Role of α1‐blockers in the current management of hypertension

There is emerging evidence that α1‐blockers can be safely used in the treatment of hypertension. These drugs can be used in almost all hypertensive patients for blood pressure control. However, there are several special indications. Benign prostatic hyperplasia is a compelling indication of α1‐blockers, because of the dual treatment effect on both high blood pressure and lower urinary tract symptoms. Many patients with resistant hypertension would require α1‐blockers as add‐on therapy. Primary aldosteronism screen is a rapidly increasing clinical demand in the management of hypertension, where α1‐blockers are useful for blood pressure control in the preparation for the measurement of plasma aldosterone and renin. Nonetheless, α1‐blockers have to be used under several considerations. Among the currently available agents, only long‐acting α1‐blockers, such as doxazosin gastrointestinal therapeutic system 4–8 mg daily and terazosin 2–4 mg daily, should be chosen. Orthostatic hypotension is a concern with the use of α1‐blockers especially in the elderly, and requires careful initial bedtime dosing and avoiding overdosing. Fluid retention is potentially also a concern, which may be overcome by combining an α1‐blocker with a diuretic.     

Benign prostatic hyperplasia: from A - Z

The management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia over the last decade underwent many changes. The introduction of many medical options including alpha blockers and 5 alpha reductase inhibitors provided alternatives to what used to be surgery or "watchful waiting". Alpha blockers evolved over the years from non specific alpha 1, and 2 blockers to alpha 1 selective and then to alpha 1a selective with a wider acceptance due to lack of need to titrate and a better safety profile. 5 alpha reductase inhibitor (finasteride) passed through a lot of changes from being the first medication directed at treating the disease process to less acceptance because of time to response and early data supporting no added benefit when combined to alpha blockers for a short period. Longer studies now demonstrate a benefit to combination causing a reduction of progression parameters and an advantage over 4 years in reducing endpoints, namely acute urinary retention and surgery. Surgical options have also undergone many changes over the last decade with introduction of minimally invasive options as well as the introduction of new energy sources to reduce complications and allow for management of larger glands such as Holmium laser enucleation of the prostate or the use of bipolar loops. The journey has been long and exciting and we are sure Ernie Ramsey enjoyed being in the forefront of the evolution.     

Drug therapy for benign prostatic syndrome (BPS)

Alpha1-receptor blockers (alfuzosin, doxazosin, tamsulosin and terazosin), 5alpha-reductase inhibitors (dutasteride and finasteride) and combinations thereof are used in the drug treatment of benign prostatic syndrome. As before, there is still no evidence supporting the use of plant extracts, the use of anticholinergic substances alone or in combination with other BPS drugs is currently under investigation and should not be attempted outside of clinical trials. For all drugs the placebo effect is considerable. Accordingly, deviations from the recommended doses are rapidly associated with an activity loss over that of placebo. alpha1-Receptor blockers show a rapid onset of action and are slightly superior to 5alpha-reductase inhibitors with regard to the relief of symptoms. All alpha1-receptor blockers are similarly effective at adequate doses, however, quantitative differences are seen in the side effect profiles. 5alpha-reductase inhibitors also provide relief from BPS-associated symptoms with the relief being volume-dependent. Prostate volume-dependent complications of BPS (operation risk and risk of acute urine retention) can be reduced by 5alpha-reductase inhibitors. Long-term drug studies have demonstrated the superiority of combination therapies over monotherapies with alpha1-receptor blockers and 5alpha-reductase inhibitors in patients with a high risk for progression. This superiority is accompanied by a combination of the respective side-effect profiles and their absolute increase. Besides poorer tolerability, combination therapies also result in higher costs. Thus, it is important to decide at an early stage which patients are to be treated with drugs and which by surgery.     

中国11城市医院老年科就诊良性前列腺增生患者患病情况及相关因素分析

目的 调查就诊于老年科的老年人中良性前列腺增生(BPH)患者的患病情况.方法 采用分层整群随机抽样的方法,对11个城市医院老年科2125例60岁及以上的就诊老年人进行横断而流行病学调查.结果 BPH占就诊疾病的构成比为47.0%,BPH患者按年龄分组60～、70～、80～岁的构成比分别为18.1%、49.4%、32.5%,BPH患者各年龄组构成比差异有统计学意义(x2=83.68,P<0.001);BPH患者职业分布存在差别,国家机关人员和专业技术人员构成比较高,分别为66.4%和18.0%,农林牧副渔业人员构成比较低为14.7%(x2=410.27,P<0.001).BPH患者下尿路症状严重程度[国际前列腺症状评分(IPSS)]在城市间不同(x2=101.00,P相似文献   

