor that is used for the treatment of benign prostatic hyperplasia as a surgical alternative. The aim of this work was to improve finasteride levels in plasma and prostate through the formulation of biodegradable finasteride nanoparticles and to quantify finasteride levels using near-infrared application. Finasteride nanoparticles were prepared by emulsion solvent evaporation method utilizing the biodegradable polymers poly(lactic- co-glycolic acid) and poly-ϵ-caprolactone. The prepared nanoparticles were characterized by particle size, zeta potential, and encapsulation efficiency. The selected finasteride-biodegradable formula was examined in vivo, and both plasma and prostate levels of finasteride were quantified utilizing near-infrared technique. Results revealed that the prepared finasteride nanoparticles size range was from 231 ± 78 to 956 ± 224 nm with finasteride–poly-ϵ-caprolactone nanoparticles showing larger particle sizes compared with finasteride–poly(lactic- co-glycolic acid) nanoparticles. The encapsulation efficiency ranged from 68.89% ± 2.99% to 99.15% ± 4.32%. The selected formula of finasteride nanoparticles showed improved levels of finasteride in both plasma and prostate of the investigated rats. The realization of sustained release of biodegradable finasteride nanoparticles for possible oral or parenteral application could improve the activity of the drug for sustaining release time with lower dosing recurrence that improves patient compliance.

Current consensus and controversy on the treatment of male lower urinary tract symptoms/benign prostatic hyperplasia

Lower urinary tract symptoms (LUTS) are highly prevalent in men and increase with age. Because LUTS are common among elderly men, they are usually considered synonymous with benign prostatic hyperplasia (BPH). Drugs should be the first-line treatment for BPH and surgical intervention should be performed only when there are complications or LUTS refractory to medical treatment. In addition to medical treatment, several minimally invasive therapies, such as thermal therapy, prostatic lift, laser evaporation, or laser enucleation techniques have been developed. Recent investigations have also revealed that bladder dysfunction such as detrusor overactivity and detrusor underactivity may also contribute to male LUTS. In the treatment of LUTS suggestive of BPH (LUTS/BPH), the following questions should be considered: Is there an obstruction? Are we treating BPH or LUTS? Can management targeting BPH reduce LUTS? Should patients with LUTS be treated before bladder outlet obstruction is confirmed? What is the role of transurethral resection of the prostate (TURP) nowadays? Will new techniques provide better outcomes than TURP? This article discusses the current consensus and controversies in the treatment of LUTS/BPH.

Prospective assessment of health-related quality of life in men with late-onset hypogonadism who received testosterone replacement therapy

The objective of this study was to characterise the status of health-related quality of life (HRQOL) in Japanese men with late-onset hypogonadism (LOH) treated with testosterone replacement therapy (TRT). HRQOL in 69 consecutive Japanese men with LOH undergoing TRT for at least 6 months was prospectively evaluated before and 6 months after the initiation of TRT using the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8). All eight-scale scores except for bodily pain (BP) in the 69 patients at 6 months after the introduction of TRT significantly improved compared with those before TRT; however, all scale scores except for BP in the 69 patients were significantly inferior to those in age-matched Japanese controls irrespective of the timing of SF-8. Multivariate analyses of several parameters revealed that both age and Aging Male Symptom (AMS) score had an independent impact on mental health (MH), despite the lack of an independent association between any score and the remaining factors examined. TRT appeared to significantly improve the status of HRQOL in men with LOH; however, even after the introduction of TRT, HRQOL associated with MH remained significantly impaired in elderly men and/or those with a high AMS score.

Association between single nucleotide polymorphism of vitamin D receptor gene FokI polymorphism and clinical progress of benign prostatic hyperplasia

Background. The aim of the study was to investigate the association between single nucleotide polymorphism (SNP) of vitamin D receptor (VDR) gene and clinical progress of benign prostatic hyperplasia (BPH) in Chinese men. Methods. The DNA was extracted from blood of 200 BPH patients with operation (progression group) and 200 patients without operation (control group), respectively. The genotypes of VDR gene FokI SNP represented by “F/f” were identified by PCR-restriction fragment length polymorphism. The odds ratio (OR) of having progression of BPH for having the genotype were calculated. Results. Our date indicated that the f alleles of the VDR gene FokI SNP associated with the progression of BPH (P = 0.009). Conclusion. For the first time, our study demonstrated that VDR gene FokI SNP may be associated with the risk of BPH progress.

Phosphodiesterase inhibitors for treatment of voiding dysfunction: An overview of experimental and clinical evidence

Recently, the focus of the origin of lower urinary tract symptoms (LUTS) has change from the prostate to the bladder. Regardless of the underlying mechanism associated with the origin of LUTS, alpha-blockers continue to be the most common medicine prescribed to treat LUTS due to benign prostatic obstruction (BPO). The newest class of drug introduced to treat LUTS/BPO is phosphodiesterase inhibitors (PDEi) and the aim of this study was to review the role of PDEi in the treatment of LUTS/BPO. In this review, the first evidence was evaluated based on epidemiological studies followed by randomized clinical trials which provide evidence on the administration of PDEi in patients with LUTS/BPO. Experimental studies were also assessed to tentatively elucidate the association between LUTS and erectile dysfunction, and to elucidate the underlying mechanism. There is still controversy regarding the administration of PDEi due to the fear of detrusor impairment, response to acute administration, and the effects of PDEi combined with alpha-blockers. Following this review, we conclude that treatment of BPO/LUTS with PDEi is beneficial, based on experimental studies, strong evidence and the large number of randomized clinical trials confirming their efficiency.

Nanostructured systems containing babassu (Orbignya speciosa) oil as a potential alternative therapy for benign prostatic hyperplasia

The oil of babassu tree nuts (Orbignya speciosa) is a potential alternative for treatment and prophylaxis of benign prostatic hyperplasia. Improved results can be obtained by drug vectorization to the hyperplastic tissue. The main objective of this work was the preparation and characterization of poly(lactic-co-glycolic acid) (PLGA) nanoparticle and clay nanosystems containing babassu oil (BBS). BBS was extracted from the kernels of babassu tree nuts and characterized by gas chromatography-mass spectrometry as well as 1H and 13C nuclear magnetic resonance. BBS-clay nanosystems were obtained by adding polyvinylpyrrolidone, Viscogel B8®, and BBS at a 2:1:1 mass ratio and characterized by X-ray diffraction, thermogravimetric analysis, infrared spectroscopy, and laser diffraction. The PLGA-BBS nanoparticles were prepared by the precipitation-solvent evaporation method. Mean diameter, polydispersity, zeta potential, and scanning electron microscopic images of the nanosystems were analyzed. Thermogravimetric analysis showed successful formation of the nanocomposite. PLGA nanoparticles containing BBS were obtained, with a suitable size that was confirmed by scanning electron microscopy. Both nanostructured systems showed active incorporation yields exceeding 90%. The two systems obtained represent a new and potentially efficient therapy for benign prostatic hyperplasia.