Relationship between serum prostate-specific antigen and prostate volume in Korean men with benign prostatic hyperplasia: a multicentre study

OBJECTIVES: To evaluate the relationship between prostate specific antigen (PSA) and prostate volume (PV) in Korean men, as PV is a key predictor of both disease progression and response to medical therapy in patients with benign prostatic hyperplasia (BPH), and PSA has been suggested as a proxy marker to estimate the total PV, mainly in Caucasians. PATIENTS AND METHODS: From 1999 to 2004, men aged 50-79 years with lower urinary tract symptoms (LUTS) and BPH were enrolled into this multicentre study. The analyses included 5716 patients presenting to 11 medical centres with LUTS (International Prostate Symptom Score >8, peak urinary flow rate <15 mL/s); they had a mean age of 64.3 years, mean baseline PV of 36.9 mL, and mean baseline PSA level of 2.2 ng/mL. Men with a baseline PSA of >10 ng/mL were excluded, to reduce the likelihood of including occult prostate cancer. A biopsy was taken in those with suspicious findings on a digital rectal examination or serum PSA level of >4 ng/mL, to exclude prostate cancer. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to predict threshold PV in men with BPH. RESULTS: The PV and serum PSA level had an age-dependent log-linear relationship, the strength of which increased with age. The ROC curve analysis showed that PSA had good predictive value for various prostate volume thresholds (30, 40 and 50 mL). CONCLUSIONS: The PSA-PV relationship in Korean men is similar to that in Caucasians, but Korean men have a slightly lower PSA level and a smaller PV than Caucasians. The approximate age-specific criteria for detecting Korean men with a PV of >40 mL were a PSA level of >1.3 ng/mL, >1.7 ng/mL and >2.0 ng/mL for men with BPH in their sixth, seventh and eighth decade, respectively.     

Benign prostatic hyperplasia

Male lower urinary tract symptoms (LUTS) have a multifactorial aetiology and are not simply solely due to bladder outflow obstruction (BOO) from benign prostatic hyperplasia (BPH). Other causes of LUTS include bladder dysfunction, malignant prostatic disease, urethral disease and medical conditions such as polyuria. Complications from BPH include acute urinary retention, urinary tract infection and haematuria. Following investigation, men are treated with medical therapy for BPH using α-blockers and 5α-reductase inhibitors. Some men undergo surgery for their symptoms and this can be in the form of open prostatectomy, transurethral resection of the prostate (TURP) and a variety of laser ablating and enucleating techniques.     

Interactions between prostate volume, filling cystometric estimated parameters, and data from pressure-flow studies in 565 men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

The aim of this study was to establish the characteristics and to investigate the interactions between prostate volume, degree of obstruction, bladder contractility, the prevalence of residual volume, bladder compliance, bladder capacities, and the prevalence of instability in a large, well-defined group of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). The 565 consecutive men included in this study met the criteria of the International Consensus Committee on BPH and voided more than 150 mL during uroflowmetry. Their residual urine volume and prostate size were estimated, and filling cystometry and pressure-flow studies were performed. Fifty-three percent of the men appeared to have obstruction. We found a positive correlation between prostate volume and Sch?fer's obstruction grade, except that mean prostate volume decreased at Sch?fer's grades 5 and 6. Significant negative correlations existed between Sch?fer's grade and cystometric bladder capacity and effective capacity. Bladder outlet obstruction results in incomplete emptying. Of all men, 26% had a significant residual volume ( > 20% of cystometric capacity). Thirty-nine percent did not have residual volume. Of the 565 men, 46% had an unstable bladder. In particular, patients with an unstable bladder in the sitting and lying positions have a significantly higher Sch?fer's grade and contractility grade and a significantly lower cystometric and effective bladder capacity compared with patients without instability. Patients with a residual volume or instability were significantly older. We conclude that in men with LUTS suggestive of BPH, abnormalities of bladder and bladder outlet function vary greatly and have complex mutual interactions.     

