Overactive bladder in the male patient: Epidemiology, etiology, evaluation, and treatment

The urologist’s approach to the diagnosis and treatment of lower urinary tract symptoms (LUTS) in male patients has changed significantly over the past decade. Advances in the basic science arena combined with a wealth of clinical data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically, men with LUTS were diagnosed with “prostatism,” an allencompassing term that includes both voiding and storage symptoms that may or may not be related to prostatic obstruction. Parallel to the scientific advances in the field, the urologic lexicon began to evolve and has allowed us to more specifically describe, and therefore investigate and treat, different aspects of male LUTS. It is now well recognized that many men suffer from storage symptoms that may be more related to bladder dysfunction than to prostatic obstruction. It will be critical to integrate our knowledge of prostatic growth and obstruction, the bladder response to outlet obstruction, environmental and lifestyle factors, and age-related changes to fully understand the complex pathophysiology of male LUTS, specifically overactive bladder syndrome.     

Current Understanding of the Interplay between Oab & Bph

Lower urinary tract symptoms (LUTS) are very common and bothersome to men. For many years all male LUTS, even the storage ones, were attributed to the prostate, which was the target of therapeutic approaches. Increasing knowledge of the contribution of bladder dysfunction to LUTS pathophysiology has brought into focus detrusor overactivity (DO) and its treatments. Available data indicate that in many cases DO and overactive bladder (OAB) symptoms are secondary to bladder outlet obstruction (BOO), due to prostatic disease. Accumulating evidence also suggests that the two pathologies may coexist because they share etiologic factors. Despite the prevalence of storage symptoms in men with benign prostatic hyperplasia (BPH), antimuscarinics, the main treatment for OAB, were infrequently used because of fear of urinary retention. Available clinical trials indicate that the addition of an antimuscarinic to prostate-targeted treatments, or treatment initiation with a combination regimen, is safe in terms of urinary retention and offers improvements in storage symptoms. Nevertheless, the improvement in overall quality of life is modest. Criteria for the selection of patients likely to benefit most from the addition of antimuscarinics to common BPH treatments are lacking.     

Combination therapy for benign prostatic hyperplasia: Does size matter?

Lower urinary tract symptoms (LUTS) in men are often associated with bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH). The current standard of care for men with LUTS is treatment with α-adrenergic receptor antagonists to reduce outlet tone or 5-α-reductase inhibitors to reduce prostatic volume. Up to 60% of men with BOO secondary to BPH have storage symptoms attributable to detrusor overactivity (DO), which makes treatment with anticholinergics, either alone or in combination, an attractive proposition. We present a review of the literature concerning the use of anticholinergic drugs in men with LUTS and focus on the studies that relate to enlarged prostate volumes. There have been a number of uncontrolled studies and one large, randomized controlled trial (RCT) evaluating anticholinergic drugs in men with LUTS, overactive bladder, and BPH. The results of these studies were not stratified by prostate size. A recent post-hoc analysis of the RCT, however, now provides data stratified by prostate size.     

Anticholinergics in men: Does the evidence support combination therapy?

Benign prostatic hyperplasia (BPH) is common in men older than age 50, and the symptoms occurring from bladder outlet obstruction (BOO) commonly overlap with lower urinary tract symptoms (LUTS) experienced in overactive bladder (OAB). Anticholinergics are often withheld from men with BOO. This article reviews seven randomized controlled trials (RCTs) and a meta-analysis study examining anticholinergic use in men with LUTS associated with OAB and BPH. There is growing evidence that anticholinergics are a suitable, safe treatment in men with persistent LUTS associated with BOO, refractory to α-blockers. Only four of 750 men treated with anticholinergics in the seven RCTs reviewed had acute urinary retention. Further well-designed, placebo-controlled RCTs are required to assess the efficacy and long-term safety outcomes of combination therapy. However, it appears feasible to effectively use adjunctive anticholinergic therapy in men with LUTS/BPH and no significant increase in postvoid residual volume.     

Medical management of benign prostatic hypertrophy

Benign prostatic hyperplasia (BPH) is a common condition of the aging male. The bladder outlet obstruction caused by this condition occurs despite variations in prostate size. Symptoms of BPH include the irritative and obstructive voiding symptoms termed lower urinary tract symptoms (LUTS). While transurethral surgery has long been the gold standard for treatment of LUTS, medical treatment has emerged as the first line of treatment for those men who fail expectant or watchful waiting treatment. Medical options include: alpha blockers, 5alpha-reductase inhibitors and newly identified PDE 5 inhibitors, drugs for erectile dysfunction that have a relieving effect on the symptoms of LUTS. Newer prostate selective alpha blockers have replaced older nonselective agents as first choice in treatment of most men, especially those with smaller prostates and in whom preservation of sexual function is important. While tamsulosin has the effect of an ejaculation, alfuzosin preserves ejaculatory function. 5alpha-reductase inhibitors may decrease ejaculate volume, libido and sexual function. While this effect is frequently a self limited, it can be a compliance issue for many men. PDE 5 inhibitors, while effective in relieving LUTS symptoms, have not shown effectiveness in reducing post void residual volumes or increasing urinary flow rates.     

