Is the higher prevalence of benign prostatic hyperplasia related to lower urinary tract symptoms in Korean men due to a high transition zone index?

OBJECTIVE: Asian men generally have smaller prostate gland sizes than their Western counterparts. Nonetheless, the prevalence of lower urinary tract symptoms (LUTS) is similar between native Asian men and men in the Western hemisphere. The purpose of this study was to determine if the enlargement of the transition zone volume (TZV) relative to the overall prostate volume (PV) might account for the prevalence of LUTS among Korean men despite having "smaller" prostates. METHODS: Three hundred and seventy consecutive age-matched men (94 Caucasian, 94 Hispanic, 93 African-American, and 89 Korean) with LUTS were evaluated utilizing the International Prostate Symptom Score (IPSS), peak flow rate (Q(max)), serum PSA and transrectal ultrasound (TRUS). The ratio of TZV to total PV was used to determine the transition zone index (TZI). RESULTS: Mean baseline IPSS and Q(max) were significantly different (p<0.001 and p<0.03) for Korean men (19.9+/-7.6 and 11.3+/-4.2) in comparison to African-American (14.6+/-3.7, 12.6+/-4.1), Caucasian (13.4+/-4.3, 12.5+/-3.8), and Hispanic (13.9+/-3.1, 11.9+/-4.5) men. Regardless of race, TZI correlated with IPSS (r=0.31, p<0.01) and Q(max) (r=0.26, p<0.04). Mean TZI was significantly (p<0.001) higher in Korean and African-American men (0.45+/-0.08 and 0.44+/-0.05, respectively) than Caucasian and Hispanic men (0.39+/-0.03 and 0.38+/-0.02, respectively). CONCLUSIONS: Among age-matched, ethnically diverse men with moderate to severe LUTS, Korean men demonstrated more clinical symptoms and a higher ratio of transition zone enlargement relative to total prostate in comparison to Caucasian, Hispanic, and African-American men. The clinical significance of these findings remains to be determined.     

Lower urinary tract symptoms,benign prostatic hyperplasia/benign prostatic enlargement and erectile dysfunction: Are these conditions related to vascular dysfunction?

Although the pathogenesis of lower urinary tract symptoms, benign prostatic hyperplasia/benign prostatic enlargement and erectile dysfunction is poorly understood and thought to be multifactorial, it has been traditionally recognized that these conditions increase with age. There is increasing evidence that there is an association between cardiovascular disease and lower urinary tract symptoms as well as benign prostatic hyperplasia/benign prostatic enlargement and erectile dysfunction in elderly patients. Age might activate systemic vascular risk factors, resulting in disturbed blood flow. Hypertension, diabetes, hyperlipidemia and atherosclerosis are also linked to the etiology of lower urinary tract symptoms, benign prostatic hyperplasia/benign prostatic enlargement and erectile dysfunction. In the present review, we discuss the relationship between decreased pelvic blood flow and lower urinary tract symptoms, benign prostatic hyperplasia/benign prostatic enlargement and erectile dysfunction. Furthermore, we suggest possible common mechanisms underlining these urological conditions.     

Lasers for lower urinary tract symptoms secondary to benign prostatic hyperplasia: When is the fuss worth it?

In the recent past, several endoscopic procedures using laser technology have evolved for the treatment of benign prostatic hyperplasia. The term “laser treatment of the prostate” comprises a variety of different application systems, different laser wavelengths, and different surgical techniques to eliminate bladder outlet obstruction. The aim of laser prostatectomy is to be less invasive than transurethral electroresection, but equally effective. Promising short-term results led to a booming laser decade in the 1990s, stimulating the development of several devices. However, the emergence of medium-term data has shown that some of these techniques did not stand the test of time due to the lack of long-term efficacy, unacceptable morbidity, and high retreatment rates. Nevertheless, the results of transurethral resection of the prostate are challenged by some of the newer laser devices, putting the socalled “gold standard” into question.     

To what extent do real life practice studies differ from randomized controlled trials in lower urinary tract symptoms/benign prostatic hyperplasia?

