The impact of nerve‐sparing robot‐assisted radical prostatectomy on lower urinary tract function: Prospective assessment of patient‐reported outcomes and frequency volume charts

Aims

To elucidate the effects of a nerve‐sparing (NS) procedure on lower urinary tract symptoms (LUTS) and urinary function after robot‐assisted radical prostatectomy (RARP), the associations between the NS procedure and LUTS and urinary function were investigated.

Methods

The participants in this study were 200 consecutive patients who underwent RARP. These patients were categorized into unilateral and bilateral NS groups and the non‐NS group. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, frequency‐volume chart, uroflowmetry, 1‐h pad test, and the 5‐item International Index of Erectile Function (IIEF‐5) questionnaire were evaluated before and after RARP.

Results

The total IPSS score was significantly lower in the unilateral (P = 0.03) and bilateral NS groups (P = 0.03) than in the non‐NS group after RARP. Diurnal maximum voided volume (MVV) values were significantly greater in the bilateral NS group than in the non‐NS group after RARP (P = 0.002). Nocturnal frequency was significantly decreased in the unilateral NS group than in the non‐NS group after RARP (3 months P = 0.01, 12 months P = 0.01). Erectile function was significantly better in both the unilateral NS group (P < 0.0001) and the bilateral NS group (P = 0.02) than in the non‐NS group 12 months after RARP.

Conclusions

The NS procedure in RARP has the possibility to improve not only erectile function, but also LUTS, owing to both the increase of MVV and the decrease of nocturia. Therefore, the NS procedure is also recommended from the viewpoint of early improvement of LUTS and lower urinary tract dysfunction after RARP.     

Managing erectile dysfunction in hypertension: the effects of a continuous training programme on biomarker of inflammation

OBJECTIVE

To determine the effect of a continuous training programme on C‐reactive protein (CRP) levels, and in the management of erectile dysfunction (ED) in older men with hypertension.

PATIENTS AND METHODS

In all, 22 men with hypertension and ED (mean age 61.8 years, sd 7.79) were involved in continuous training (35–59% of heart rate maximum reserve) for 8 weeks for 45–60 min, while 21 age‐matched control hypertensives (mean age 64 years, sd 8.53) remained sedentary during this period. The International Index of Erectile Function (IIEF) questionnaire was used to assess the outcome of ED. The Mann–Whitney U‐test and Spearman correlation were used to analyse the results of the changes in IIEF and CRP.

RESULTS

There was a significant effect of continuous exercise training on erectile function and CRP levels in hypertensive men with ED (P < 0.05).

CONCLUSIONS

A continuous training programme decreases CRP levels and is an effective means of noninvasive and nonpharmacological management of ED in men with hypertension.     

An Asian multinational prospective observational registry of patients with benign prostatic hyperplasia, with a focus on comorbidities, lower urinary tract symptoms and sexual function

OBJECTIVE

To examine the characteristics, management practices and outcomes of patients presenting with symptoms of benign prostatic hyperplasia (BPH) in Asia, with a focus on comorbidities and sexuality.

PATIENTS AND METHODS

In this multinational prospective observational registry, eligible patients with BPH attending a urology clinic for the first time were enrolled. Details of comorbidities, sexuality and symptoms of BPH were collected through the International Prostate Symptom Score (IPSS), International Index of Erectile Dysfunction‐5 (IIEF‐5) and the Danish Prostate Symptom Score (DAN‐PSS‐1) questionnaires. The follow‐up was scheduled at 1–3 or 3–6 months, depending on the treatment.

RESULTS

In 994 men aged 40–88 years the most common comorbidities were hypertension (38%) and obesity (36%). Nocturia was the most common symptom for consultation. A previous episode of acute urinary retention (AUR) was recorded in 12%. About 90% of the men had moderate‐to‐severe lower urinary tract symptoms (LUTS), and the severity increased with age. Sexual dysfunction was reported by 82%, and it correlated with the severity of LUTS. Of 918 sexually active men, only 20% had normal erectile function; 36%, 19% and 25% reported severe, moderate and mild erectile dysfunction (ED), respectively. BPH medication was started in 78%, 9% had surgery, and in 13% an approach of watchful waiting was adopted. In all, 89% of patients completed the follow‐up. The symptoms of BPH resolved in 93% after surgery, in 83% on BPH medication and in 34% of those on ‘watchful waiting’. Surgery, which led to a mean reduction of 17.0 IPSS points, was the most effective in improving LUTS. Improvement on the DAN‐PSS‐1 items of reduced erection and reduced ejaculation was higher with medication, while surgery led to better outcomes on the DAN‐PSS‐1 item of pain/discomfort on ejaculation. For ED, from baseline to after treatment, the mean IIEF‐5 scores changed from 19.1 to 18, from 14.2 to 14.8, and from 4.5 to 5.5 for those with mild, moderate and severe ED at baseline, respectively. Only 2.3% of patients had an episode of AUR while on treatment. About 5.5% of patients on BPH medication and 6% of surgical patients reported adverse events.