Management of Lower Urinary Tract Symptoms in Men

Abstract. This clinical update, written for the non‐urologist, aims to highlight the important concepts behind understanding and treating men with uncomplicated lower urinary tract symptoms (LUTS). In the last five years there have been important changes in the preferred terminology and guidelines for managing men with voiding symptoms. In particular, the assessment of a patient's degree of bother is the most important factor when making management decisions for men with uncomplicated LUTS. Although this clinical update does not attempt to address the management of prostate cancer it does include some brief guidelines on prostate specific antigen (PSA) testing. The following information is based on the NH&MRC Clinical Practice Guidelines, published 1996 [1]. It is acknowledged that opinion remains divided among urologists concerning some of these guidelines.     

A review of the L-arginine - nitric oxide - guanylate cyclase pathway as a mediator of lower urinary tract physiology and symptoms

Lower urinary tract symptoms (LUTS) are common and costly conditions that affect millions of men and women worldwide. A focal area of research into the cause and potential treatment of LUTS is the nitric oxide pathway, which is involved in nerve-induced relaxation in the lower urinary tract. Isoforms of NOS, including nNOS, eNOS, and iNOS, have been identified in the lower urinary tract of both animals and humans. Nerves that are immunoreactive to nitric oxide synthase (NOS) mainly serve the bladder outlet region, but some serve the detrusor. Pathology of the l-arginine-nitric oxide-cGMP pathway involving nNOS and eNOS may lead to impaired relaxation of the urethral outlet, increased bladder afferent activity, and detrusor smooth muscle overactivity. Such pathology has been implicated in the conditions of detrusor instability, urinary incontinence and outlet obstruction. iNOS may play an important role in inflammatory and infectious conditions of the bladder. Strategic manipulation of nitric oxide (NO), or interventions that address its mechanisms of action, possibly by pharmacological means or with gene therapy, may restore function or produce desired functional effects in the lower urinary tract.     

Management of benign prostatic hyperplasia by the primary care physician in the 21st century: the new paradigm

Benign prostatic hyperplasia (BPH) is one of the commonest causes of lower urinary tract symptoms (LUTS) in men over age 50. Fifty percent of men over age 50 will require some type of management for BPH/LUTS symptoms. Until about 15 years ago, the most common management for BPH was a transurethral resection of the prostate (TURP) operation. Initially, once a diagnosis of BPH has been made, most men are treated medically. One must first rule out other serious causes of these symptoms, such as prostate cancer, bladder cancer, and other obstructions. For men with an enlarged prostate, there is a good chance that therapy with a 5-alpha-reductase inhibitor (5-ARI) can prevent disease progression and the need for surgery. There has been a lot of recent work on different combination therapies for the treatment of BPH/LUTS. If a patient's serum prostate-specific antigen (PSA) level is greater than 1.5 ng/ml and his prostate volume is greater than 30 cc and he has significant LUTS, then combination medical therapy of an alpha blocker with a 5-ARI is the most effective therapy. After a careful workup, it is quite reasonable and appropriate for the primary care physician to initiate this therapy for a patient with BPH/LUTS.     

Minimally Invasive Treatment for Male Lower Urinary Tract Symptoms: the Prostatic Urethral Lift

Male lower urinary tract symptoms (LUTS) are one of the most common non-malignant conditions afflicting quality of life in aging men. Treatment modalities for bothersome LUTS consist of pharmacotherapeutic and surgical options. There is particular interest in the development of minimally invasive procedures showing good efficacy with a favorable safety profile. An innovative technique offering rapid and durable relief without compromising sexual function is in great demand. The prostatic urethral lift represents a promising minimally invasive approach for the relief of bladder outlet obstruction (BOO) with few adverse events. The principle includes the application of retracting implants under cystoscopic guidance to unobstruct encroaching lateral lobes of the prostate. Clinical trials have confirmed improvement in LUTS with preservation of sexual function. The prostatic urethral lift appears to be a promising addition to the current repertoire of minimally invasive treatments for the management of LUTS.     

