Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023

PURPOSE

The purpose of this American Urological Association (AUA) Guideline amendment is to provide a useful reference on the effective evidence-based management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH).

MATERIALS AND METHODS

The Minnesota Evidence Review Team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies relevant to the management of BPH. The guideline was updated in 2023 to capture eligible literature published between September 2020 and October 2022. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

The BPH amendment resulted in changes to statements/supporting text on combination therapy, photoselective vaporization of the prostate (PVP), water vapor thermal therapy (WVTT), laser enucleation, and prostate artery embolization (PAE). A new statement on temporary implanted prostatic devices (TIPD) was added. In addition, statements on transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) were removed and information regarding these legacy technologies was added to the background section. References and the accompanying treatment algorithms were updated to align with the updated text.

CONCLUSION

This guideline seeks to improve clinicians' ability to evaluate and treat patients with BPH/LUTS based on currently available evidence. Future studies will be essential to further support these statements to improve patient care.

When Venom Meets the Heart: A Rare Case of Scorpion Sting-Induced Acute Myocardial Infarction

Scorpion sting cases are everyday encounters in the Emergency Department (ED). However, scorpion sting-induced systemic manifestations are rarely seen. Signs and symptoms of envenomation involve the central nervous system, stimulation of the autonomic nervous system and rarely respiratory and heart failure leading to death. Cardiovascular manifestations are particularly prominent following stings by the Indian red scorpion. This case report is of an 18-year-old male patient who presented to ED with complaints of scorpion sting. Twelve lead electrocardiography (ECG) done was suggestive of acute inferior wall myocardial infarction with raised cardiac markers. He also had autonomic dysfunction in the form of hypertension, hypothermia and priapism. He was treated with an alpha-blocker, dual antiplatelets and analgesics. ECG changes reverted to normal the next day, and he was discharged. So, the anticipation of life-threatening complications of scorpion stings plays a vital role in the treatment and prognosis of patients presenting to ED.

Sympathetic Nervous System and Atherosclerosis

Atherosclerosis is characterized by the narrowing of the arterial lumen due to subendothelial lipid accumulation, with hypercholesterolemia being a major risk factor. Despite the recent advances in effective lipid-lowering therapies, atherosclerosis remains the leading cause of mortality globally, highlighting the need for additional therapeutic strategies. Accumulating evidence suggests that the sympathetic nervous system plays an important role in atherosclerosis. In this article, we reviewed the sympathetic innervation in the vasculature, norepinephrine synthesis and metabolism, sympathetic activity measurement, and common signaling pathways of sympathetic activation. The focus of this paper was to review the effectiveness of pharmacological antagonists or agonists of adrenoceptors (α1, α2, β1, β2, and β3) and renal denervation on atherosclerosis. All five types of adrenoceptors are present in arterial blood vessels. α1 blockers inhibit atherosclerosis but increase the risk of heart failure while α2 agonism may protect against atherosclerosis and newer generations of β blockers and β3 agonists are promising therapies against atherosclerosis; however, new randomized controlled trials are warranted to investigate the effectiveness of these therapies in atherosclerosis inhibition and cardiovascular risk reduction in the future. The role of renal denervation in atherosclerosis inhibition in humans is yet to be established.

The Role and Efficacy of Coenzyme Q10 in the Management of Erectile Dysfunction in a Hypertensive Male: An Interventional Study

Introduction

Erectile dysfunction (ED) is a prevalent medical condition that affects millions of men globally. A number of pharmacological and complementary options are used in the management of ED, including Coenzyme Q10 (CoQ10). Oxidative stress has been linked to the progression of ED, and Co Q10 protects against oxidative damages and improves erectile function as well as the activity of antioxidant enzymes. This study aimed to determine the efficacy of CoQ10 in the treatment of erectile dysfunction in hypertensive males.

Method

An open-labeled parallel arm interventional study was conducted in the cardiology unit of Hayatabad Medical Complex Hospital, Peshawar, Pakistan, from March 2020 to March 2021. Hypertensive male patients (n = 230) were randomly allocated to either receiving 200-gram CoQ10 daily along with their current antihypertensive therapy (n=104) or anti‐hypertensive treatment only (n=105). The patient’s erectile function was assessed at baseline and three months using the International Index of Erectile Function Test (IIEF-5) during the study period.