Serum prostate-specific antigen as a predictor of prostate volume in Korean men with lower urinary tract symptoms

The aim of the study was to assess the utility of prostate-specific antigen (PSA) as a predictor of prostate volume indexes (total prostate volume (TPV), transition zone volume and transition zone index) in Korean men with lower urinary tract symptoms (LUTS). From September 2003 to April 2006, 3431 patients with LUTS were included in the study; they had a median age of 63.8 years, a median prostate volume of 22.6 ml and a median serum PSA of 1.04 ng/ml. Men with a baseline PSA of >10 ng/ml were excluded, to reduce the likelihood of including occult prostate cancer. Prostate volume indexes and serum PSA levels had an age-dependent log-linear relationship. Receiver operating characteristic curve analysis showed that PSA had good predictive value for various prostate volume indexes thresholds. The approximate age-specific criteria for detecting men with a TPV of >40 ml are PSA levels of 1.20, 1.44 and 1.72 ng/ml for men with LUTS in their sixth, seventh and eighth decades, respectively. The results show that serum PSA identifies Korean men with large prostates reasonably well. Korean men may produce and/or release more PSA per unit prostate volume than white men. The cutoffs for PSA and prostate volume to response to LUTS therapy should be determined in this population.     

Medikamentöse Therapie der benignen Prostatahyperplasie

The majority of men with benign prostatic hyperplasia (BPH) seek medical help because of lower urinary tract symptoms (LUTS). Pharmacological treatment of BPH is indicated if the patient has no absolute indications for prostate surgery or benign prostatic obstruction (BPO), but LUTS with a decrease of quality of life. Plant extracts can be prescribed in men with mild to moderate symptoms. α-Blockers can quickly and effectively decrease LUTS and symptomatic disease progression. If patients have predominantly bladder filling symptoms and a small prostate, muscarinic receptor antagonists are a viable treatment option. The combination of an α-blocker plus a muscarinic receptor antagonist is more effective than single drugs used alone. Especially in men with larger prostates, 5α-reductase inhibitors can decrease LUTS and the probability of acute urinary retention as well as need for prostate surgery. The combination of α-blocker plus 5α-reductase inhibitor can reduce LUTS and disease progression more effectively than single drugs.     

TREATMENT FOR BENIGN PROSTATIC HYPERPLASIA AMONG COMMUNITY DWELLING MEN: THE OLMSTED COUNTY STUDY OF URINARY SYMPTOMS AND HEALTH STATUS

PURPOSE: We describe treatments for benign prostatic hyperplasia (BPH) among men participating in the Olmsted County study of urinary symptoms and health status among men during 10,000 person-years of followup. MATERIALS AND METHODS: A cohort of 2,115 men 40 to 79 years old was randomly selected from an enumeration of the Olmsted County, Minnesota population (55% response rate). Participants completed a previously validated baseline questionnaire to assess symptom severity and voided into a portable urometer. A 25% random subsample underwent transrectal sonographic imaging of the prostate to determine prostate volume and measurement of serum prostate specific antigen. Followup included retrospective review of community medical records and completion of a biennial questionnaire to determine the occurrence of medical and surgical treatment for BPH in the subsequent 6 years. RESULTS: During more than 10,000 person-years of followup 167 men were treated, yielding an overall incidence of 16.0/1,000 person-years. There was a strong age related increase in risk of any treatment from 3.3/1,000 person-years for men 40 to 49 years old to more than 30/1,000 person-years for those 70 years old or older. Men with moderate to severe symptoms (American Urological Association symptom index greater than 7), depressed peak urinary flow rates (less than 12 ml. per second), enlarged prostate (greater than 30 ml.) or elevated serum prostate specific antigen (1.4 ng./ml. or greater) had about 4 times the risk of BPH treatment than those who did not. After adjustment for all measures simultaneously an enlarged prostate (hazard ratio 2.3, 95% confidence interval [CI] 1.1, 4.7), depressed peak flow rate (hazard ratio 2.7, 95% CI 1.4, 5.3) and moderate to severe symptoms (hazard ratio 5.3, 95% CI 2.5, 11.1) at baseline each independently predicted subsequent treatment. CONCLUSIONS: While repeat contact and availability of urological measurements during the study period may have influenced treatment decisions in this cohort, the data demonstrate that treatment is common in elderly men with nearly 1 in 4 receiving treatment in the eighth decade of life. Furthermore, these data suggest that men with moderate to severe lower urinary tract symptoms, impaired flow rates or enlarged prostates are more likely to undergo treatment, with increases in risk of similar magnitude to those associated with adverse outcomes, such as acute urinary retention.     