Role of Bladder Dysfunction in Men with Lower Urinary Tract Symptoms Refractory to Alpha‐blocker Therapy: A Video‐urodynamic Analysis

Objectives

Lower urinary tract symptoms (LUTS) in men result from a complex interplay of pathophysiology, including bladder and bladder outlet dysfunction. This study retrospectively analyzed bladder dysfunction in men with LUTS based on the results of video‐urodynamic studies (VUDS).

Methods

Male patients (aged ≥40 years), with LUTS and an International Prostate Symptom Score of 8 or more, who were refractory to alpha‐blocker treatment were retrospectively recruited and evaluated with VUDS and total prostate volume (TPV). Patients were further divided into subgroups of bladder dysfunction and bladder outlet dysfunction according to characteristic VUDS findings. Age, TPV and VUDS findings were compared among different subgroups.

Results

After VUDS, bladder outlet obstruction (BOO) was only noted in 48.6% of men. Of patients, 919 of 2991 (30.7%) had bladder dysfunction including detrusor underactivity (DU, 5.1%), detrusor overactivity and inadequate contractility (DHIC, 5.3%), detrusor overactivity (DO, 17%) and hypersensitive bladder (HSB, 3.3%). In addition, 1941 (64.9%) had bladder outlet dysfunction including BOO + DO (33.8%), BOO alone (14.8%), and poor urethral sphincter relaxation (PRES, 16.3%). Among the 1519 patients with DO, 66.6% (1012) had BOO while, among 1454 patients with BOO, 69.5% (1010) had DO. Patients with DHIC, DU and DO were 5 years older than patients with HSB and normal men. TPV was significantly smaller in patients with DHIC, DU and DO as compared with BOO + DO.

Conclusion

Approximately one‐third of male LUTS was due to bladder dysfunction. A man older than 70 years with LUTS and TPV less than 30 mL usually indicates the presence of bladder dysfunction rather than BOO.     

Update on the use of dutasteride in the management of benign prostatic hypertrophy

Benign prostatic hyperplasia (BPH) is a frequent cause of lower urinary symptoms, with a prevalence of 50% by the sixth decade of life. Hyperplasia of stromal and epithelial prostatic elements that surround the urethra cause lower urinary tract symptoms (LUTS), urinary tract infection, and acute urinary retention. Medical treatments of symptomatic BPH include; 1) the 5α-reductase inhibitors, 2) the α1-adrenergic antagonists, and 3) the combination of a 5α-reductase inhibitor and a α1-adrenergic antagonist. Selective α1-adrenergic antagonists relax the smooth muscle of the prostate and bladder neck without affecting the detrussor muscle of the bladder wall, thus decreasing the resistance to urine flow without compromising bladder contractility. Clinical trials have shown that α1-adrenergic antagonists decrease LUTS and increase urinary flow rates in men with symptomatic BPH, but do not reduce the long-term risk of urinary retention or need for surgical intervention. Inhibitors of 5α-reductase decrease production of dihydrotestosterone within the prostate resulting in decreased prostate volumes, increased peak urinary flow rates, improvement of symptoms, and decreased risk of acute urinary retention and need for surgical intervention. The combination of a 5α-reductase inhibitor and a α1-adrenergic antagonist reduces the clinical progression of BPH over either class of drug alone.     

Evaluation and Management of Lower Urinary Tract Symptoms After Outlet Surgery for Benign Prostatic Hyperplasia

There are many options available in the surgical treatment of outlet obstruction secondary to benign prostatic hyperplasia (BPH). While most patients exhibit improvement in their lower urinary tract symptoms (LUTS) following intervention, up to 35 % of patients may exhibit persistent or recurrent LUTS. In the present review, we discuss the pathophysiology of LUTS after bladder outlet surgery and discuss considerations in evaluating and managing such patients. We highlight the crucial role of thorough evaluation with complete urodynamics testing, as pure obstruction only accounts for a minority of post-operative LUTS. Hence, detrusor contractility, detrusor overactivity, urethral sphincter function, and urinary incontinence must be assessed to appropriately guide subsequent therapy and improve patients’ quality of life.     