良性前列腺增生症与部分代谢因素相关性概述

良性前列腺增生症是老年男性常见疾病。目前流行病学研究证明良性前列腺增生症发生率除随年龄增长而增加外，随经济发展增长，有城乡差别，提示其与代谢因素相关。有学者提出良性前列腺增生症亦应作为代谢综合征一个组分的“代谢综合征假说”。     

Medical management of benign prostatic hyperplasia

The management of benign prostatic hyperplasia has undergone a rapid evolution over the past decade from a surgical emphasis to a medical emphasis. Great strides in the development of α-adrenergic blockers, 5α-reductase inhibitors and a variety of phytotherapeutics have fueled this evolution. This article reviews the past, present and future of the medical management of benign prostatic hyperplasia.     

Benign prostatic hyperplasia

In both ageing men and women, there is an increasing incidence of lower urinary tract symptoms (LUTS) which are increasing. These infections have many possible causes, including smooth muscle dysfunction, neurological factors and benign prostatic hyperplasia. Up to 15% to 25% of men aged 50-65 years have LUTS of sufficient severity to interfere with their quality of life. Although benign prostatic hyperplasia is an important cause of these symptoms, and can have serious consequences, clinicians should be aware of these other causes so that the appropriate diagnosis is made before invasive treatments are started. New medical treatments, including alpha-adrenergic blocking agents and 5 alpha-reductase inhibitors mean that many men without complications such as infection, bleeding, or chronic retention, and with mild to moderate symptoms, should be managed in primary care. Combined local protocols between primary and secondary care will help to establish which men with persistent symptoms or complications need referral for a urological opinion to determine the need for further investigation and more invasive forms of management. We review the pathophysiology of the disease, and current approaches to investigation and management of this common problem.     

Benign prostatic hyperplasia: drug and nondrug therapies.

Benign prostatic hyperplasia (BPH) is a frequent finding in older men. Patients with symptoms have traditionally been treated with transurethral resection of the prostate, a surgical technique that effectively reduces infravesical obstruction. Nonsurgical management of BPH also has the potential to play an important role in the treatment of patients with moderate or severe symptoms or in those who do not elect surgery. Data are being evaluated to determine the efficacy of treating symptomatic BPH with such modalities as balloon dilation, prostate hyperthermia, androgen suppression, the 5-alpha reductase inhibitor finasteride, and selective alpha blockers.     

老年人良性前列腺增生与心血管疾病的关系

目的 了解老年良性前列腺增生(BPH)患者临床特点及用药情况,探讨BPH与心血管疾病的关系. 方法 搜集本院老年病科100例BPH患者临床资料,采用国际前列腺症状评分表(IPSS)、生活质量量表(QOL)对患者进行评价,所有患者均详细询问心血管病史,并检测前列腺特异性抗原(PSA)水平,采用腹部超声测量前列腺体积(PV). 结果 老年BPH患者PV和PSA随年龄增长而升高;疾病严重程度以中度(IPSS 8～19分)多见;BPH患者高血压、冠心病和糖尿病患病率高,冠心病者PV显著高于非冠心病者(P＜0.05);我院BPH患者服用5-α还原酶抑制剂和α-受体阻滞剂者多见,治疗依从性好. 结论 老年BPH患者严重程度与年龄、冠心病发病相关;药物干预治疗以5-α还原酶抑制剂使用率最高.     

Stage A: Can Heart Failure Be Prevented?

Heart failure (HF) is an epidemic associated with significant morbidity and mortality, affecting over 5 million people in the United States and 1-2%of the population worldwide. Observational studies have suggested that a healthy lifestyle can reduce HF risk. Although no clinical trials have targeted the prevention of HF as a primary endpoint, many have evaluated outcomes associated with the development of symptomatic disease (i.e., progression to HF, HF hospitalization or death) as secondary endpoints. Blood pressure treatment represents the most effective strategy in preventing heart failure; each 5 mm Hg decrease in systolic blood pressures reduces the risk of HF development by 24%. Thiazide diuretics appear to be the most efficacious agents in patients with hypertension. Angiotensin converting enzyme inhibitors and angiotensin-II receptor blockers are first line agents for patients with chronic atherosclerosis, diabetes, or chronic kidney disease. Beta blockers appear less effective as single agents and cardioselective agents are preferred. Calcium channel blockers, specifically non-dihydropyridines, should be avoided and alpha blockers should not be used to reduce HF risk.     