Result

Of the total 230, 209 (90.87%) patients were included in the final analysis. There were no significant differences in demographics, history of illness, co-morbid conditions, and current medication of both groups. After three months, 21 (20.1%) participants scored more than 17 in the IIEF-5 and no longer had ED. Overall, no significant difference was found in the mean IIEF-5 score between the study group and control group (14.41 ± 4.49 Vs. 15.61 ± 4.82; p=0.06). However, in subgroup analysis, significant improvement in the study group was seen in participants with mild ED (p=0.03).

Conclusion

With the demonstration of its efficacy in hypertensive patients with mild ED, co-enzyme Q10 supplementation can be proposed as a potential candidate in patients with long-term hypertension and can play a role in erectile dysfunction.

Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART I, Initial Work-up and Medical Management

PURPOSE

Benign prostatic hyperplasia (BPH) is a histologic diagnosis describing proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The prevalence and severity of lower urinary tract symptoms (LUTS) in aging men are progressive and impact the health and welfare of society. This revised Guideline provides a useful reference on effective evidence-based management of male LUTS/BPH. See the accompanying algorithm for a summary of the procedures detailed in the Guideline (figures 1 and 2).

MATERIALS AND METHODS

The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible English language studies published between January 2008 and April 2019, then updated through December 2020. Search terms included Medical Subject Headings (MeSH) and keywords for pharmacological therapies, drug classes, and terms related to LUTS or BPH. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table 1).

RESULTS

Nineteen guideline statements pertinent to evaluation, work-up, and medical management were developed. Appropriate levels of evidence and supporting text were created to direct both primary care and urologic providers towards streamlined and suitable practices.

CONCLUSIONS

The work up and medical management of BPH requires attention to individual patient characteristics, while also respecting common principles. Clinicians should adhere to recommendations and familiarize themselves with standards of BPH management.

The Risk of Venous Thromboembolism (VTE) in Men with Benign Prostatic Hyperplasia Treated with 5-Alpha Reductase Inhibitors (5ARIs)

Background

Many men receive 5-alpha reductase inhibitors (5ARIs) for ongoing treatment of benign prostatic hyperplasia (BPH). The increased risk of cardiovascular complications with 5ARIs has been documented in BPH studies and the occurrence of cerebral venous thrombosis, presumably due to increased estrogen level following 5ARI use, was described in multiple case reports. The objective of this study was to determine if 5ARIs with or without alpha blockers (AB) were associated with an increased risk of venous thromboembolism (VTE) in males with BPH.

Methods

We conducted a nested case–control study among a population of men ages 40–79 who received at least one 5ARI or AB prescription for treatment of BPH between 1995 and 2015 in the UK-based Clinical Practice Research Datalink GOLD. Cases of incident VTE (pulmonary embolism [PE] or deep venous thrombosis [DVT]) and matched controls were identified from this population. We used descriptive analyses and conditional logistic regression to evaluate the risk of VTE in users of 5ARIs compared to users of ABs.

Results

For 5ARI only users, the adjusted odds ratios (aORs), (95% CI) for VTE were 1.51 (0.98–2.32) in current 5ARI users and 1.23 (0.70–2.17) in recent/distant past, compared to AB only users. However, the aOR (95% CI) in men who had 50 or more current 5ARI prescriptions compared to users of ABs only was higher: 2.29 (1.14–4.63). For 5ARI with AB use, the aORs, (95% CI) for VTE were 1.16 (0.64–2.10) in current 5ARI+AB users and 1.93 (0.71–5.25) in recent/distant past, compared to AB only users. The aOR (95% CI) in men who had 50 or more current 5ARI+AB prescriptions compared to users of ABs only was 1.65 (0.64–4.26).

Conclusion

Current use of 5ARI, particularly long-term use, is associated with an increased risk of incident idiopathic VTE compared to patients treated with AB use only.

Differences in the Treatment of Benign Prostatic Hyperplasia: Comparing the Primary Care Physician and the Urologist

INTRODUCTION

Benign prostatic hyperplasia is a prevalent chronic condition with expenditures exceeding $1 billion each year. Little is known about management of patients by primary care physicians compared to urologists. We assessed changes in management after medication initiation in these two settings.

METHODS

From the Chronic Condition Warehouse 5% sample of Medicare beneficiaries linked to Medicare Part D data, we defined a cohort of men, 66 to 90 years old, with initial prescriptions for alpha-blocker, 5-alpha reductase inhibitor (5-ARI), or both. We assessed the initial change in therapy for up to four years after medication initiation: add a medication, switch medication, stop medication, or have surgery/retention. We estimated the cumulative incidence functions from competing risks data, and tested equality across groups (primary care physician vs. urologist).

