Pharmacology of the lower urinary tract: update on LUTS treatment

Developmental polychlorinated biphenyl (PCB) exposure impacts on voiding physiology persist into adulthood and influence sensitivity to bladder stimuli in mice

Polychlorinated biphenyls (PCBs) are toxicants present in the environment, foodstuff, animal and human tissues. PCBs are linked to numerous adverse health effects; however, impacts of developmental PCB exposure on lower urinary tract function are a comparatively newer area of interest. We have previously found developmental exposure (in utero and lactational) to a human-relevant PCB mixture in mice leads to sex- and dose- dependent changes to urinary voiding physiology at 6 weeks of age. This study expands upon previous findings to investigate if developmental PCB-induced urinary voiding phenotypes persist or shift as mice age to 12 weeks of age. Urinary voiding physiology testing through void spot assays, uroflowmetry, and cystometry demonstrated several sex- and dose- dependent effects of PCB exposure at 12 weeks of age. Further, patterns of dysfunction were either maintained, newly acquired, or reversed compared to those from younger adult mice in a previous study. Here, developmental PCB exposure decreased number of small urine spots in adult male and female mice in a dose dependent manner, and female mice had more frequent voiding events assessed by anesthetized cystometry. Mice also had PCB dose-dependent changes to urinary voiding physiology when challenged with intravesical capsaicin infusion to target transient receptor potential cation channel subfamily V member 1 (TRPV1)-mediated pathways. PCBs either blocked or exacerbated capsaicin induced responses depending on the endpoint examined, suggesting this pathway may play a role in PCB-dependent changes in voiding. PCBs also had subtle impacts on prostate wet weight, with high PCB doses reducing tissue mass compared to low PCB doses, while none differed from vehicle. This study demonstrates developmental exposure to PCBs continues to impact lower urinary tract function in adulthood to at least 12 weeks of age both during homeostatic conditions and upon challenge of capsaicin. Better understanding of how early life stressors like PCBs contribute to aging-associated voiding dysfunction are imperative as these findings may help mitigate risk or improve treatment strategies for patients suffering from lower urinary tract symptoms.

Inhibition of LIMK reduces contraction and proliferation in bladder smooth muscle induced by TGF- β1

Overactive bladder (OAB) significantly impacts quality of life and poses substantial healthcare costs. Despite current treatments, there is an unmet need for innovative therapeutic strategies due to limited efficacy and high discontinuation rates. Our study aimed to investigate the role of transforming growth factor-β1 (TGF-β1) in bladder smooth muscle contraction and the potential of Lim kinase (LIMK) inhibitors in reducing TGF-β1-induced effects, offering a novel approach to OAB treatment. We found elevated urinary TGF-β1 levels in benign prostate hyperplasia (BPH) patients with OAB compared to those without. TGF-β1 significantly enhanced acetylcholine-induced detrusor contractions in rat detrusor, which were attenuated by LIMK inhibitors (SR7826 and LIMKi3). TGF-β1 also induced actin cytoskeleton reorganization and increased proliferation inhuman bladder smooth muscle cells (HBSMCs), both of which were inhibited by LIMK inhibitors in a dose-dependent manner. In conclusion, TGF-β1 appears to play a critical role in the pathophysiology of OAB by promoting detrusor contraction and smooth muscle cell proliferation. Inhibition of LIMK represents a potential therapeutic strategy for OAB by countering TGF-β1-induced effects. Further in vivo studies are warranted to explore the clinical implications of these findings.

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

Prostatic Therapeutic Efficacy of LENILUTS®, a Novel Formulation with Multi-Active Principles

Lower Urinary Tract Symptoms (LUTs) in men are usually associated to benign prostatic hyperplasia (BPH), a non-malignant prostate enlargement. Unfortunately, BPH etiology is still unclear. Recent works highlighted a relevant inflammation role in BPH onset and development. Consequently, to complement the 5-α reductase (and α-adrenergic receptor agonists-based therapy, an anti-inflammatory therapy should be devised. To reduce potential adverse effects of multi-drug treatment, plant extract-based therapies are becoming increasingly common. Serenoa repens, the main phytotherapic treatment for BPH, is not sufficient to front the multi-faceted etiology of BPH. In response to this, a novel, multiple phytotherapic agents-based formulation, LENILUTS®, was developed. In the present work, we compared, using an in vitro approach, the prostatic safety and efficacy of LENILUTS® with a commercial formulation, based only on Serenoa repens, and a 5αR inhibitor, Dutasteride. Furthermore, preliminary in vitro experiments to investigate the active principles, bioaccessibility and bioavailability of LENILUTS® were performed. Our results showed a better prostatic safety and therapeutic efficacy of LENILUTS® compared to the commercial formulation and Dutasteride, with increased anti-inflammatory, and pro-apoptotic activity, and a stronger inhibitory effect on the release of the key enzyme 5αR and Prostatic-Specific Antigen (PSA). The limited bioaccessibility and bioavailability of the active principles of LENILUTS® were highlighted. Considering the results obtained, the LENILUTS® formulation is more promising for BPH and LUTs therapy compared to formulations based on Serenoa repens only, but further efforts should be made to improve the bioaccessibility and bioavailability of the active principles.