Diabetes and sexual dysfunction: results from the Olmsted County study of urinary symptoms and health status among men

PURPOSE: We examined the association of diabetes and domains of sexual dysfunction in a population based sample of men residing in Olmsted County, Minnesota. MATERIALS AND METHODS: A cohort of 2,115 white men 40 to 79 years old as of January 1, 1990 was randomly selected from the Olmsted County population. Men who had a history of prostate or bladder surgery, urethral surgery or stricture, or medical or other neurological condition that could affect normal urinary function were excluded from analysis. Diabetes itself was not used as an exclusionary criterion, although those with end stage organ failure as a result of diabetes were excluded. A previously validated male sexual function index was included in the questionnaires administrated to the cohort in 1996, which consisted of 11 questions on the 5 sexual function domains of sexual drive, erectile function, ejaculatory function, sexual problem assessment and sexual satisfaction. The baseline questionnaire also included whether they had ever been diagnosed by a physician as having diabetes. Only men with regular sexual partners were included. RESULTS: Individuals with diabetes at baseline had significantly greater dysfunction in all 5 sexual function domains. In multivariate adjusted analyses diabetes was significantly associated with all sexual dysfunction domains. The associations remained significant after adjusting for numerous predictors of sexual dysfunction. CONCLUSIONS: The presence of diabetes at baseline was significantly associated not only with erectile dysfunction but with all aspects of sexual dysfunction, including sexual drive, ejaculatory function, sexual problems and sexual satisfaction in this population based sample of men residing in Olmsted County.     

Botulinum toxin A treatment for lower urinary tract symptoms/benign prostatic hyperplasia

Botulinum toxin A (BoNT-A) has been widely used in the treatment of overactive bladder and neurogenic detrusor overactivity. Recently, prostatic injection of BoNT-A had been tried to reduce the prostate volume and relieve lower urinary tract symptoms (LUTS) in patients with benign prostatic enlargement (BPE) due to benign prostatic hyperplasia (BPH). However, the efficacy of BoNT-A on BPE is still controversial. Traditionally, male LUTS have been considered as synonym of BPE because most male LUTS developed in aging men. Recent investigations have revealed that bladder dysfunction and bladder outlet dysfunction other than BPE contribute equally in male LUTS. Injecting BoNT-A into the prostatic urethra and bladder neck yielded improvement of LUTS, but not reduction of the prostatic volume, especially in men with small prostatic volume. The therapeutic effects of BoNT-A on LUTS might not be due to prostatic volume reduction, but through inhibiting the adrenergic hyperactivity in men with LUTS/BPH. This article discusses the current consensus and controversy of BoNT-A treatment on LUTS/BPH.     

Sustained beneficial effects of intraprostatic botulinum toxin type A on lower urinary tract symptoms and quality of life in men with benign prostatic hyperplasia

OBJECTIVE: To present a comprehensive experience with intraprostatic botulinum toxin-type A (BoNT-A) injection in men with symptomatic benign prostatic hyperplasia (BPH) and to assess the efficacy on lower urinary tract symptoms (LUTS) and quality of life (QoL). PATIENTS AND METHODS: In all, 41 men (mean age 69.1 years, sd 7.1 ) with an International Prostate Symptom Score of > or = 8, peak flow rate of < 12 mL/s, and who were refractory to medical treatment were injected with BoNT-A (Botox, Allergan, Inc., CA, USA) at 100 U (21 men, for prostate volume < 30 mL) or 200 U (20, for prostate volume > 30 mL) into the prostate transperineally under transrectal ultrasonography guidance. Study exclusion criteria were confirmed or suspected malignancy, previous pelvic surgery or trauma and previous invasive treatment for BPH. The clinical effects were evaluated at baseline and at 1, 3 and 6 months after treatment. RESULTS: There were no significant local or systemic side-effects in any men. LUTS and QoL indices improved by > 30% in 31 of the 41 men (76%), and four of five men with urinary retention for > 1 month could void spontaneously at 1 week to 1 month after the BoNT-A injection. In 12 of 41 men (29%) there was no change in prostate volume, yet seven of these men still had a > 30% improvement in maximum flow rate, LUTS and QoL. The efficacy was sustained at 12 months. CONCLUSION: BoNT-A injected into the prostate is safe and effective for men with symptomatic BPH. The mechanisms of relief of symptoms might not depend totally on the volume shrinkage; the inhibitory effect on the smooth muscle tone and aberrant sensory function might also be important.     

