The role of alpha-blockers in the management of acute urinary retention caused by benign prostatic obstruction

OBJECTIVES: To consider theories concerning the etiology of acute urinary retention (AUR), which may influence the outcome of a trial without catheter (TWOC), and to discuss evidence regarding the use of medical therapy in the management and secondary prevention of AUR. METHODS AND MATERIALS: A search of the literature discussing measurable parameters that may identify patients at risk for AUR and who require further intervention after initial treatment was undertaken. Studies of the effect of medical interventions for benign prostatic hyperplasia (BPH) and AUR were also identified. RESULTS: The etiology of acute urinary retention remains unknown in many cases, which are often described as spontaneous, but catheterization remains standard management followed by a TWOC and bladder outlet surgery in those who do not void satisfactorily. Alpha-blockers (alpha(1)-adrenoreceptor antagonists) effectively reduce the symptoms associated with BPH and improve the urodynamic parameters of obstruction, without the sexual adverse events associated with the 5alpha-reductase inhibitors. They may diminish the incidence of AUR and the need for surgical intervention in symptomatic men. There is now good evidence that alfuzosin, in particular, improves the success rate of a TWOC, although other uroselective alpha-blockers have also been shown to improve the success rates of TWOC. CONCLUSIONS: The proven effects of alpha-blockers support the hypothesis that they will increase the chances of a successful TWOC following AUR, which has now been proven in several well-designed and conducted studies. However, it is not yet clear whether these or other medical therapies have a role to play in the secondary prevention of further AUR or the need for further surgery. It is clear that certain measurable parameters may be used to identify patients at highest risk of a further episode of AUR following a successful TWOC; these patients may then be offered urgent surgical intervention.     

The economic impact of using alfuzosin 10 mg once daily in the management of acute urinary retention in the UK: a 6-month analysis

OBJECTIVE: To calculate the economic consequences of using alfuzosin 10 mg once daily for managing acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH). METHODS: We examined whether alfuzosin use during hospitalization for AUR and for 6 months after a successful trial without catheter (TWOC) is cost effective compared to placebo and immediate prostatectomy, from the perspective of patients managed in the National Health Service (NHS) in the UK. A decision-analysis model was developed to estimate the costs of various treatment options within the first 6 months after a first episode of AUR. Clinical data were obtained from a large randomized clinical trial comparing alfuzosin 10 mg with placebo, and from published reports. Cost data were obtained from both NHS and resource-use data gathered during the clinical trial. A Monte Carlo analysis, allowing variability in all uncertain variables of the model, was used to calculate the uncertainty surrounding the results. RESULTS: Treating patients with alfuzosin during initial hospitalization for AUR and in the first 6 months after a successful TWOC generates a cost-saving of pounds 349 relative to placebo. Savings related to immediate prostatectomy were pounds 892; both savings were significant (P < 0.05). Alfuzosin treatment was associated with a lower rate of prostatectomy after discharge from hospital after a successful TWOC. CONCLUSION: Treatment with alfuzosin 10 mg once daily before and after a successful TWOC has both clinical and economic benefits. It decreases the need for emergency surgery for BPH and reduces treatment costs in the first 6 months.     

A prospective study of conservatively managed acute urinary retention: prostate size matters

OBJECTIVE: To evaluate in a prospective study the medium- to long-term outcome of a policy of conservatively managing acute urinary retention (AUR), arising solely by bladder outlet obstruction caused by benign prostatic enlargement (BPE), and to identify the factors favouring a positive outcome of a trial without catheter (TWOC). PATIENTS AND METHODS: All men admitted as an emergency with primary AUR caused by BPE (from August 1997 to March 2000) underwent a TWOC. The following variables were recorded; the nature and duration of any preceding lower urinary tract symptoms, previous episodes of retention, concomitant anticholinergic medication, coexisting constipation, alcohol as a precipitating cause of AUR, previous prostatectomy, confirmed urinary tract infection, residual urine drained on catheterization and prostate size, as determined by a digital rectal examination (DRE) carried out by one consultant urologist in all patients. Those voiding successfully were followed up prospectively using the International Prostate Symptom Score (IPSS), quality-of-life score, urinary flow rate measurement and ultrasonographic measurement of the postvoid residual (PVR). RESULTS: Of the 40 men with AUR, 22 (55%) voided spontaneously after removing the catheter and continued to do so with mean peak flow rates of 12.2 mL/s and mean PVRs of 69.6 mL over a follow-up of 8-24 months. These patients remained asymptomatic, with a mean IPSS of 5.2 and quality-of-life score of 0.9. These men had a mean prostatic size of 15.9 g and a mean catheterized residual volume of 814 mL, while in those who had an unsuccessful TWOC the mean prostate size was 27.5 g (P = 0.006) and a mean catheterized residual volume of 1062 mL (P = 0.09). Prostate size as assessed by the DRE was the most significant factor in predicting the outcome of a TWOC. CONCLUSION: A TWOC is justified in the long-term for men presenting with AUR caused by BPE. Prostate size is the most important factor for predicting the outcome of such a trial.     

Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled.

OBJECTIVE: To establish whether the administration of sustained-release (SR) alfuzosin improves the outcome of a trial without catheter (TWOC) after an episode of acute urinary retention. PATIENTS AND METHODS: In a prospective, randomized, placebo-controlled trial, 81 patients with acute urinary retention related to benign prostatic obstruction received either SR alfuzosin (n=40), an alpha1-selective blocker, given at a dose of 5 mg twice daily, or placebo (n=41) for 48 h. The catheter was removed after 24 h of treatment. The main outcome measurement was success or failure of the TWOC. At the end of this double-blind phase the patients were followed up on an open basis. RESULTS: After removal of the catheter, 42% of patients voided successfully, 22 of 40 (55%) with SR alfuzosin and 12 of 41 (29%) with placebo (P=0.03). The mean age of patients voiding successfully, regardless of treatment group, was 68. 4 years, whilst the mean age of those who were not successful was 72. 9 years (P=0.015). In an intention-to-treat analysis of outcome adjusted for this age difference, the benefit in favour of those receiving SR alfuzosin was not significant, but at P=0.052 there was a strong suggestion of a positive treatment effect. The observed benefit remained significant in a per-protocol analysis adjusted for age. Taken together, these results indicate that treatment with SR alfuzosin was effective and that the observed benefit was not simply the effect of age difference between the groups. Of the 34 patients who voided successfully 23 (68%) required no further intervention within a mean follow-up of 7 months. CONCLUSIONS: Treatment with SR alfuzosin is effective in improving the success rate of a TWOC after an episode of acute urinary retention, although older patients are less likely to void successfully. By reducing the numbers of men sent home with urinary catheters, such treatment may result in a reduction in the associated perioperative morbidity in those undergoing prostatic surgery, and is clearly desirable for the patients' comfort and convenience.     

A comparative study on the use of tamsulosin versus alfuzosin in spontaneous micturition recovery after transurethral catheter removal in patients with benign prostatic growth

Purpose

To compare the efficacy and safety of tamsulosin and alfuzosin in patients with acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH).

Methods

Ninety men with AUR due to BPH underwent urinary catheterization and were randomly assigned to treatment groups with tamsulosin 0.4 mg (37 patients), alfuzosin 10 mg (34 patients), and placebo (19 patients). After 4 days of the drug treatment, the catheters were removed, and the patients underwent trial without catheter (TWOC). A TWOC was considered successful if the patient had a voided volume >100 ml and post-void residual urine <200 ml.

Results

TWOC was successful in 16 patients (43.2 %) in the tamsulosin group, 12 patients (35.2 %) in the alfuzosin group, and 5 patients (26.3 %) in the placebo group. Logistic regression analysis showed that both drugs were equally effective and that the type of alpha-blocker was not a predictive factor for TWOC success (OR 1.137, 95 % CI 0.639–2.022) (p = 0.662).

Conclusion

Even though there were no statistically significant differences when comparing the three groups, tamsulosin showed a tendency to be more effective in a successful catheter removal. The lack of objective criteria in the definition of successful micturition leads us to believe that the effectiveness of both drugs reported in the literature is overestimated.     

The management of acute urinary retention in France: a cross-sectional survey in 2618 men with benign prostatic hyperplasia

In an important study from France, the authors assessed the management of acute urinary retention in a cross‐sectional survey of many patients in their country. They describe what has become standard practice for men with BPH who present in this manner. They also suggest that efforts should be made to reduce the duration of catheterization, to reduce morbidity. In an international study, a group of authors found that alfuzosin prevents BPH progression but not acute urinary retention. This was a 2‐year study, and the authors also found that the drug improved LUTS and quality of life.