Association between markers of the metabolic syndrome and lower urinary tract symptoms in the Third National Health and Nutrition Examination Survey (NHANES III)

OBJECTIVE: To examine the association of components of the metabolic syndrome with lower urinary tract symptoms (LUTS), which often result from prostate enlargement and heightened tone of prostate and bladder smooth muscle. DESIGN: Third National Health and Examination Survey (NHANES III), from which LUTS cases and controls were selected. SUBJECTS: A total of 2372 men aged 60+ y who participated in NHANES III. LUTS cases were men with at least three of these four symptoms: nocturia, incomplete bladder emptying, weak stream, and hesitancy, and who never had noncancer prostate surgery. Controls were men without any of the symptoms and who never had noncancer prostate surgery. MEASUREMENTS: As part of NHANES III, an oral glucose tolerance test was carried out, glycosylated hemoglobin, HDL and LDL cholesterol, and triglycerides were measured, and history of diabetes mellitus and hypertension were assessed. Logistic regression was used to calculate odds ratios (ORs) after applying sampling weights. RESULTS: History of diabetes (OR 1.67; 95% confidence interval (CI) 0.72-3.86) and hypertension (OR 1.76; 95% CI 1.20-2.59) appeared to be positively associated with LUTS. The odds of LUTS increased with increasing glycosylated hemoglobin (P-trend = 0.005). No statistically significant associations between fasting or 2-h glucose or fasting insulin and LUTS were observed. However, men classified as having three or more components of the metabolic syndrome had an increased odds of LUTS (OR = 1.80; 95% CI 1.11-2.94). CONCLUSION: These findings support the role for metabolic perturbations in the etiology of LUTS.     

The use of baseline clinical measures to predict those at risk for progression of benign prostatic hyperplasia

Although histologic changes of benign prostatic hyperplasia (BPH) begin in men when they are in their thirties, symptomatic BPH characterized by lower urinary tract symptoms (LUTS) typically do not develop for several decades. Progression of BPH may lead to significant voiding symptoms, acute urinary retention, and the need for prostate surgery. However, developing LUTS is not inevitable for men with histologic evidence of BPH. The ability to predict those men who are risk for BPH progression is increasingly important because of recent evidence provided by the Medical Therapy of Prostate Symptoms study. This landmark study demonstrated that 5α-reductase inhibitors, alone or in combination with selective α-blockers, can delay or prevent the progression of BPH. In addition, the most important and consistent predictive factors for BPH progression are baseline prostatespecific antigen and prostate volume. Integration of these clinical parameters into clinical practice is influencing the decision regarding which men should observe or initiate treatment. This article highlights recent studies regarding the use of baseline clinical parameters on predicting BPH progression.     

Combination antimuscarinics and alpha-blockers for benign prostatic hyperplasia

Millions of men suffer from lower urinary tract symptoms and overactive bladder. The adverse effects on quality of life and the costs associated with the condition have been well described. Though α-adrenergic antagonists have long been considered first-line therapy for male lower urinary tract symptoms, many patients have persistent storage symptoms and do not reach their treatment goal. Increasing data and clinical experience support the efficacy and safety of anticholinergics in men, either as monotherapy or in combination with α-blockers.     

Medical Treatment of BPH: An Update on Results

Benign prostatic hyperplasia (BPH) is a common condition in older men, resulting in chronic lower urinary tract symptoms (LUTS) that are bothersome and cause impaired physiological and functional well-being and interference with activities of daily living. BPH is rarely life-threatening, but it can lead to acute urological problems, for example acute urinary retention (AUR). The clinical manifestations of BPH include LUTS, poor bladder emptying, urinary retention, detrusor instability, urinary tract infection, hematuria, and renal insufficiency. Surgery remains the most effective treatment for complicated or severe symptomatic BPH, especially where medical treatment has failed. Its invasive nature and potential side-effects have led to the development of potentially less traumatic techniques and the widespread adoption of medical strategies. Medical management continues to evolve and refinements are aimed at achieving reduced frequency of dosage and achieving minimal side-effects, while maintaining clinical efficacy. In the current era of male health promotion the number of men who seek and receive treatment for uncomplicated BPH continues to rise. Thus the medical management of BPH is likely to continue playing an important role in the future.     

Retroperitoneal disorders associated with IgG4-related autoimmune pancreatitis

Ig G4-related autoimmune pancreatitis is frequently accompanied by relevant lesions in the genitourinary tract and retroperitoneal organs, which cause various clinical problems, ranging from non-specific back pain or bladder outlet obstruction to renal failure. The diagnosis of Ig G4-related retroperitoneal fibrosis requires a multidisciplinary approach, including serological tests, histological examination, imaging analysis, and susceptibility to steroid therapy. Radiological examinations are helpful to diagnose this condition, but surgical resection is occasionally unavoidable to exclude malignancy, particularly for patients with isolated retroperitoneal involvement. Steroid therapy is the treatment of choice for this condition, the same as for other manifestationsof Ig G4-related disease.For patients with severe ureteral obstruction,additional ureteral stenting needs to be considered prior to steroid therapy to preserve the renal function.Some papers have suggested that Ig G4-related disease can affect male reproductive organs including the prostate and testis.Ig G4-related prostatitis usually causes lower urinary tract symptoms,such as dysuria and pollakisuria.Patients sometimes state that corticosteroids given for Ig G4-related disease at other sites relieve their lower urinary tract symptoms,which leads us to suspect prostatic involvement in this condition.Because of the limited number of publications available,further studies are warranted to better characterize Ig G4-related disease in male reproductive organs.     