CONCLUSION

Asian patients with BPH usually present with LUTS; sexual dysfunction is also very common. BPH medication is the most frequent treatment approach, followed by watchful waiting and surgery. Medication and surgery resulted in a greater reduction of LUTS and improvement in sexual dysfunction than watchful waiting. As Asian men remain sexually active even at advanced ages, sexual function should be assessed and discussed with the patient before deciding the management strategy for LUTS associated with BPH.     

Chronic kidney disease among men with lower urinary tract symptoms due to benign prostatic hyperplasia

Study Type – Diagnosis (case series)
Level of Evidence 4

OBJECTIVE

To analyse potential association of various clinical characteristics of benign prostatic hyperplasia (BPH) with chronic kidney disease (CKD) among men presenting with lower urinary tract symptoms (LUTS) secondary to BPH of varying severity.

PATIENTS AND METHODS

We reviewed the data of 2741 consecutive patients who presented to our clinic with LUTS secondary to BPH. For our analysis, CKD was defined by an elevated serum creatinine level or decreased estimated glomerular filtration rate (eGFR). Univariate and multivariate logistic regression analyses were used to address associations of CKD with various clinical characteristics.

RESULTS

Of the 2741 patients, 161 (5.9%) were initially classified as having CKD (serum creatinine ≥133 µmol/L). In multivariate analysis, peak flow rate (P = 0.001) and a history of hypertension and/or diabetes (both P < 0.001) were significantly associated with CKD, whereas age, body mass index, prostate‐specific antigen level, prostate volume, postvoid residual, or International Prostate Symptom Score (IPSS) were not. When individual symptoms from the IPSS were analysed, only weak stream (P = 0.041) and hesitancy (P = 0.048), both obstruction‐related, were significantly associated with CKD status in age and comorbidity‐adjusted analyses. The results of secondary analysis with CKD defined as an eGFR of <60 mL/min/1.73 m² were similar.

CONCLUSION

Our results show that decreased peak flow rate and a history of hypertension and/or diabetes are significantly associated with CKD in men seeking management for LUTS from BPH of varying severity.     

The relationship between lower urinary tract symptoms (LUTS), diagnostic indicators of benign prostatic hyperplasia (BPH), and erectile dysfunction in patients with moderate to severely symptomatic BPH

Purpose  To evaluate the relationship between lower urinary tract symptoms (LUTS), different diagnostic indicators of benign prostatic hyperplasia (BPH), and erectile dysfunction (ED) in a selected group of BPH patients with moderate-or-severe symptoms, for whom either transurethral or open prostatectomy was planned. Materials and methods  Between 2003 and 2006, 453 patients were included in this study. LUTS and ED were assessed by validated symptom scales. Maximum and average urine flow rates and post-void residual urine volumes (PVRU) of all patients were measured. Additionally, prostate volumes for all patients were detected with transrectal ultrasound (TRUS). Results  The incidence of LUTS and ED increased significantly with aging (P < 0.001). ED was reported to be 36% in men with moderate LUTS and 94% in men with severe LUTS (P < 0.001). The odds ratio for ED was 28.7 for severe LUTS. When age, IPSS, and IIEF scores were analyzed we observed that the occurrence of LUTS is an age-independent risk factor for the development of ED (P < 0.001). There was a positive correlation between IIEF score, Q _max (r = 0.441, P < 0.001), and Q _ave (r = 0.326, P < 0.001), and a negative correlation was found between IIEF score, prostate volume (r = -0.299, P < 0.001), and PVRU (r = -0.486, P < 0.001). Conclusions  The presence of LUTS, particularly severe LUTS, is an independent risk factor for ED. It is crucial to assess ED of the patient before BPH surgery, otherwise ED may be regarded as an outcome of the surgery rather than a preoperative, already existing condition.     

Relationship between lower urinary tract symptoms and serum levels of sex hormones in men with symptomatic benign prostatic hyperplasia

Study Type – Aetiology (case series)
Level of Evidence 4

OBJECTIVES

To investigate a possible association between the severity of lower urinary tract symptoms (LUTS) and the serum levels of sex hormones in men with symptomatic benign prostatic hyperplasia (BPH) that underwent surgery for severe benign prostatic obstruction.