OBJECTIVE

To evaluate current practice in the management of acute urinary retention (AUR) in men with benign prostatic hyperplasia (BPH) in France.

PATIENTS AND METHODS

In all, 2618 men (median age 72 years) presenting with non‐febrile AUR were enrolled by 658 French urologists in a prospective cross‐sectional survey. The patients’ demography, history of BPH, type of AUR and its management (trial without catheter, TWOC, use of α₁‐blockers, immediate or elective surgery, other alternatives) were collected.

RESULTS

Of the 2618 men analysed, 1875 (71.6%) had spontaneous AUR (sAUR) and 743 (28.4%) had precipitated AUR (pAUR), mainly after surgery with locoregional or general anaesthesia. BPH was revealed by AUR in 52.3% of men with pAUR and 25.9% of men with sAUR. A urethral catheter was inserted in most cases (82.7%) while only 16.7% had a suprapubic catheter. After initial catheterization, 72.8% of men had a TWOC (pAUR 89.4%, sAUR 66.2%, P < 0.001) after a median of 3 days of catheterization, 17.9% had elective surgery after a median of 8 days of catheterization (pAUR 7.1%, sAUR 22.1%, P < 0.001), 5.7% had immediate surgery after a median of 4 days of catheterization (pAUR 1.1%, sAUR 7.5%, P < 0.001), 0.4% had a urethral stent inserted and 1.1% had an indwelling catheter. Of the 1906 men who had a TWOC, 79% received an α₁‐blocker (mainly alfuzosin) before catheter removal. The TWOC was successful in 50.2% of men (pAUR 52.3%, sAUR, 49.0%, P = 0.17) and the success rate was significantly higher in men receiving an α₁‐blocker (53.0% vs 39.6%, P < 0.001) before the TWOC. If the TWOC failed, 33.4% had a second TWOC (pAUR 39.9%, sAUR 30.2%, P = 0.003) after a median of 7 days re‐catheterization, 57.5% had elective surgery (pAUR 49.1%, sAUR, 61.7%, P < 0.001) after a median of 8 days re‐catheterization, 1.5% had a stent inserted and 1.1% had an indwelling catheter. The overall success rate of a second TWOC was 25.9% (pAUR 32.2%, sAUR 21.9%, P = 0.04). Men catheterized for >3 days had a slightly lower success rate for TWOC, greater comorbidity and double the rate of prolonged hospitalization due to adverse events than those catheterized for ≤ 3 days.

CONCLUSIONS

TWOC after a median of 3 days of catheterization has become standard practice in France for men with BPH and AUR. α₁‐blockade before a TWOC significantly increases the chance of a successful TWOC. If the TWOC fails, only a quarter of men will have a successful second TWOC. All efforts should be made to reduce the duration of catheterization, to reduce the comorbidity.

     

Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey

OBJECTIVE: To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence-based. METHODS: In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of alpha-blockers and the follow-up. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed. RESULTS: We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two-thirds (65.5%) admitted the patient after catheterization. Most consultants initiated alpha-blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re-admitting the patient for surgery later. Routine follow-up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH. CONCLUSION: This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence-based.     

Randomised,placebo controlled,double blind study of alfuzosin SR in patients undergoing trial without catheter following acute urinary retention

INTRODUCTION: Acute urinary retention caused by bladder outlet obstruction resulting from prostatic enlargement is one of the commonest causes for acute admission to urology wards. More recently, there has been a trend to commence treatment with alpha-blockers after catheterisation followed by a trial without catheter (TWOC), in the hope that surgery may be avoided in a significant proportion of patients. There is no conclusive evidence of the efficacy of this treatment. We conducted a study to evaluate the efficacy of using the alpha-blocker alfuzosin SR in patients with acute urinary retention. PATIENTS AND METHODS: All patients presenting with acute urinary retention to our unit were included in the trial. Exclusion criteria included patients with known bladder or prostate malignancy, bladder calculi, urinary tract infections, urethral stricture or patients on alpha-blockers. A total of 81 patients consented and were randomised. Sixty-two patients completed the study. The retention volume was recorded. Trial medicine was recorded on a twice-daily dose and the first TWOC was carried out after a minimum of three doses or 36 hours after admission. TWOC was considered successful on voiding with a residual volume of <200 ml. Unsuccessful patients were recatheterised and discharged home on trial medication, and called for a second TWOC after 2 weeks. Successful patients were continued on alpha-blockers and failures were put on the operating list for TURP. Patients on active treatments were reviewed at 2 year. RESULTS: Of the 34 patients treated with alfuzosin SR, 17 (50%) resumed voiding and of the 28 patients from placebo group, 16 (57%) voided successfully. All 33 patients were continued open labelled on alfuzosin SR 5mg BD. Out of 33 patients, 13 (43%) had TURP within first year after TWOC and three died due to various medical causes. Out of remaining 17 patients, 15 attended for follow-up. The mean peak flow rate was 8.4 ml/s and the mean residual volume was 112 ml. Six patients (40%) required TURP for severe lower urinary tract symptoms (LUTS). So out of 28 patients followed at 2 year, 19 (68%) had TURP. CONCLUSIONS: These data do not support the routine use of alpha-blockers in patients with acute urinary retention. Also continuing use of alpha-blockers does not seem to prevent further requirements of TURP, although larger studies are needed to support this.     