Arterial protection: a neglected but crucial therapeutic goal

Hypertension is accompanied by 2 major types of arterial pathologic conditions: smooth muscle hypertrophy of arteriolar resistance vessels and atherosclerosis, primarily involving the larger arteries. Smooth muscle hypertrophy may develop either as a secondary defense against elevated intravascular pressure or as a primary defect responsible for the increased pressure. Insulin and a number of other trophic stimuli may play a pathogenetic role in vascular hypertrophy. Reducing blood pressure and trophic stimuli may cause hypertrophy to be reversed. Because atherosclerosis may be markedly accelerated by hypertension, especially in the presence of concomitant risk factors, such as hypercholesterolemia, cigarette smoking and diabetes mellitus, antihypertensive treatment may attenuate or even reverse the extent of atherosclerosis, but only when the causative factors are also corrected. Some commonly used antihypertensive agents, e.g., diuretics and beta blockers without intrinsic sympathomimetic activity, often aggravate hypercholesterolemia and glucose intolerance, thereby diminishing their potential protective value. Other types of drug therapy, such as alpha blockers, beta blockers with intrinsic sympathomimetic activity or other vasodilator activity, angiotensin-converting enzyme inhibitors and calcium entry blockers that may not induce biochemical changes, should provide better control of multiple risks and thereby better protection against atherosclerosis. With a better understanding of how hypertension induces arterial damage, clinicians will be able to provide more appropriate treatment and, it is hoped, alleviate such damage.     

Efficacy of Additional Dutasteride on Lower Urinary Tract Symptoms in Patients with Alpha‐1 Blocker‐Resistant Benign Prostatic Hyperplasia

Objective: We investigated the effects of dutasteride on urination and quality of life (QOL) in patients diagnosed with benign prostatic hyperplasia (BPH) who showed poor improvement in lower urinary tract symptoms (LUTS) with alpha‐1 blockers. Methods: We retrospectively analyzed 108 patients with BPH who took dutasteride for more than 3 months from October 2009 to October 2011. The patients showed poor improvement in LUTS despite administration of alpha‐1 blockers for more than 3 months; all had an International Prostate Symptom Score (IPSS) of eight or greater. We investigated changes in prostate‐specific antigen and prostate volume and performed uroflowmetry and medical interviews to assess IPSS‐QOL score and BPH impact index (BII). Results: Mean prostate volume was 52.8 ± 22.2 mL, and the mean period of dutasteride administration was 284 ± 118 days. Prostate volume decreased 24.1% from baseline to 6 months after administration. Voiding symptoms and storage symptoms showed improvements with longer administration periods, but only nocturia showed no clear improvement. There was a 0.9‐point decrease in BII after 6 months. There was no statistically significant association between the rate of prostate volume reduction and improvement in voiding and storage symptoms. Conclusion: Additional administration of dutasteride to patients with alpha‐1 blocker‐resistant BPH led to improvements in all voiding and storage symptoms except nocturia, and showed no correlation between the prostate volume reduction rates and improvement in LUTS.     

Alpha1-adrenergic blockers: current usage considerations

Alpha1-adrenergic-blocking drugs are effective in reducing blood pressure and do so in a fashion comparable to most other antihypertensive drug classes. These compounds are most effective in patients in the upright position, reducing systolic and diastolic pressures by 8%-10%. Alpha1-adrenergic-blocking drugs incrementally reduce blood pressure when combined with most drug classes and are the only antihypertensive drug class to improve plasma lipid profiles. Alpha1-adrenergic-blocking drugs are also accepted as important elements of the treatment plan for symptomatic benign prostatic hypertrophy. Dose escalation of an alpha1-adrenergic-blocking drug can trigger renal Na+ retention, and the ensuing volume expansion can attenuate its blood pressure-lowering effect. Orthostatic hypotension can occur with these compounds, particularly when a patient is volume-contracted. Dizziness, headache, and drowsiness are common side effects with alpha1-adrenergic blockers. A modest decline in the use of doxazosin and other alpha1-adrenergic-blocking drugs has occurred coincident to the early termination of the doxazosin treatment arm in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.     