PATIENTS AND METHODS

In all, 127 selected men with symptomatic BPH attending our urology clinic were recruited. The clinical conditions of BPH were assessed by digital rectal examination, serum prostate‐specific antigen (PSA) determination, International Prostate Symptom Score (IPSS), transrectal ultrasonography and maximum urinary flow rate (Q_max) value at uroflussimetry. Before surgery, we measured the serum concentrations of total testosterone (TT) and free testosterone (FT), oestradiol, prolactin, luteinizing hormone and follicle‐stimulating hormone. We excluded men with endocrine diseases, those with prostate disease who were receiving antiandrogen therapy and those with psychological diseases. The relationships between the IPSS score and serum sex hormone levels were determined.

RESULTS

The final study population consisted of 122 men (mean age of 70.66 years), as five were excluded (three due to incomplete evaluation and two who were diagnosed with prostate cancer). On statistical analysis, the total IPSS was significantly associated with age (r= 0.405, P < 0.001) and TT (r= 0.298, P= 0.020) but not with FT or the serum levels of the other sex hormones. The serum levels of testosterone and IPSS did not correlate with prostate volume and Q_max. PSA level and age correlated with prostate volume (r= 0.394, P < 0.001; r = 0.374, P < 0.001, respectively). We distinguished two subgroups of patients: the first group of 40 men with an IPSS of <19 and the second group of 82 with an IPSS of >19, and we evaluated the median levels of TT in each group. There was an increased risk of LUTS in men with a greater serum concentration of TT (P= 0.042), although the mean TT level was in the normal range.

CONCLUSIONS

In the present study, the severity of LUTS was associated with age and serum levels of TT but only age correlated with the measures of BPH, especially prostate volume. The potential effects of testosterone on LUTS may well be indirect. Additional large studies are needed to confirm these preliminary results.     

Natural history of lower urinary tract symptoms in Japanese men from a 15-year longitudinal community-based study

Study Type – Symptom prevalence (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? There have been few longitudinal community‐based studies on LUTS suggestive of BPH. It is important to determine the natural history of LUTS suggestive of BPH among men in various countries because it is known that there are differences according to race. Although we previously reported a cross‐sectional community‐based survey on LUTS suggestive of BPH in Japanese men, no longitudinal data were available. The present study provides 15‐year longitudinal data on LUTS suggestive of BPH and related variables in Japanese men.

OBJECTIVE

• ? To report the natural history of benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS) in Japanese men.

PATIENTS AND METHODS

• ? From 1992 to 1993, we conducted a cross‐sectional community‐based study on LUTS suggestive of BPH in Japanese men aged 40–79 years.
• ? After 15 fifteen years, a follow‐up study was conducted to determine their longitudinal changes of LUTS.
• ? Of the 319 participants taking part in the initial study, 135 participated again in the follow‐up study.
• ? We investigated International Prostate Symptom Score (IPSS), quality of life index and bother score using a questionnaire, and measured prostate volume (PV), prostate‐specific antigen (PSA) level and peak urinary flow rate (Q_max) using a method that we have employed previously.

RESULTS

• ? The change in the total IPSS during 15 years was significant (P= 0.001) and its mean (sd ) annual change was 0.11 (0.40).
• ? Although there was little change in the bother score, a significant correlation was observed between changes in the IPSS and bother score (r= 0.528, P < 0.001).
• ? For the individual IPSS and bother scores, only changes in urgency, weak stream and nocturia were significant.
• ? The changes in PV, PSA level and Q_max were significant.
• ? The change in the total IPSS did not correlate with the changes in these variables.

CONCLUSION

• ? In a 15‐year‐longitudinal community‐based study for Japanese men, we have shown that the IPSS and quality of life index deteriorated, PV and PSA level increased, and Q_max decreased.

     

Lower urinary tract symptoms increase the risk of falls in older men

OBJECTIVE

To evaluate the association of lower urinary tract symptoms (LUTS) with the risk of falls in elderly community‐dwelling men.

SUBJECTS AND METHODS

We evaluated 5872 participants in the Osteoporotic Fractures in Men, a prospective cohort study of risk factors for falls and osteoporotic fractures among community‐dwelling men aged ≥65 years. The primary outcome was the 1‐year cumulative incidence of falls in men with moderate or severe, vs mild LUTS at baseline, as measured by the American Urological Association Symptom Index. We used Poisson regression models and considered multiple variables as potential confounders.