The Reten-World survey of the management of acute urinary retention: preliminary results

Acute urinary retention (AUR) is a urological emergency characterized by a sudden and painful inability to pass urine. It represents a significant worldwide public health issue, as mortality within the year following an AUR episode appears much higher than in the general population, especially in younger patients. Management of AUR involves immediate bladder catheterization usually followed, until recently, by prostatic surgery. The greater morbidity and mortality associated with emergency surgery (within a few days after AUR), and the potential morbidity associated with prolonged catheterization (bacteriuria, fever, urosepsis) has led to an increasing use of a trial without catheter (TWOC). TWOC involves catheter removal after 1-3 days, allowing 23-40% of patients to void successfully, so that surgery can be performed at a later stage, if needed. Use of an alpha(1)-blocker before a TWOC may also be of help, as it has been demonstrated that it increases the chances of successful voiding after catheter removal. In the UK, this TWOC policy has resulted in a progressive decrease in the number of surgical procedures following a first episode of AUR, with the detriment of a slight increase in the AUR recurrence rate. Currently, there is no consensus on the optimal management of AUR in terms of type of catheterization, duration of catheterization and management following catheterization. The Reten-World survey is aimed at assessing current practice in the management of AUR in France, Asia, Latin America, North Africa and the Middle East. Interim results based on 3785 men with AUR associated with benign prostatic hyperplasia show that a urethral catheter is inserted in most cases (87%). Following this initial step, a TWOC after a median of 3 days' catheterization has become standard practice worldwide, with only a minority of men (6%) undergoing immediate surgery. Treatment with an alpha(1)-blocker before a TWOC improves the chances of success, regardless of the duration of catheterization. There is also evidence that prolonged catheterization (>3 days) is associated with a significantly higher rate of comorbidity and prolonged hospitalization due to adverse events. Every effort should thus be made to reduce the comorbidity and mortality associated with AUR.     

Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia

Study Type – Therapy (symptom prevalence) Level of Evidence 2a What's known on the subject? and What does the study add? Largest survey ever conducted evaluating the management of AUR in real life practice in a wide range of health care systems. It shows that urethral catheterization followed by a TWOC has become a standard worldwide and that α₁‐blockade prior to TWOC doubles the chances of success. It also evidences important differences (hospitalization rate, duration of catheterization ...) between countries/regions reflecting lack of guidelines. This large survey also clearly identifies predictors of TWOC failure.

OBJECTIVES

• ? To evaluate the management of acute urinary retention (AUR) associated with benign prostatic hyperplasia (BPH) in real‐life practice.
• ? To identify predictors of successful trial without catheter (TWOC).

MATERIALS AND METHODS

• ? In all, 6074 men catheterized for painful AUR were enrolled in a prospective, cross‐sectional survey conducted in public and private urology practices in France, Asia, Latin America, Algeria and the Middle East.
• ? Patient clinical characteristics, type of AUR and its management (type of catheterization, hospitalization, TWOC, use of α₁‐blockers, immediate or elective surgery) and adverse events observed during the catheterization period were recorded.
• ? Predictors of TWOC success were also analysed by multivariate regression analysis with stepwise procedure.