Medikamentöse Therapie des benignen Prostatasyndroms

The pharmacological treatment of benign prostatic hyperplasia (BPH) is indicated when men suffer from lower urinary tract symptoms (LUTS) but there are no absolute indications for prostate surgery or severe bladder outlet obstruction. Phytotherapy can be used in men with mild to moderate LUTS and alpha-blockers can quickly and effectively decrease the LUTS and symptomatic disease progression. Phosphodiesterase type 5 inhibitors (PDE5-I) are an alternative to alpha-blockers when men experience bothersome side effects from alpha-blockers or erectile dysfunction. If patients predominantly have bladder storage symptoms and a small prostate, muscarinic receptor antagonists are a viable treatment option. The combination of alpha-blocker plus muscarinic receptor antagonist is more efficacious in reducing LUTS than the single drugs alone. The 5 alpha-reductase inhibitors (5ARI) can significantly decrease LUTS and disease progression (e.g. acute urinary retention and need for prostate surgery) in men with larger prostates (>?30–40 ml). The combination of 5ARI plus alpha-blocker can reduce LUTS and disease progression more effectively than drug monotherapy. Combination therapy with PDE5-I (tadalafil) plus 5ARI (finasteride) reduces LUTS more substantially than 5ARI alone and, additionally, PDE5-Is reduce the sexual side effects during 5ARI treatment.     

Rising PSA in patients with minor LUTS without evidence of prostatic carcinoma: a missing link?

Objectives To determine the role of pressure flowmetry in patients without bothersome lower urinary tract symptoms (LUTS), rising prostate-specific antigen (PSA) levels and diagnosed as having clinical benign prostatic hyperplasia (BPH) after negative (multiple) extended multi-site biopsy. Methods The study enrolled patients with minor LUTS who were referred to our urological practice by their general practitioner because of a rising PSA level (≥4 ng/ml). After exclusion of clinical prostatic carcinoma by digital rectal examination and transrectal ultrasound, all patients underwent at least one set of extended multi-site biopsies to exclude T1c prostate cancer. Patients with negative biopsies (clinical BPH) were subjected to pressure flowmetry whereafter those with bladder outlet obstruction underwent TURP. Results The study included 82 patients, with a mean age of 64.8 years (50.2–78.2 years), satisfying the inclusion criteria. Urodynamic analysis showed that all patients had bladder outlet obstruction. After TURP, eight patients (9.8%) were diagnosed as having histologically proven prostate cancer; 74 patients (90.2%) were diagnosed as having BPH. Patients of the BPH group had a mean preoperative PSA level of 8.8 ng/ml (4.3–25.8 ng/ml) and a mean international prostate symptom score of 8.8 (2–18). The mean detrusor pressure at maximum flow in BPH patients was 89.5 cmH₂O (20–200 cmH₂O). Conclusions An increased PSA in patients with minor or no LUTS, clinical BPH and negative extended multi-site prostate biopsy is strongly correlated to bladder outlet obstruction. Therefore, patients with these characteristics should be treated with TURP.     

Non-steroidal anti-inflammatory drug use and the risk of benign prostatic hyperplasia-related outcomes and nocturia in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

Study Type – Therapy (cohort) Level of Evidence 4 What's known on the subject? and What does the study add? Accumulating evidence suggests that inflammation may contribute to the development of BPH and LUTS. Therefore, it is plausible that anti‐inflammatory agents, such as aspirin and other NSAIDs, may reduce the risk of BPH/LUTS, as was observed in a recent analysis of daily aspirin use and BPH/LUTS risk in the Olmsted County Study of Urinary Symptoms and Health Status in Men. The present study, conducted in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, found no association for recent aspirin or ibuprofen use with the risk of BPH/LUTS.

OBJECTIVE

• ? To investigate the relationship between non‐steroidal anti‐inflammatory drug (NSAID) use and the incidence of benign prostatic hyperplasia (BPH)‐related outcomes and nocturia, a lower urinary tract symptom (LUTS) of BPH, in light of accumulating evidence suggesting a role for inflammation in BPH/LUTS development.