RESULTS

At baseline, 3188 (54%) reported mild, 2301 (39%) moderate, and 383 (7%) severe LUTS. Compared with men who had mild symptoms, the adjusted 1‐year cumulative incidence of falls was significantly higher among men with moderate or severe LUTS. The risk of at least one fall was increased by 11% among those with moderate (relative risk 1.11, 95% confidence interval, CI, 1.01–1.22; P = 0.02) and by 33% among those with severe LUTS (1.33, 1.15–1.53; P < 0.001). Further, those with moderate LUTS had a 21% (1.21, 1.05–1.40; P = 0.01) and those with severe LUTS a 63% (1.63, 1.31–2.02; P < 0.001) greater risk of at least two falls. LUTS most strongly associated with falls were urinary urgency, difficulty initiating urination, and nocturia.

CONCLUSIONS

Moderate and severe LUTS independently increase the 1‐year risk of falls, particularly recurrent falls, in community‐dwelling older men. Because of the serious consequences of falls, these results might justify the routine assessment of LUTS with a validated questionnaire in the primary care of this population.     

The correlation between international prostate symptoms score and sexual health inventory in men with lower urinary tract symptoms

Objective  

Lower urinary tract symptoms (LUTS) are common in aging men and are often associated with erectile dysfunction (ED). The International Prostate Symptoms Score (IPSS) and the Sexual Health Inventory for Men (SHIM) are commonly used validated instruments for LUTS and ED, respectively. We explored the correlation between LUTS (assessed by IPSS) and ED (assessed by SHIM) in men over 40 years of age.     

Is there a relationship among age,international index of erectile function,international prostate symptom score,and aging males’ symptoms score?

Purpose To investigate the relationship among the International Index of Erectile Function (IIEF), International Prostate Symptom Score (IPSS), and Aging Males’ Symptoms (AMS) scale scores in various age groups of males. Patients and methods A total of 307 male patients enrolled in the study. Mean age was 52.3 (range 21–77) years. Group 1 consisted of 51 (≤39 years), Group 2 consisted of 160 (40–59 years), and Group 3 consisted of 96 (≥60 years) patients. First five and 15th questions of the IIEF, IPSS, and AMS scale were replied by all the patients. The patients were assessed based on the IIEF for erectile dysfunction (ED), IPSS for lower urinary tract symptoms (LUTS), and AMS scale for Symptomatic Late-Onset Hypogonadism (SLOH). Results ED, LUTS, and SLOH symptoms were detected in 236 (76.8%), 162 (52.8%), and 184 (59.9%) patients. Except for total AMS scores, IIEF and IPSS scores were significantly different among the groups (p _AMS = 0.320, p _IIEF = 0.000, p _IPSS = 0.000). In the comparisons of the IIEF scores between the each group, significant differences were observed (p _{Group1–Group2} = 0.000, p _{Group1–Group3} = 0.000, p _{Group2–Group3} = 0.000). Nevertheless, IPSS score was significantly lower in the patients with age ≤39 years than the other age groups (p = 0.000). Conclusions In the present study, ED ratio and LUTS severity significantly increased in older men. We did not find significant relationship between aging and SLOH symptoms. In the light of our results, LUTS seems to be an important risk factor on erectile function.     

Investigation of a complex plant extract for mild to moderate erectile dysfunction in a randomized,double‐blind,placebo‐controlled,parallel‐arm study

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVE

To assess the effects of a complex plant extract (Prelox®, a formulation of pine bark extract and l ‐arginine aspartate; Horphag Research UK Ltd, London, UK) on erectile dysfunction (ED) in men, as sexual desire typically persists in ageing men, while their erectile and endothelial function gradually declines.

PATIENTS AND METHODS

In this double‐blind, placebo‐controlled study we assessed the effects of Prelox in 124 patients (aged 30–50 years) with moderate ED over an investigational period of 6 months. The International Index Of Erectile Function (IIEF) was used to quantify changes in sexual function.

RESULTS

The erectile domain of the IIEF (questions 1–5 plus 15) improved with Prelox from a baseline mean (sd ) score of 15.2 (6.6) to 25.2 (2.1) after 3 months and 27.1 (2.1) after 6 months of treatment. In the placebo group there was an increase from a baseline score of 15.1 (7.0) to 19.1 (3.0) and 19.0 (3.1) after 3 and 6 months, respectively. The effects with Prelox were statistically significant compared with placebo (P < 0.05). Mean (sd ) total plasma testosterone levels increased significantly from 15.9 (2.3) to 18.9 (2.6) nmol/L (P < 0.05) after 6 months with Prelox, compared to an increase from 16.9 (2.4) to 17.3 (2.3) nmol/L in the placebo group.