RESULTS

5714 men started medication with a primary care physician, 1970 with a urologist. The most common change in treatment after medication initiation across all groups was medication discontinuation (55% alpha blocker; 46% 5-ARI; 30% combination therapy cumulative incidence at 3 years). Patients who started with primary care physicians were more likely to discontinue BPH-related medications, than patients with urologists (HR 1.19; 95% CI 1.09 - 1.29). The majority of patients who stopped alpha blocker therapy did not have further BPH therapy.

CONCLUSIONS

Men given combination therapy are most likely to have continued medication use. Surgical therapy and retention are relatively rare events. Patients who initiate care with urologists are more likely to continue medical therapy than patients with care initiated by primary care providers.

Efficacy of silodosin in the treatment of distal ureteral stones 4 to 10 mm in diameter

PURPOSE

Few studies have investigated the efficacy of silodosin, a recently introduced selective alpha 1-A adrenoceptor antagonist, in medical expulsive therapy (MET) for ureteral calculi. The results of these studies, which all evaluated the efficacy of 8 mg/day, indicate that silodosin is a potential treatment for ureteral calculi. This study investigated the efficacy of 4 mg/day of silodosin for MET of distal ureteral stones 4 to 10 mm in diameter.

MATERIAL AND METHOD

After 70 patients had been randomized into 2 groups of 35 patients each, both the control and experimental groups (groups 1 and 2, respectively) were advised to take 75 mg/day of diclofenacsodiumas needed for pain relief but only the experimental group to take 4 mg/day of silodosin. After 21 days, the groups were compared regarding the stone expulsion rate and duration, number of renalcolicepisodes, and analgesicdosage.

RESULTS

The median expulsion rates were 71.4% and 91.4% in groups 1 and 2, respectively, and the difference between them was significant (P=0.031). The median expulsion durations were 12.91±6.14 and 8.03±4.99 days, respectively, and the difference between them was significant (P<0.001). No significant differences were found regarding the median number of renal colic episodes or median analgesic dosage. While no patients in group 1 experienced side effects, 5 patients (14%) in group 2 experienced retrograde ejaculation.

CONCLUSION

These results indicate that 4 mg/day of silodos in facilitates the expulsion of distal ureteral stones 4 to 10 mm in diameter but does not significantly reduce the number of renal colic episodes or analgesic dosage.

Alpha blocker and angiotensin-converting enzyme inhibitor in the management of severe pulmonary valve stenosis: from bench to bedside

INTRODUCTION

Neonates with severe pulmonary valve stenosis tend to remain oxygen dependent, despite resolution of the transpulmonary gradient. Alpha 2 blockers – phentolamine – and angiotensin-converting enzyme inhibitors – captopril – were reported to improve oxygen saturation.

OBJECTIVE

To describe the role of phentolamine and captopril in the treatment of these patients.

METHODS

In a retrospective cohort study, 28 neonates with severe pulmonary valve stenosis underwent balloon valvuloplasty. Among them, 20 remained oxygen or prostaglandin dependent after intervention, and were treated with phentolamine or captopril. Oxygen saturation was monitored before and after intervention and following treatment with these medications. Mean duration of hospitalisation was recorded.

RESULTS

Mean age and weight were 25.2 days and 3.1 kg, respectively. Before balloon dilation, 18/20 (90%) neonates were on prostaglandin, whereas after the procedure only 6/18 patients required it. All 20 patients required oxygen after the procedure, and nine patients (45%) were started on phentolamine. Among them, one patient with severe infundibular stenosis did not respond favourably, and 11 patients (55%) were started on captopril. After starting phentolamine or captopril treatment, prostaglandin could be discontinued after a mean time of 15.86 hours. Within <2 days, there was an increase in mean oxygen saturation from 76.6 to 93.0%.

CONCLUSION

Phentolamine and captopril seem to have therapeutic roles in neonates with severe pulmonary valve stenosis who remain oxygen dependent after balloon dilation. Both drugs led to vasodilation of the pulmonary and systemic vascularisation and facilitated inflow to the right ventricle. Right-to-left shunt across a patent foramen ovale or atrial septal defect decreased and saturation improved, leading to a significant reduction in the length of hospitalisation.

Oral drug treatments in patients with erectile dysfunction and multiple comorbidities: a retrospective observational study

OBJECTIVE

To investigate factors associated with demographic/clinical characteristics and drug selection in patients with erectile dysfunction (ED). The prevalence of ED is increasing worldwide. Studies have shown that ED is associated with age, lifestyle and comorbidities. However, the factors associated with patient characteristics as well as drug selection are incompletely understood.