RESULTS

• ? Of the 6074 men, 4289 (71%) had a spontaneous AUR and 1785 (29%) had a precipitated AUR, mainly as the result of loco‐regional/general anaesthesia (28.5%) and excessive alcohol intake (18.2%).
• ? Presence of BPH was revealed by AUR in 44% of men. Hospitalization for AUR varied between countries, ranging from 1.7% in Algeria to 100% in France. A urethral catheter was inserted in most cases (89.8%) usually followed by a TWOC (78.0%) after a median of 5 days. Overall TWOC success rate was 61%.
• ? Most men (86%) received an α₁‐blocker (mainly alfuzosin) before catheter removal with consistently higher TWOC success rates, regardless of age and type of AUR. Multivariate regression analysis confirmed that α₁‐blocker before TWOC doubled the chances of success (odds ratio 1.92, 95% CI 1.52–2.42, P < 0.001).
• ? Age ≥70 years, prostate size ≥50 g, severe lower urinary tract symptoms, drained volume at catheterization ≥1000 mL and spontaneous AUR favoured TWOC failure. Catheterization >3 days did not influence TWOC success but was associated with increased morbidity and prolonged hospitalization for adverse events.
• ? In the case of TWOC failure, 49% of men were recatheterized and had BPH surgery and 43.5% tried another TWOC with a success rate of 29.5%. Elective surgery was preferred to immediate surgery.

CONCLUSIONS

• ? TWOC has become a standard practice worldwide for men with BPH and AUR.
• ? In most cases, an α₁‐blocker is prescribed before TWOC and significantly increases the chance of success.
• ? Prolonged catheterization is associated with an increased morbidity.

     

前列腺增生急性尿潴留TWOC失败的因素分析

目的分析前列腺增生引起的急性尿潴留患者进行留置导尿后再予以试行拔除尿管(TWOC)后患者再次发生尿潴留的危险因素。方法回顾性分析2017年4月至2019年4月在自贡市第一人民医院治疗的前列腺增生并发第一次急性尿潴留的65例患者的临床资料,65例患者既往均接受了在留置尿管后口服0.4mg/d盐酸坦索罗辛并在第3天进行试行拔管的处理,拔管后患者再次出现尿潴留视为TWOC失败,单因素及多因素Logistic回归分析患者年龄、前列腺体积、膀胱内前列腺突出度(IPP)、国际前列腺症状评分(IPSS)等相关参数与TWOC失败的相关性。结果 TWOC成功组23例(35.4%),TWOC失败组42例(64.6%),单因素分析结果显示TWOC成功组与失败组比较前列腺体积(P=0.030)、IPSS(P<0.001)、IPP(P=0.002)存在明显统计学差异。多因素Logistic回归分析得出患者IPSS(OR=2.462,95%CI:1.216~4.985,P=0.012),IPP(OR=2.606,95%CI:1.224~5.545,P=0.013)是TWOC失败的独立危险因素。结论患者IPP、IPSS评分是预测TWOC失败的重要指标。     

Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: Prevention or Retention?

BackgroundAcute urinary retention (AUR) is a severe complication of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). The prevention and management of AUR is subject to debate and varies considerably among countries.ObjectiveTo review the current and future prevention and management of AUR secondary to LUTS/BPH.Evidence acquisitionThis paper summarises the content of an update lecture that was part of a symposium on the management of LUTS/BPH held at the annual meeting of the European Association of Urology (EAU) in 2008. During the symposium, the results of a Web-based survey evaluating urologists’ opinions on the management of LUTS/BPH were also presented and discussed.Evidence synthesisPrevention of AUR secondary to LUTS/BPH implies delaying the progression of this condition in patients at risk. Risk factors for AUR include the following: an advanced age, moderate-to-severe lower urinary tract symptoms (LUTS), an enlarged prostate, a low peak urinary flow rate, an elevated postvoid residual, and an elevated prostate-specific antigen (PSA) level. Chronic inflammation of the prostate might also be a predictor of AUR. First-line treatment of AUR usually involves decompression of the bladder by catheterisation, which can be followed by a trial without catheter (TWOC) or immediate surgery. Elective surgery after TWOC is preferred to immediate surgery because it is associated with a lower morbidity and mortality risk. Treatment with an α₁-adrenoceptor (α₁-AR) antagonist can increase the success rate of a TWOC.ConclusionsPrevention and management of AUR secondary to LUTS/BPH should be based on the presence of risk factors. In most cases, elective surgery after TWOC is preferred to immediate surgery. Treatment with α₁-AR antagonists is usually indicated when performing a TWOC.     

Long-term outcome of patients with a successful trial without catheter,after treatment with an alpha-adrenergic receptor blocker for acute urinary retention caused by benign prostatic hyperplasia

Objective  

To perform a retrospective review of long-term outcome for patients with a first episode of acute urinary retention (AUR) who could void successfully after the initial trial without catheter (TWOC) after treatment with an alpha-adrenergic receptor blocker (AR blocker).     