CONCLUSION

This study shows that Prelox is effective for improving erectile function, and that this effect persists on continuous therapy for up to 6 months. Moreover, there is some evidence that erectile function continues to improve the longer the therapy is used.     

A placebo‐controlled exploratory study investigating the efficacy and safety of the phosphodiesterase type 5 inhibitor UK‐369,003 for the treatment of men with storage lower urinary tract symptoms associated with a clinical diagnosis of overactive bladder

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVES

To evaluate the efficacy and safety of the phosphodiesterase type 5 inhibitor, UK‐369,003 modified release (MR), for the treatment of storage lower urinary tract symptoms (LUTS) in men with and without erectile dysfunction (ED).

PATIENTS AND METHODS

This was a multicentre, double‐blind, placebo‐controlled, parallel‐group study conducted across 50 centres in North and South America, Europe and Australia. In all, 310 men aged ≥18 years with a clinical diagnosis of overactive bladder (OAB; voiding frequency ≥8 times/24 h, urgency episode frequency once or more per 24 h and a mean voided volume of <300 mL) and maximum urinary flow rate of >5 mL/s in a voided volume of >150 mL were stratified into two groups (with or without ED) and randomized to one of five treatment groups (10, 25, 50 or 100 mg UK‐369,003; or placebo once a day) for 12 weeks. The primary study endpoints were those derived from the bladder diary that recorded the number of voluntary urinary voids, volume of urine per void, leaks and urgency episodes over a 72‐h period, before baseline and again at 2, 4 and 12 weeks. Secondary efficacy measures included the International Prostate Symptom Score (total and storage and voiding subscores), International Index of Erectile Function–Erectile Function domain (IIEF‐EF), questions 5 and 6 of the Quality of Erection Questionnaire (QEQ), the Overactive Bladder Questionnaire Short Form, the Patient Perception of Bladder Condition, the International Consultation on Incontinence Questionnaire–Male LUTS, and the patient‐reported treatment impact questionnaire.

RESULTS

Overall, there were no clinically relevant treatment differences in voiding frequency, mean voided volume, urgency episode frequency, or nocturia frequency for any dose of UK‐369,003 MR compared with placebo. In the subset of patients with ED there were improvements in the IIEF‐EF and QEQ scores in all UK‐369,003 treatment groups compared with placebo.

CONCLUSIONS

These data provide no evidence of efficacy for UK‐369,003 in the treatment of storage LUTS in men (based on classic OAB eligibility criteria). However, although the endpoints on these classic OAB efficacy variables were negative, there is evidence to suggest a greater preference, satisfaction and willingness to use UK‐369,003 again for all treatment groups compared with placebo.     

The prevalence of erectile dysfunction among Brazilian men screened for prostate cancer

OBJECTIVE

To determine the prevalence of erectile dysfunction (ED) in a large cohort of Brazilian men who were screened for prostate cancer, and to determine risk factors in this population, as there are large cultural differences among countries in reporting the frequency of ED, and it is likely that the prevalence of ED among men screened for prostate cancer cannot be generally applied across countries.

SUBJECTS AND METHODS

The analysis focused on the baseline characteristics of 1008 consecutive South American men from Brazil with no known prostate disease who had routine screening for prostate cancer by urologists. The variables analysed were patient age, urinary symptoms, patient health‐related quality of life (HRQL), prostate‐specific antigen (PSA) levels, prostate volume and erectile function. To assess lower urinary tract symptoms (LUTS) and HRQL, we used the American Urological Association symptom score and its appended eighth question, respectively. Benign prostatic hyperplasia was defined as a prostate volume of >30 g. Sexual function was assessed using the five‐item version of the International Index of Erectile Function questionnaire. Thus, ED was considered to absent for scores of 22–25, mild for 17–21, mild to moderate for 12–16, moderate for 8–11, or severe for 5–7. Obesity was defined by calculating the body mass index (BMI), and categorized as underweight (<18.5 kg/m²), normal weight (18.5–24.9 kg/m²), overweight (25–29.9 kg/m²) or obese (= 30 kg/m²). The mean (sd ) PSA level was 4.3 (6.7) ng/mL and the mean prostate volume 37.8 (21.8) mL. The correlation of ED with these variables was estimated using unconditional logistic regression models.