Prevalence of Urgency in Patients with LUTS Due to BPE

Purpose of Review

To review recent data on the prevalence and treatment of the symptom of urgency in men with benign prostatic enlargement (BPE).

Recent Findings

In recent years, researchers have moved to separate out individual lower urinary tract symptoms (LUTS) to see the individual impact. A recent registry trial put the prevalence of urgency at 38% in men with BPE. Other studies have reported urgency present in 64% of men with LUTS. While urgency is not as frequent a complaint in BPE as nocturia and frequency, it does have an impact on health-related quality of life. It is not increased in men with diabetes or the metabolic syndrome. Contributing factors may include prostate inflammation and decreased bladder blood flow from outlet obstruction. While some response is seen with treatment with alpha-blockers, more recently, anticholinergic and beta 3 medications are being used for refractory urgency in men with BPE.

Summary

Urinary urgency is commonly reported in men with benign prostatic enlargement and is just beginning to be better evaluated with screening tools commonly used in overactive bladder patients. Specific medical therapy for urgency is helping to improve the response rate above traditional BPE therapy.

     

前列腺癌^125I粒子植入治疗对下尿路症状的影响（附70例报道）

目的探讨前列腺癌^125I粒子植入治疗后下尿路症状的变化规律,为临床治疗提供参考。方法接受^125I粒子植入治疗的前列腺癌患者72例,失访2例,随访70例,年龄58～85岁,平均年龄（73．6±10．4）岁。临床分期T1bNoMo～T3bNoMo。治疗前PSA0．4～55．2ng／mL,Gleason评分6～9分,前列腺体积19mL～59mL。国际前列腺症状评分（IPSS评分）5～21分,平均14分。植入粒子30～90粒,平均活度0．38mCi,总活度平均27．22mCi;植入针12～23根。术前1周至术后6个月常规使用α-肾上腺能受体阻滞剂。观察治疗后下尿路症状的变化。结果70例随访3～72个月,中位随访时间29．3个月。出院后无急性尿潴留发生;轻度尿失禁2例（2．9％）,均在术后2～4个月好转。出现尿频、尿急及排尿困难或加重65例（92．9％）。术后0．5、1、2、3、6、9、12、18、24个月出现尿频、尿急及排尿困难或加重者分别为34．3％、85．7％、92．9％、82．8％、45．7％、28．6％、17．1％、8．5％、2．8％。下尿路症状持续时间与治疗前IPSS评分成正相关,P值为0．007。结论前列腺癌^125I粒子植入治疗后下尿路症状常见,持续时间较长,但不严重,大多数可恢复。持续时间与治疗前IPSS评分相关,使用α-肾上腺能受体阻滞剂可以有效缓解症状并避免手术干预。     

Doxazosin in the treatment of benign prostatic hypertrophy: an update

We evaluated the efficacy and safety of a1 - blocker doxazosin for treatment of lower urinary tract symptoms (LUTS) compatible with benign prostatic hypertrophy (BPH). Fourteen randomized controlled trials enrolled 6261 men, average age 64 years, who had moderately severe LUTS and flow impairment. Compared with baseline measures and placebo effect, doxazosin resulted in a statistically significant improvement in both LUTS and flow. However, when compared with placebo, the average magnitude of symptom improvement (International Prostate Symptom Score [IPSS] improvement <3 points) typically did not achieve a level detectable by patients. Combined doxazosin and finasteride therapy improved LUTS and reduced the risk of overall clinical progression of BPH compared to each drug separately in men followed over 4 years. Reported mean changes from baseline in the IPSS were −7.4, −6.6, −5.6, and −4.9 points for combination therapy, doxazosin, finasteride, and placebo, respectively. Combination therapy reduced the need for invasive treatment for BPH and the risk of long-term urinary retention. The absolute reductions compared with placebo were less than 4% and primarily seen in men with prostate gland volume >40 mL or PSA levels >4 ng/mL. Efficacy was comparable with other a1–blockers. Withdrawals from treatment for any cause were comparable to placebo. Dizziness and fatigue occurred more frequently with doxazosin compared to placebo.