PURPOSE OF THE REVIEW: To compare the real-life practice studies and randomized controlled trials on benign prostatic hyperplasia in order to understand the applications of the data from the two types of study. RECENT FINDINGS: Until recently, much of the available information on benign prostatic hyperplasia has come from randomized controlled trials conducted by secondary care urologists on selected populations of patients, who are likely to represent the more symptomatic among the cohort of men with lower urinary tract symptoms in the community. The strict inclusion criteria in these trials led to uncertainty about the applicability of the results to community populations. Moreover, as patients in randomized controlled trials are specially recruited, rather than being drawn from a general population of men with lower urinary tract symptoms, the calculations of incidence and prevalence rates may not be possible. In the last few years, there have been a few important real-life practice studies such as the Triumph project, the Quadraet study and the ALF-ONE study, which have provided very useful data regarding the incidence and prevalence of lower urinary tract symptoms/benign prostatic hyperplasia, the incidence of acute urinary retention, the impact of therapy on the risk of surgery related to benign prostatic hyperplasia and the predictors of disease progression during treatment with alpha-blocker. SUMMARY: As the results from randomized controlled trials cannot always be generalized to daily urological practice, it is important to complement them with data made available by the real-life practice studies. In order to do that, the salient features in the methodology of both types of study must be understood.     

A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?

OBJECTIVE: To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence. METHODS: An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application. RESULTS: Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year. CONCLUSION: The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients.     

Are lower urinary tract symptoms associated with erectile dysfunction in aging males of Taiwan?

INTRODUCTION: This study was conducted to evaluate the relationship between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in aging males of Taiwan. PATIENTS AND METHODS: A free health screening for aging males (>or=45 years old) was conducted in Kaohsiung Medical University Chung-Ho Memorial Hospital in August 2004. LUTS and ED were assessed by validated symptom scales: the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function-5 (IIEF-5). The subjects also completed a health and demographics questionnaire and underwent detailed physical examination, serum prostate-specific antigen level determination, and transrectal ultrasonography. RESULTS: The final study population consisted of 141 patients with a mean age of 59.8 years. The severity of LUTS and ED increased with age. After controlling for comorbidities, age (p<0.001) and IPSS score (p<0.001) were significantly associated with the IIEF-5 score. Furthermore, men with moderate to high IPSS scores were more likely to have ED as compared with those with mild symptoms after age adjustment (age-adjusted odds ratio 3.27, p=0.002). CONCLUSIONS: ED and LUTS are highly prevalent in our study population, and this prevalence increases with age. ED is significantly associated with the severity of LUTS after controlling for age and comorbidities. These results highlight the clinical importance of evaluating LUTS in patients with ED and the need to consider sexual issues in the management of patients with benign prostatic hyperplasia.     

Combination 5-α-reductase inhibitors and α-blockers for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Open or transurethral resection of the prostate was once the only option for men afflicted with symptomatic benign prostatic hyperplasia (BPH). In the past 10 to 15 years, however, medical management has become a common step in the treatment of BPH, often postponing or eliminating the need for surgical intervention. The two drug classes used in the medical management of BPH are α-blockers and 5-α-reductase inhibitors. This paper reviews major studies related to the use of these medications in combination and discusses patient populations best served by combination therapy.     

The effect of α-blocker therapy on erectile functions in patients with lower urinary tract symptoms due to benign prostate hyperplasia