RESULTS

Information about erectile function was available for 908 patients. ED was considered to be absent, mild, mild to moderate, moderate and severe in 169 (18.6%), 210 (23.1%), 169 (18.6%), 138 (15.2%) and 222 (24.5%) patients, respectively. The ED was severe in 18.4%, 25.7% and 43.4% of patients with mild, moderate and severe LUTS, respectively (P < 0.001). The answer to the HRQL question was also significantly associated with ED; ED was severe in 16.5% of patients feeling delighted/pleased and in 35.8% of patients feeling unhappy/terrible (P < 0.001). The prostate volume was significantly related to ED. The BMI category showed that normal weight, overweight and obese patients had similar rates of ED (P = 0.415); ED was severe in about a quarter of the patients in each of these categories, and 50% and 24% of patients in the underweight and greater BMI groups had severe ED, respectively.

CONCLUSIONS

Of men screened for prostate cancer in Brazil, ≈40% have moderate or severe ED. Severe LUTS, higher HRQL scores, a large prostate volume, a low BMI and higher PSA levels might be associated with higher rates of ED. These variables should be considered when analysing the erectile function of patients screened for prostate cancer.     

Can preoperative detrusor underactivity influence surgical outcomes of 120 W HPS vaporization of the prostate (PVP) or holmium laser enucleation of the prostate (HoLEP)? A serial 3‐year follow‐up study

Aims

To determine the influence of preoperative detrusor underactivity (DU) on serial long‐term outcomes of HPS/PVP or HoLEP for LUTS/BPH, and to compare the influence between the two surgeries.

Methods

A total of 382 men, who underwent 120W‐HPS/PVP or HoLEP for LUTS/BPH and for whom 36‐month follow‐up data were available, were classified into four groups: HPS with DU (n = 145), HPS without DU (n = 44), HoLEP with DU (n = 105), and HoLEP without DU (n = 88). DU was defined as bladder contractility index of <100. Surgical outcomes were assessed at postoperative 6, 12, 24, and 36 months using IPSS, uroflowmetry, and serum PSA.

Results

All four groups maintained improvements in voiding symptom score (VSS), storage symptom score, total‐IPSS, QOL index, maximum flow rate (Qmax), post‐void residual urine volume (PVR), and bladder voiding efficiency (BVE) compared with baseline up to 3 years postoperatively. There were no significant differences in improvements of postoperative IPSS parameters including QOL index between men with and without DU throughout the follow‐up period after HPS or HoLEP. In men with DU, there were no significant differences in improvements of postoperative QOL index, Qmax, PVR, or BVE between HPS and HoLEP groups throughout the follow‐up period, except for VSS and total IPSS. Serum PSA reductions after HoLEP were greater than after PVP.

Conclusions

Improvements in LUTS, Qmax, and BVE can maintain up to 3 years after HPS or HoLEP for LUTS/BPH, irrespective of the presence or absence of preoperative DU. Although HoLEP may provide more durable improvement of VS in men with DU than HPS, there seems to be no difference in improvement of QOL or Qmax or BVE between HPS and HoLEP.     

Assessment of lower urinary tract symptoms in men by international prostate symptom score and core lower urinary tract symptom score

Study Type – Therapy (symptom prevalence) Level of Evidence 2a What's known on the subject? and What does the study add? The International Prostate Symptom Score (IPSS) has been most commonly used for the symptom assessment of men with lower urinary tract symptoms (LUTS). However, LUTS in men are so variable that they may not be fully captured by the IPSS questionnaire alone. This study has demonstrated that the Core Lower Urinary Tract Symptom Score (CLSS) questionnaire, which addresses 10 important symptoms, is an appropriate initial assessment tool for LUTS in men with various diseases/conditions.

OBJECTIVE

? International Prostate Symptom Score (IPSS) has been commonly used to assess lower urinary tract symptoms (LUTS). We have recently developed Core Lower Urinary Tract Symptom Score (CLSS). The aim of this study is to compare IPSS and CLSS for assessing LUTS in men.

PATIENTS AND METHODS

? Consecutive 515 men fulfilled IPSS and CLSS questionnaires. ? IPSS QOL Index was used as the QOL surrogate. ? The clinical diagnoses were BPH (n = 116), BPH with OAB wet (n = 80), prostate cancer (n = 128), prostatitis (n = 68), underactive bladder (n = 8), others (n = 72), and controls (e.g., occult blood) (n = 42). ? Simple statistics and predictability of poor QOL (QOL Index 4 or greater) were examined.

RESULTS

? All symptom scores were significantly increased in symptomatic men compared with controls. Scores of corresponding symptoms of two questionnaires were significantly correlated (r = 0.58–0.85, all P < 0.0001). ? A multivariate regression model to predict poor QOL indicated nine symptoms (daytime frequency, nocturia, urgency, urgency incontinence, slow stream, straining, incomplete emptying, bladder pain and urethral pain) as independent factors. ? The hazard ratios for bladder pain (2.2) and urgency incontinence (2.0) were among the highest. ? All the nine symptoms are addressed in CLSS, while three symptoms (urgency incontinence, bladder, and urethral pain) are dismissed in IPSS.