Emerging drugs for the treatment of bladder storage dysfunction

INTRODUCTION

Current drug treatment of lower urinary tract disorders, for example, overactive bladder syndrome and lower urinary tract symptoms associated with benign prostatic hyperplasia, is moderately effective, has a low treatment persistence and some short- and long-term adverse events. Even if combination therapy with approved drugs may offer advantages in some patients, there is still a need for new agents.

AREAS COVERED

New b₃-adrenoceptor agonists, antimuscarinics, the naked Maxi-K channel gene, a novel 5HT/NA reuptake inhibitor and soluble guanylate cyclase activators are discussed. Focus is given to P2X3 receptor antagonists, small molecule blockers of TRP channels, the roles of cannabis on incontinence in patients with multiple sclerosis, and of drugs acting directly on CB1 and CB2 receptor or indirectly via endocannabinoids by inhibition of fatty acid aminohydrolase.

EXPERT OPINION

New potential alternatives to currently used drugs/drug principles are emerging, but further clinical testing is required before they can be evaluated as therapeutic alternatives. It seems that for the near future individualized treatment with approved drugs and their combinations will be the prevailing therapeutic approach.

Extract from Cucurbita pepo improves BPH symptoms without affecting sexual function: a 24-month noninterventional study

Purpose

To assess the symptoms, quality of life and sexual well-being in patients with lower urinary tract symptoms due to benign prostatic hyperplasia LUTS/BPH treated with pumpkin seed soft extract (PSE) in routine practice.

Methods

This noninterventional study included 130 men treated for up to 24 months. The International Prostate Symptom Score (IPSS) and related quality of life, Aging Males’ Symptoms Scale (AMS), and International Index of Erectile Function (IIEF-5) were recorded. Descriptive statistical methods were applied. The mean with 95% confidence interval (CI) was calculated for the primary end point (change in IPSS after 12-month treatment).

Results

Analysis at 12 months included 83 patients [mean (SD) age 65.2 (8.7) years and IPSS (15.6 (3.4), IPSS-QoL 3.4 (0.9)]. AMS and IIEF-5 indicated mild or mild to moderate disorder regarding sexual well-being and erectile dysfunction, respectively. After 12 months, the mean IPSS change from baseline was − 4.7 (95% CI − 5.4 to − 3.9), with 83% (95% CI 65.3 to 84.1) and 53% (95% CI 42.3 to 63.7) of the patients achieving reductions by at least 3 and 5 points, respectively. The proportion of patients with IPSS-QoL below 3 points (mostly satisfied) was 11% (9/83) at baseline and rose to 62% (51/83) and 73% (40/55) at 12 and 24 months, respectively. AMS and IIEF-5 scores did not indicate a negative impact on sexual function during treatment.

Conclusion

In men with a moderate LUTS suggestive of BPH, a low progression risk and an active sex life, treatment with pumpkin seed soft extract provided symptomatic relief, improved IPSS-QoL, and maintained sexual well-being.

Trial registration

DRKS00010729, June 22, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04036-w.

Management strategies for neurogenic lower urinary tract dysfunction: a qualitative study of the experiences of people with multiple sclerosis and healthcare professionals

PURPOSE

Urinary symptoms are highly prevalent among people with MS. This study aimed to explore the experiences of people with MS and HCPs in managing urinary symptoms and explore their views on using TTNS to treat urinary symptoms.

MATERIALS AND METHODS

Audio-recorded semi-structured, interviews were employed with people with MS and HCPs. All transcribed interviews were exported to NVivo software (Version 12) and analyzed using a reflexive approach to thematic analysis.

RESULTS

Four main themes were identified; The wide-ranging negative impacts of urinary symptoms ("It's limited everything else"), Gaps in urinary services ("Is there somebody like that, sort of specialized in that area?"), Management strategies ("I don't go too far from the toilet in case I need to use one"), and optimism about TTNS ("Are you giving Me Hope?").

CONCLUSION

Urinary symptoms are common and very troublesome for people with MS. Despite their prevalence, many people with MS continue to suffer in silence. People with MS require skilled multidisciplinary services guided by clinical care pathways to improve service provision and to address urinary symptoms. HCP's and people with MS are open to the use of TTNS for urinary symptoms and have clear preferences for location and duration of intervention delivery.Implications for rehabilitationUrinary symptoms are very common and troublesome for people with multiple sclerosis, yet many continue to suffer in silence.People with multiple sclerosis lack knowledge about treatment options for urinary symptoms.There is an on-going need for healthcare provider education on guidelines for screening and managing urinary symptoms in people with MS and the role of specialist urinary service providers.HCP's and people with MS are open to the use of TTNS for urinary symptoms.