PATIENTS AND METHODS

• ? At baseline, participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial completed questions on recent, regular aspirin and ibuprofen use, BPH surgery, diagnosis of an enlarged prostate/BPH, and nocturia. Participants in the intervention arm also underwent a digital rectal examination (DRE), from which prostate dimensions were estimated, as well as a prostate‐specific antigen (PSA) test. Only participants in the intervention arm without BPH/LUTS at baseline were included in the analysis (n= 4771).
• ? During follow‐up, participants underwent annual DREs and PSA tests, provided annual information on finasteride use, and completed a supplemental questionnaire in 2006–2008 that included additional questions on diagnosis of an enlarged prostate/BPH and nocturia.
• ? Information collected was used to investigate regular aspirin or ibuprofen use in relation to the incidence of six BPH/LUTS definitions: diagnosis of an enlarged prostate/BPH, nocturia (waking two or more times per night to urinate), finasteride use, any self‐reported BPH/LUTS, prostate enlargement (estimated prostate volume ≥30 mL on any follow‐up DRE) and elevation in PSA level (>1.4 ng/mL on any follow‐up PSA test).

RESULTS

• ? Generally, null results were observed for any recent, regular aspirin or ibuprofen use (risk ratio = 0.92–1.21, P= 0.043–0.91) and frequency of use (risk ratios for one category increase in NSAID use = 0.98–1.11, P‐trends = 0.10–0.99) with incident BPH/LUTS.

CONCLUSION

• ? The findings obtained in the present study do not support a protective role for recent NSAID use in BPH/LUTS development.

     

Prevalence and factors associated with uncomplicated storage and voiding lower urinary tract symptoms in community-dwelling Australian men

Purpose

To determine the prevalence of, and associated risk factors for, voiding and storage lower urinary tract symptoms (LUTS) in a population-based sample of Australian men.

Methods

Data were collected from 1,103 men randomly selected, community-dwelling men, as part of the Florey Adelaide Male Ageing Study, after exclusion of men with prostate or bladder cancer or prior surgery to either organ. The presence of LUTS was assessed using the International Prostate Symptom Score. Urine flow was measured via flow meter. Demographic, clinical, and bio-psychosocial data were collected by questionnaire.

Results

The prevalence of total, storage, and voiding LUTS was 18.1, 28.0 and 12.6%, respectively. The most common storage symptoms were frequency (12.3%), nocturia (9.9%) and urgency (8.1%), and voiding symptoms were weak stream (8.5%), intermittency (5.4%), incomplete emptying (5.1%) and straining (2.4%). There were linear associations between storage LUTS and increased abdominal fat mass, plasma glucose and low HDL cholesterol (components of the metabolic syndrome), obstructive sleep apnoea (OSA) risk, and retirement. Voiding symptoms were associated with a previous diagnosis of benign prostatic enlargement (BPH), mean peak urine flow, total energy intake, elevated risk of OSA, erectile dysfunction, physician-diagnosed thyroid dysfunction and higher household income.

Conclusions

The close association of storage LUTS with the metabolic syndrome, and of both storage and voiding LUTS with OSA, suggest that these conditions should be considered in men presenting with LUTS.     

The natural history of benign prostatic hyperplasia

The progression of benign prostatic hyperplasia (BPH) can be defined as a deterioration of clinical variables such as lower urinary tract symptoms (LUTS), health-related quality of life and peak flow rate, increased prostate size, or unfavourable outcomes such as acute urinary retention (AUR) and BPH-related surgery. The natural history of BPH is best analysed from longitudinal studies of community-dwelling men. In the Olmsted county study, which followed for 12 years a randomly selected cohort of 2115 men aged 40-79 years, there was an average increase in the International Prostate Symptom Score (IPSS) of 0.18 points per year, ranging from 0.05 for men in their fifties to 0.44 for those in their seventies. There was also a decrease in peak flow rate of 2% per year and a median prostate growth of 1.9% per year. The cumulative incidence of AUR was low (2.7% over 4 years). Information can also be collected from the placebo arms of controlled studies of men with symptomatic BPH, although the strict trial inclusion criteria and indeed the taking of a placebo itself introduce biases which limit the analysis of the natural history of the disease in this way, and its applicability to the general population. Hence, in the Medical Therapy of Prostatic Symptoms study, there is clear evidence that symptom deterioration, defined by a worsening of the IPSS of > or = 4 points, was by far the most prevalent progression event (79.5%), with a cumulative incidence of 14% over a mean follow-up of 4.5 years. As in the longitudinal community-based studies, AUR was rather uncommon (14.8% of overall progression events) with a cumulative incidence of 2%. BPH-related surgery, which was a secondary criterion in the study, was required in 5% of men. Similar conclusions can be drawn from a 2-year placebo-controlled study (ALTESS) assessing the impact of alfuzosin 10 mg once daily on LUTS/BPH progression in 1522 men with symptomatic BPH at high risk of developing AUR. Symptom deterioration was clearly the main progression event, with a cumulative incidence of 16.8%, compared to BPH-related surgery (6.5%) and AUR (2.2%). Thus, there is evidence from longitudinal studies, and to a lesser extent from the placebo arms of large controlled studies, that BPH is a progressive disease. Symptom worsening is by far the most frequently occurring progression event. Identifying those patients at risk of BPH progression is crucial to optimize their management.     