CONCLUSION

? CLSS questionnaire is more comprehensive than IPSS questionnaire for symptom assessment of men with various diseases/conditions, although both questionnaires can capture LUTS with possible negative impact on QOL.     

The prevalence of lower urinary tract symptoms (LUTS) in Brazil: Results from the epidemiology of LUTS (Brazil LUTS) study

Aims

We performed the first large population‐based study to evaluate lower urinary tract symptoms (LUTS) in Brazil. The study objective was to assess the prevalence and bother of LUTS in the population aged ≥40 years in five major cities of Brazil.

Methods

This study was conducted as a telephone survey with assessment of LUTS using a standardized protocol, which included the International Prostate Symptom Score (IPSS) and, for overactive bladder (OAB), the OAB‐V8 questionnaire. Participants were asked to rate how often they experienced individual LUTS and the degree of associated bother.

Results

Of the 5184 participants, 53% were women, and the age group with most participants (34%) was 50‐59 years. The prevalence of LUTS (symptoms occurring less than half the time or more) was 75%: 69% in men and 82% in women. There was a statistically significant association between the frequency and bother intensity of each symptom (P < 0.001). The prevalence of OAB was similar in men and women (25% and 24%, respectively). According to the IPSS questionnaire, moderate‐to‐severe symptoms were present in 21% of men and 24% of women. LUTS detrimentally affected quality of life in many individuals: 39% would be “mostly dissatisfied,” “unhappy,” or consider it “terrible” to spend the rest of their life with their urinary condition as it is currently.

Conclusions

This was the first nationwide, population‐based epidemiological study of LUTS to be performed in Brazil. LUTS are highly prevalent and often bothersome among men and women aged ≥40 years.     

Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function?

OBJECTIVE

To define the ability of the International Index of Erectile Function (IIEF) to differentiate between organic and psychogenic erectile dysfunction (ED).

PATIENTS AND METHODS

Patients presenting for the evaluation and treatment of ED who had penile duplex Doppler ultrasonography (DUS) completed the IIEF questionnaire. Accepted ranges of the IIEF EF domain were used to grade baseline severity (severe, moderate and mild ≤11, 11–17, 18–25, respectively). Accepted criteria were used to define normality on DUS (peak systolic velocity >30 cm/s and end‐diastolic velocity <5 cm/s). Patients with documented Peyronie’s disease, hypogonadism and a history of radical prostatectomy were excluded.

RESULTS

In all, 112 patients were enrolled, with a mean (sd ) age and duration of ED of 56 (16) and 2 (0.6) years, respectively. The vascular risk‐factor profile included diabetes in 15%, hypertension in 26% and hyperlipidaemia in 20%. The baseline severity of ED was mild, moderate and severe in 28%, 41% and 32% men, respectively. All patients had normal testosterone levels. Patients also with a normal DUS were diagnosed with psychogenic ED, in 50%, 13% and 17% of men with mild, moderate and severe ED by the IIEF, respectively. No patient with venous leak had mild ED, and 62% of men with venous leak had severe ED.

CONCLUSIONS

These results indicate that the IIEF is not completely accurate in differentiating between organic and psychogenic ED, and that almost a fifth of men in this study population with severe ED by the IIEF had normal erectile haemodynamics. These data have potential ramifications for evaluating the baseline severity of ED in trials of erectogenic agents.     

Association of lower urinary tract symptoms with sexual dysfunction: a cross‐cultural study between Japanese and American men with localized prostate cancer

OBJECTIVE

To assess the association of lower urinary tract symptoms (LUTS) with sexual function, and estimate the correlates of LUTS among Japanese and American men with localized prostate cancer.

PATIENTS AND METHODS

In all, 343 Japanese men and 307 American men with prostate cancer were enrolled in the study. Sexual function and sexual bother were measured separately with the University of California‐Los Angeles Prostate Cancer Index and obstructive/irritative voiding symptoms were measured with the American Urological Association Symptom Index (AUA SI).