In this study we aimed to evaluate the impact of doxazosin treatment on erectile functions in patients with lower urinary tract symptoms （LUTS） and having erectile dysfunction （ED） at baseline. Fifty-three patients with LUTS （IPSS score 〉 7） whose maximum flow rate （Qmax） 〈 15 mL s-1 and PSA 〈 4 ng dL^-1 were enrolled in the study. Patients received doxazosin 4 nag once daily for 6 weeks. Subjective efficacy was assessed by IPSS, IPSS- Quality of Life （IPSS-QoL） for LUTS and efficacy was assessed by International Index of Erectile Function （IIEF） for erectile functions at baseline and sixth weeks. The objective efficacy was assessed by Q The patients were classified according to their self reported erectile status： group I had ED and group II did not have ED. At the endpoint, doxazosin significantly improved the total IPSS score （-7.7 ±6.1, P = 0.006）, IPSS-QoL score （-1.5 ± 1.5, P = 0.024） and Qmax （3.2 ± 4.6 mL s^-1, P = 0.002） over baseline. Mean decrease in IPSS and IPSS-QoL scores after the treatment period were 6.9 ＋ 6.4 （P 〈 0.001） and 0.95 4- 1.80 （P 〈 0.05） in group I, whereas 8.2 4- 5.8 （P 〈 0.001） and 1.9 4- 1.1 in group IX （P 〈 0.001）, respectively. Mean changes of Qmax values were 2.3 4- 3.3 mL s^-1 in group I （P 〈 0.05） and 3.7 4- 5.3 mL s-1 in group II （P 〈 0.001）. The improvement of IIEF-EF scores after the treatment period was only significant for group I. The efficacy of a-blocker therapy for LUTS was better by means of symptomatic relief for patients who did not have ED when compared with patients who had ED at baseline. However, slight improvement in erectile functions with a-blocker therapy was only seen in LUTS patients with ED.     

Systematic review of lower urinary tract symptoms/benign prostatic hyperplasia surgical treatments on men's ejaculatory function: Time for a bespoke approach?

Although ejaculatory dysfunction is common for patients undergoing benign prostatic hyperplasia surgery, no clear evidence is present to counsel men seeking to preserve ejaculation. Our aim was to evaluate ejaculatory dysfunction in relation to benign prostatic hyperplasia surgery. We carried out a web and manual search using MEDLINE and Embase including randomized controlled trials reporting ejaculatory dysfunction after benign prostatic hyperplasia surgery: 42 randomized controlled trials comprising a total of 3857 patients were included. Only one study had ejaculatory dysfunction as a primary outcome, and just 10 evaluated ejaculatory dysfunction before and after surgery. The definition of ejaculatory dysfunction was not standardized. Similarly, just seven studies used internationally validated questionnaires to address ejaculatory dysfunction. The reported rates of ejaculatory dysfunction after resectional elecrosurgery, laser procedures, coagulation, ablation and implant techniques were assessed and compared. Transurethral resection of the prostate and recent laser procedures including holmium, thulium and GreenLight cause similar rates of ejaculatory dysfunction, occurring in almost three out of four to five men. Although providing less symptomatic benefit compared with transurethral resection of the prostate, transurethral incision of the prostate, transurethral needle ablation and transurethral microwave thermotherapy should be considered for men aiming to maintain normal ejaculation. UroLift is also a recent promising option for this category of patients. The vast majority of studies reporting ejaculatory dysfunction after benign prostatic hyperplasia surgery used poor methodology to investigate this complication. Future studies able to address clear hypothesis and considering ejaculatory dysfunction anatomical and pathophysiological features are required to develop ejaculation preserving techniques and to increase the evidence to counsel men aiming to preserve ejaculation.     

Should we explain lower urinary tract symptoms to patients?

AIM: The aim of our study was to evaluate the understanding of lower urinary tract symptom (LUTS) terminology used by patients. MATERIALS AND METHODS: Women attending urodynamic clinics in United Kingdom, Australia, and Italy were asked to complete a questionnaire testing the women's understanding of stress urinary incontinence, urge urinary incontinence, frequency, urgency, nocturia, and hesitancy. Five possible explanations for the meaning of each symptom were given. RESULTS: A total of 138 consecutive women were prospectively recruited. The terms of daytime frequency, nocturia, urgency, urge urinary incontinence, stress urinary incontinence, and hesitancy were defined correctly, according to the International Continence Society terminology, only by 33% (45/138), 44% (61/138), 46% (64/138), 39% (54/138), 37% (51/138), and 41% (57/138) of women, respectively. Over 20% of women were unsure about the meaning of each symptom. We did not find any statistical difference between the three groups in determining the correct definition (P = 0.5). CONCLUSIONS: Our findings showed that most women do not know the correct meaning of LUTS terminology currently used by physicians.