Effect of diabetes mellitus on lower urinary tract symptoms and dysfunction in patients with benign prostatic hyperplasia

This article reviews the recent literature on men with diabetes mellitus (DM) and concomitant lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Diabetes is reported to be associated with greater BPH symptom severity. Men with non-insulin-dependent diabetes had the highest median annual prostate growth rate compared with those who had other metabolic disease. Urodynamic evaluations in the reviewed studies were absent. Extensive diagnostic evaluations with urodynamics in our outpatient department revealed that patients with LUTS suggestive of BPH and with concomitant DM hardly differed from those without DM.     

When to Treat the Prostate,the Bladder,or Both?

ContextPharmacological therapy for relieving lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) has evolved during the past years. The possible benefits of combination therapies to prevent disease progression or to treat LUTS/BPH with concomitant overactive bladder (OAB) or erectile dysfunction (ED) are currently studied.ObjectivesTo review the evidence provided in clinical trials and to assess the current medical practice concerning the pharmacological treatment of men suffering from LUTS/BPH.Evidence acquisitionThis paper is based on a presentation during the symposium “The future of LUTS/BPH: management beyond the prostate” at the European Association of Urology's 2008 annual meeting. The results of a Web survey evaluating the opinion of urologists about treatment of LUTS/BPH patients were discussed and an update lecture on medical therapy for LUTS/BPH was given.Evidence synthesisMen who are highly bothered by their symptoms but with a low risk of disease progression can achieve fast relief of symptoms with α₁-adrenoceptor (α₁-AR) antagonist monotherapy. Those patients at risk for LUTS/BPH progression can benefit from additional 5α-reductase inhibitor therapy. Concomitant OAB symptoms in LUTS/BPH patients can be treated with a combination of an α₁-AR antagonist and an antimuscarinic agent. An α₁-AR antagonist combined with a phosphodiesterase-5 inhibitor might improve symptoms in men with lower urinary tract symptoms (LUTS) and concomitant ED.ConclusionsThe pharmacological treatment of LUTS/BPH patients should be adapted to their individual risk of progression and their individual symptom profile.     

New Data on Tolterodine: Do Recent Findings Dispel Questions About Treating Overactive Bladder in Men?

Overactive bladder (OAB) is a syndrome characterized by urinary urgency, with or without urgency urinary incontinence (UUI), usually with frequency and nocturia. These symptoms represent a subset of lower urinary tract symptoms (LUTS). Results from epidemiologic studies conducted in the United States and Europe suggest that OAB affects 11–16% of men. Although OAB is frequently associated with detrusor overactivity, the coexistence of OAB symptoms and prostatic conditions (e.g., benign prostatic hyperplasia, benign enlargement of the prostate, and bladder outlet obstruction [BOO]) in men adds complexity to the diagnosis and appropriate treatment. Men with OAB symptoms are more often prescribed pharmacotherapies that target the prostate (e.g., α-receptor antagonists, 5α-reductase inhibitors) rather than the bladder (e.g., antimuscarinics), possibly due to a tendency among clinicians to attribute all LUTS to prostate disease. Thus, a subset of men who receive treatment for prostatic conditions may have persistent OAB symptoms. Moreover, some physicians may be concerned that the inhibitory effect of antimuscarinic agents on detrusor contraction could aggravate the voiding difficulties of, or cause urinary retention in, men with OAB and possible BOO. Recent prospective studies and post hoc analyses of data from men with OAB symptoms and other LUTS, with or without concomitant BOO (not significant BOO at risk for urinary retention), have suggested that tolterodine improves OAB symptoms without an increased incidence of acute urinary retention. However, the literature would benefit from larger and longer placebo-controlled studies.     

Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related outcomes

OBJECTIVES: To assess the utility of voiding and filling symptom subscores in predicting features of benign prostatic hyperplasia (BPH) progression, including acute urinary retention (AUR) and prostate surgery. METHODS: The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year study designed to evaluate the effects of finasteride versus placebo in men with lower urinary tract symptoms (LUTS), clinical evidence of BPH, and no evidence of prostate cancer. A self-administered questionnaire was employed to quantify LUTS at baseline. Receiver operating characteristics (ROC) curves were used to assess baseline characteristics from patients treated with placebo as predictors of outcomes. The characteristics assessed included the overall symptom score (Quasi-AUA SI), separate voiding and filling subscores, prostate volume (PV) and serum prostate-specific antigen (PSA) levels. RESULTS: PV and PSA were superior to the symptom scores at predicting episodes of spontaneous AUR and all types of AUR. The Quasi-AUA SI and the filling and voiding subscores were effective at predicting progression to surgery; however, PSA was more effective at predicting this outcome. To better evaluate symptoms as predictors of surgery, patients who experienced a preceding episode of AUR were excluded from the surgery analysis. In the absence of preceding AUR, the best predictors of future surgery were the Quasi-AUA SI and the filling subscore. CONCLUSIONS: Among men with LUTS, clinical BPH and no history of AUR, the overall symptom score and storage subscore are useful parameters to aid clinicians in identifying patients at risk for future prostate surgery. PV and PSA were the best predictors of AUR, while PSA was the best predictor of prostate surgery (for all indications).     

Data from frequency-volume charts versus filling cystometric estimated capacities and prevalence of instability in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

The aim was to examine associations of filling cystometric estimated compliance, capacities, and prevalence of bladder instability with data from frequency-volume charts in a well-defined group of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Men with LUTS suggestive of BPH were included if they met the criteria of the International Consensus Committee on BPH, i.e., they voided more than 150 mL during uroflowmetry, their residual volume and prostate size were estimated, and they completed frequency-volume charts correctly. From the frequency-volume charts, voiding habits, and fluid intake in the daytime and at night were evaluated. Filling cystometric studies were performed in these men as well. Decreased compliance was an exceptional finding. Cystometric capacity and especially effective capacity (cystometric capacity minus residual volume) corresponded significantly with the maximum voided volume on the frequency-volume charts. Effective capacity was almost twice as high as the average voided volume. Minimum voided volume on frequency-volume charts was not related to filling cystometric data. The presence of instability in the supine or sitting position or in both positions was not significantly associated with smaller voided volumes, higher nocturia, or diuria. Filling cystometric capacities were strongly associated with maximal and mean voided volumes derived from frequency-volume charts. The presence of detrusor instability during filling cystometry did not significantly affect voided volumes, diuria, or nocturia     

Correlations between longitudinal changes in transitional zone volume and measures of benign prostatic hyperplasia in a population-based cohort

OBJECTIVE: To determine whether measures of transitional zone volume (TZV) are more strongly associated than total prostate volume with longitudinal urologic outcomes. METHODS: In 1990, 2,115 randomly selected Caucasian men from Olmsted County, Minnesota (USA) completed validated questionnaires during a home visit. A 25% subsample underwent clinical evaluation that included transrectal ultrasonography, assessment of serum prostate-specific antigen levels, and maximum urinary flow rates. Examinations and questionnaires were repeated biennially through 2004. TZV measures were taken at the fifth through eighth visits. Men with at least one TZV measurement were included in this study (n=336). RESULTS: Changes in TZV correlated weakly with changes in peak urinary flow rate and urinary symptoms. After accounting for age and change in total prostate volume, change in TZV added no information to models that predict changes in urinary symptoms and peak urinary flow rates. Men who experienced the most rapid annual changes in TZV were not more likely to experience more rapid changes in urinary symptoms or maximum flow rate. CONCLUSION: Tracking changes in TZV over time may be unlikely to provide a good surrogate measure for the development of benign prostatic hyperplasia.