RESULTS

Japanese men had worse sexual function scores than the American men before treatment, whereas no differences were reported between Japanese and American men in sexual bother scores. Japanese and American men also did not differ meaningfully in AUA SI. However, those with moderate to severe LUTS reported significantly worse sexual bother scores than those with mild symptoms in both Japanese and American men (P = 0.004 and <0.001, respectively). The Japanese men were more likely to have LUTS than were American men (odds ratio 1.60, P = 0.029). Age and sexual function were highly associated with LUTS (odds ratio 1.35, P = 0.027; and 0.652, P = 0.001, respectively). The comorbidity count was independently associated with worse urinary symptoms (odds ratio 1.23, P = 0.015).

CONCLUSIONS

We posit that cultural differences in the meaning or salience of sexual functioning, and the interpretation of the questionnaire in quality‐of‐life surveys, might explain the different profiles in the association of LUTS with sexual activity in Japanese and American men with localized prostate cancer.     

Safety and efficacy of sildenafil citrate in treating erectile dysfunction in patients with combat‐related post‐traumatic stress disorder: a double‐blind,randomized and placebo‐controlled study

OBJECTIVE

To evaluate the safety and efficacy of sildenafil citrate for treating erectile dysfunction (ED) in patients with combat‐related post‐traumatic stress disorder (PTSD).

PATIENTS AND METHODS

In all, 266 combat‐exposed war veterans with ED (aged 37–59 years) were recruited. They met the Diagnostic and Statistical Manual of Mental Disorders‐IV criteria for PTSD according to the Structured Clinical Interview for Patients, Investigator Version. The patients were also evaluated with the Clinician‐Administered PTSD Scale, both to establish the diagnosis of PTSD and to measure symptom severity. Only patients with psychogenic ED were included in the study. Patients with comorbid conditions (diabetes mellitus, hypercholesterolaemia, hypertension, Peyronie’s disease) and smokers of more than five cigarettes daily were excluded. The patients were randomly divided into a group of 133 who received 100 mg of on‐demand sildenafil 0.75–2 h before sexual stimulation, and 133 who received placebo. Patients were asked to use ≥16 doses or attempts at home. The efficacy of the treatments was assessed every four attempts during treatment, and at the end of the study, using responses to the 15‐question International Index of Erectile Function (IIEF), Sexual Encounter Profile diary questions 2 and 3, Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, patients’ event logs of sexual activity, and a Global Assessment Question about erections.

RESULTS

Sildenafil did not produce significantly and substantially greater improvement than placebo in each of the primary and secondary outcome measures (P = 0.08). A normal EF domain score (≥26) at endpoint was reported by 13 (9.8%), and 11 (8.3%) of patients on the sildenafil and placebo regimens, respectively (P = 0.09). Patients treated with sildenafil had no statistically significantly greater improvement in the five sexual function domains of the IIEF questionnaire than those treated with placebo (P = 0.08). The incidences of treatment‐emergent adverse events were significantly greater in the sildenafil arm than in the placebo group (P = 0.01).

CONCLUSIONS

Sildenafil is no better than placebo in treating PTSD‐emergent ED. Further randomized clinical trials are warranted in combat veterans and other populations with PTSD to better elucidate the role of phosphodiesterase type 5 inhibitors in treating PTSD‐emergent ED.     

The correlation between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED): results from a survey in males from Mexico City (MexiLUTS)

Introduction

ED and LUTS affect a high proportion of male population. Although Hispanics are suspected to have a higher risk of experiencing LUTS, detailed information on its frequency and association with ED in this population is scarce.

Objective

To determine the frequency of LUTS and ED, and its correlation in Mexican males.

Methods

A cross-sectional analytical survey was answered by 1041 men. It included the International Prostate Symptom Score and the quality of life question (IPSS/QoL); International Index of Erectile Function (IIEF-5); the short form of the International Consultation of Incontinence Questionnaire (ICIQ-SF); and demographic data. For the analysis, we divided our population into 2 groups (18–39 and 40 and older), and then an exploratory correlation analysis was performed to search for significant differences among IPSS severity groups, and finally a multivariate regression model was applied.

Results

Mean age was 48.6 ± 14.5 years. One hundred twenty-three individuals (11.8 %) were asymptomatic, and 611 (58.7 %) had mild, 226 (21.7 %) had moderate, and 81 (7.8 %) had severe IPSS score. The most common symptoms were nocturia (72.4 %), increased urinary frequency (58.3 %), and slow urinary stream (42.6 %). Two hundred fifty-eight (24.7 %) complained of incontinence. Of 765 individuals, 484(63.2 %) reported some degree of ED. Severe LUTS, DM, and age were independent risk factors for ED severity.

Conclusion

LUTS and ED may represent one of the largest sources of morbidity in our population, and their association was demonstrated. Awareness on these entities should be raised, and further research is required to determine the higher frequency of LUTS and ED in Hispanics.