Management of acute urinary retention

Acute urinary retention (AUR) is a common urological emergency, characterized by a sudden and painful inability to pass urine. There is high variability within and among countries in its management, which can be explained not only by differences in access to care but also by a lack of harmonization and consensus on the best way to proceed. Immediate treatment consists of bladder decompression, usually by a urethral catheter, although a suprapubic catheter offers several advantages not often exploited by urologists. Until recently, secondary management consisted almost exclusively of prostatic surgery within a few days (emergency surgery) or a few weeks (elective surgery) after a first AUR episode. The greater morbidity and mortality associated with emergency surgery, and the potential morbidity associated with prolonged catheterization, has led to the increasing use of a trial without catheter; this involves catheter removal after 1-3 days, allowing the patient to void in 23-40% of cases, and surgery, if needed, at a later stage. Alpha1-adrenergic blockers given before catheter removal improve the chances of success. A high prostate-specific antigen level and postvoid residual urine volume, and response to alfuzosin treatment after a first AUR episode managed conservatively, may help to identify patients at risk of an unfavourable outcome.     

Reporting of acute urinary retention in BPH treatment trials: importance of patient follow-up after discontinuation and case definitions

Objectives. A growing number of reports of retrospective analyses of adverse events occurring during studies with alpha-blockers in men with benign prostatic hyperplasia (BPH) have compared acute urinary retention (AUR) event rates with placebo-controlled finasteride trials. Because of differences in study designs, the present analysis was undertaken to compare data on the rates of AUR across different BPH trials accurately.Methods. We report the incidence of spontaneous AUR for placebo, finasteride, and alpha-blockers based on published data in randomized clinical trials in men with BPH.Results. On the basis of the data from all published randomized finasteride and alpha-blocker studies reporting AUR, the overall incidence rate for spontaneous AUR during active treatment with placebo, alpha-blockers, and finasteride ranged from 0.9 to 5.2, 0 to 1.2, and 0.3 to 1.2, respectively. The only study to provide data on AUR occurring during post-treatment follow-up was the Proscar Long-Term Efficacy and Safety Study (PLESS), in which approximately 25% of events occurred in patients after they had discontinued the study. Several of the alpha-blocker studies had significantly shorter durations, relatively small patient populations with smaller prostate volumes, lower numbers of events reported, and higher discontinuation rates with no follow-up, all of which could tremendously affect the reporting of AUR. Additionally, only PLESS reported on both spontaneous and precipitated AUR.Conclusions. Simply comparing the reported rates of AUR from published studies without taking into consideration spontaneous versus precipitated AUR, discontinuation rates, total patient follow-up, and prostate volume does not adequately allow for comparison of the true event rate across different clinical trials.     

Alfuzosin 10 mg once daily prevents overall clinical progression of benign prostatic hyperplasia but not acute urinary retention: results of a 2-year placebo-controlled study

OBJECTIVES: To evaluate the effect of alfuzosin 10 mg once daily administered for 2 years on progression events in men with lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH). PATIENTS AND METHODS: In all, 1522 men at risk of having progression events from LUTS/BPH were randomized to receive alfuzosin 10 mg once daily (759) or placebo (763) for 2 years. Endpoints assessed were the occurrence of a first episode of acute urinary retention (AUR; primary) and the need for BPH-related surgery. Post hoc analyses included a deterioration in the International Prostate Symptom Score (IPSS) of > or = 4 points and overall clinical progression of BPH (occurrence of AUR and/or surgery and/or symptom deterioration). RESULTS: Over 2 years, symptom deterioration was the most common progression event (14.3%), followed by BPH-related surgery (5.8%) and AUR (2.0%). Alfuzosin did not reduce the risk of AUR (alfuzosin 2.1% vs placebo 1.8%, P = 0.82) but tended to reduce the risk of surgery (5.1% vs 6.5%, P = 0.18); the reduction in risk (RR) and 95% confidence interval with alfuzosin was 22 (-18 to 48)%; and significantly reduced the risk of symptom deterioration (11.7% vs 16.8%; P = 0.0013); the RR was 30 (10-46)%. The overall clinical progression of BPH was significantly lower with alfuzosin than with placebo (16.3% vs 22.1%, P < 0.001); RR 26 (9-40)%. Alfuzosin also significantly improved the IPSS (P = 0.017), quality of life (P < 0.001) and peak flow rate (P = 0.001) compared with placebo. Baseline levels of prostate-specific antigen (PSA) predicted both AUR and BPH-related surgery events, while the baseline postvoid residual urine volume predicted symptom deterioration. The incidence of adverse events with alfuzosin was comparable to that with placebo. CONCLUSIONS: Alfuzosin 10 mg once daily prevents the overall clinical progression of BPH, defined by the occurrence of a deterioration in IPSS of > or = 4 points and/or AUR and/or BPH-related surgery, but does not reduce the primary occurrence of AUR. Alfuzosin significantly improves LUTS and quality of life over 2 years, and is well tolerated.     