SETTING

A tertiary medical centre in Kuala Lumpur, Malaysia.

PARTICIPANTS

A total of 219 patients (range 23-80 years) who had received phosphodiesterase type-5 (PDE-5) inhibitors as ED treatment were evaluated.

INCLUSION CRITERIA

Adult patients aged ≥18 years, diagnosed with ED, and prescribed with sildenafil, tadalafil or vardenafil.

EXCLUSION CRITERIA

Patients diagnosed with ED but who did not receive any PDE-5 inhibitor, or those with missing data.

PRIMARY AND SECONDARY OUTCOME MEASURES

Factors associated with demographic and clinical characteristics as well as drug selection were assessed.

RESULTS

Ischaemic heart disease (p=0.025), benign prostatic hyperplasia (p<0.001), obesity (p=0.005), lower urinary tract symptoms (LUTS) (p=0.006) and α-blockers (p<0.001) were significantly associated with elderly patients with ED. Additionally, LUTS (p=0.038) and α-blockers (p=0.008) were significantly associated with the selection of PDE-5 inhibitor.

CONCLUSIONS

These data showed that elderly patients with ED were significantly associated with comorbidities and α-blockers, whereas LUTS and α blockers were associated with drug selection.

Alpha antagonists and intraoperative floppy iris syndrome: A spectrum

Background

To determine occurrence of features of intraoperative floppy iris syndrome (IFIS) during cataract surgery in patients taking systemic alpha-antagonists (AA).

Methods

We prospectively studied patients on AA and who underwent phacoemulsification. The following were recorded: pupil diameter preoperatively, iris flaccidity, iris prolapse and peroperative miosis.

Results

We studied 40 eyes of 31 subjects. Mean age was 78 years. Overall, 14 eyes (13 patients) showed signs of IFIS: 9/13 (69%) eyes of patients on tamsulosin, 1/18 (6%) eyes in the doxazosin group, 2/2 prazosin patients, 1/4 eyes in the indoramin group, and 1/2 eyes in two patients on a combination of doxazosin and tamsulosin. Most cases (92%) had only one or two signs of IFIS. Bilateral cataract surgery was undertaken in 9 patients but only one patient (on tamsulosin) had features of IFIS in both eyes, while 4 patients (2 on tamsulosin and 2 on other AA) showed signs of IFIS in one eye only, and 4 patients did not show IFIS in either eye.

Conclusion

Most AA were associated with IFIS, but it tends to present as a spectrum of signs rather than full triad originally described. Tamsulosin was most likely to be associated with IFIS; however, its intake does not necessarily mean that IFIS will occur. For patients on AA, the behavior of the iris intraoperatively in one eye is a poor predictor of the other eye. Surgeons should anticipate the occurrence of IFIS in any patient on AA.

Effects of Silodosin on Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia: Evaluation by Frequency/Volume Chart

OBJECTIVES

To prospectively evaluate the efficacy of silodosin, a new α1A -adrenoceptor selective antagonist, for the treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) on the basis of a frequency/volume chart.

METHODS

Forty male patients (71.1 ± 6.6 years old) with LUTS/BPH were treated with silodosin (4 mg twice daily). The effects of the drug were assessed by changes in International Prostate Symptom Score, uroflowmetry, and frequency/volume chart at 1 and 3 months after therapy.

RESULTS

The mean total International Prostate Symptom Score, the mean total storage and voiding scores and the mean quality of life score decreased significantly at 1 and 3 months after therapy (all P < 0.01). Average and maximum flow rates increased significantly, and postvoid residual volume decreased significantly after 1 and 3 months (all P < 0.05). The frequency/volume chart showed that daytime frequency in those who initially voided over eight times/day (n = 12) decreased significantly (P = 0.0391) after 1 month, and nighttime frequency in those who initially voided over two times (n = 16) tended to decrease (P = 0.0833) after 3 months. Mean voided volume in those who initially voided less than 250 mL (n = 31) increased significantly after 1 and 3 months (P = 0.0446 and P = 0.0138, respectively), and maximum voided volume in those who initially voided less than 300 mL (n = 18) tended to increase (P = 0.0833) after 1 month.

CONCLUSION

Silodosin appears to be effective for both storage and voiding symptoms by increasing bladder capacity in patients with LUTS/BPH.