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).     

Definition of at-risk patients: dynamic variables

Benign prostatic hyperplasia (BPH) is a progressive disease, mainly characterized by a deterioration of symptoms over time, but also the occurrence in some patients of serious outcomes such as acute urinary retention (AUR) and the need for BPH-related surgery. The goals of therapy are not only to improve symptoms and restore an acceptable quality of life, but also to identify patients at risk of disease progression, to optimize their management. Baseline variables such as age, severe lower urinary tract symptoms (LUTS), a low peak flow rate, increased postvoid residual urine volume (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels have been identified as predictors of AUR and BPH-related surgery in community-based longitudinal studies. In the placebo arm of controlled studies, baseline serum PSA level and to a lesser extent prostate size consistently predict the risk of AUR and BPH-related surgery, while quantitative variables such as baseline symptom severity and peak flow rate behave paradoxically and are poor predictors of BPH progression. There is increasing evidence from longitudinal community-based studies and the Medical Therapy of Prostatic Symptoms study that dynamic variables (e.g. symptom and PVR worsening) serve as good predictors of AUR in men with LUTS suggestive of BPH. The 'real-life' practice study Alf-One also suggests that men not responding to alfuzosin treatment (International Prostate Symptom Score stable or worsening, and bother score >3 under treatment) have a greater risk of having AUR or requiring BPH-related surgery. First-line treatment with alfuzosin might thus help to select patients at risk of BPH progression, to optimize their management.     

Intravesical prostatic protrusion is better than prostate volume in predicting the outcome of trial without catheter in white men presenting with acute urinary retention: a prospective clinical study

PURPOSE: Trial without catheter after a short course of an alpha-blocker in men presenting with acute urinary retention is successful in up to 50% of cases. The ability to better predict outcome could avoid a trial without catheter for some men. Intravesical prostatic protrusion and not prostate volume has been shown to predict trial without catheter outcome in an Asian cohort. We investigated the relationship between the outcome of trial without catheter and prostate volume and intravesical prostatic protrusion in white men given alpha-blockers before a trial without catheter. MATERIALS AND METHODS: Consecutive men 50 years old or older presenting with acute urinary retention were prospectively recruited based on strict selection criteria. At presentation factors thought to precipitate acute urinary retention were treated, alpha-blocker therapy started and the patient brought back for a trial without catheter after 2 weeks. Prostate volume and intravesical prostatic protrusion were measured by standard transrectal ultrasonography. RESULTS: Of 121 men presenting with acute urinary retention 57 fulfilled the study selection criteria. Mean (+/- SD) age, prostate volume and intravesical prostatic protrusion of recruited men were 70 +/- 9.2 years, 69.7 +/- 36.3 ml and 12.8 +/- 10.1 mm, respectively. A total of 25 men (43.9%) had a successful trial without catheter. Mean intravesical prostatic protrusion was significantly smaller in those who had a successful trial without catheter (7.2 vs 16.5 mm, 95% CI 4.5-14, p <0.001). With intravesical prostatic protrusion correlating well with prostate volume (r = 0.588), mean prostate volume was also smaller in men with a successful trial without catheter, albeit with a smaller effect size. Men with an intravesical prostatic protrusion of 10 mm or less, compared to those with a larger intravesical prostatic protrusion, were 6 times more likely to have a successful trial without catheter. CONCLUSIONS: In this cohort presenting with acute urinary retention related to benign prostatic hyperplasia and receiving alpha-blockers before a trial without catheter, intravesical prostatic protrusion appears to strongly predict the outcome of a trial without catheter. A trial without catheter is more likely to fail in patients with intravesical prostatic protrusion larger than 10 mm.