中国11城市老年科门诊良性前列腺增生患者药物治疗的现状及分析

目的 了解中国老年科门诊良性前列腺增生药物治疗的现状,并对其进行总结和分析.方法 2008年2月至2008年9月在全国11个中心城市的34个老年科门诊进行调研,首先对在调查时间内前来老年科门诊就诊的全部男性患者进行有关良性前列腺增生的病史询问,然后从中选取11000例正在进行良性前列腺增生药物治疗的患者填写详细的调查问卷并进行相关检查.结果 在1000名被调查者中,共收到有效问卷774份,其中国际前列腺症状评分(IPSS)偏高且前列腺体积偏大者比例较高.在良性前列腺增生患者的药物治疗方面,联合药物治疗(5α还原酶抑制剂+α受体阻滞剂)的比例最高,达45.48%,以下依次是α受体阻滞剂(36.30%)、5α还原酶抑制剂(13.05%)和其他药物(主要是中成药和植物制剂,5.17%).结论 当前,我国老年科门诊在良性前列腺增生的药物治疗方面,还存在着只重视症状的改善而轻视疾病进展的倾向,和当前的国际、国内的治疗指南以及众多的随机、对照研究的结论相比还存在着一定的差距.     

Prostatic inflammation in benign prostatic hyperplasia - the third component?

The etiology, diagnosis, therapy and treatment outcome of the two most common nonmalignant disease of the prostate remain problematic. Benign prostatic hyperplasia and prostatic inflammation can coexist yet these conditions have been studied in almost complete isolation. The author develops the hypothesis that prostatic inflammation (prostatitis) can influence the clinical presentation and perhaps surgical outcome in patients treated for symptomatic benign prostatic hyperplasia.     

High Rates of Prostate-specific Antigen Testing in Men with Evidence of Benign Prostatic Hyperplasia

Purpose: Benign prostatic hyperplasia is common among men who may be candidates for prostate cancer screening using prostate-specific antigen (PSA) testing. Patterns of PSA testing among men with evidence of benign prostatic hyperplasia have not been studied.Methods: We examined the prevalence and correlates of a self-reported history of PSA testing. In 1994, 33,028 US health professionals without prostate cancer aged 47 to 85 years provided information on prior PSA testing, lower urinary tract symptoms characteristic of benign prostatic hyperplasia, history of prostatectomy, and prostate cancer risk factors. In 1995, a subset of 7,070 men provided additional information on diagnosis and treatment of benign prostatic hyperplasia.Results: From 39% of men in their 50s to 53% of men in their 80s reported PSA testing in the prior year (P <0.0001 for trend with age). Men were more likely to report PSA testing if they had lower urinary tract symptoms characteristic of benign prostatic hyperplasia (age-adjusted odds ratio for severe symptoms 2.2, 95% confidence interval 1.8 to 2.6), a prior history of prostatectomy (age-adjusted odds ratio 1.1, 95% confidence interval 1.02 to 1.2), or a physician diagnosis of benign prostatic hyperplasia (odds ratio 1.9, 95% confidence interval 1.7 to 2.2; adjusted for age, signs or symptoms of benign prostatic hyperplasia, and prostate cancer risk factors).Conclusions: These US health professionals reported preferential use of PSA testing among men least likely to benefit from early cancer detection (older men) and among men most likely to have a false-positive PSA result (men with benign prostatic hyperplasia). Physician and patient education are needed to promote more rational and selective use of this screening test.     

Benign prostatic hyperplasia as a frequent senile disease of the male

An adenofibromyomatous proliferation starting from the region of the periurethral glands is referred to as benign prostatic hyperplasia. It is the result of a senile endocrinopathy, which leads to a disbalance of the peripheral hormonal milieu, and of an intraglandular disturbance of the utilization of the hormone. It becomes a disease when it is followed by an increase of the vesical outlet resistance and thus by an obstructive disturbance of the voiding of the urinary bladder. The indication for operation is determined by the degree of the obstruction and its pathophysiological sequelae as well as the complaints of the patients. The conservative therapy is above all symptomatic and indicated only at the initial stage of the disease. The transurethral resection is the operative therapy of choice. In very large hyperplasias the open surgical intervention may be necessary. In inoperable patients a urethral catheter should be renounced for a suprapubic puncture cystostomy. Also after operative ectomy of a benign prostatic hyperplasia the patients may fall ill with a carcinoma of the prostatic gland. Therefore, the duty for undergoing an annual preventive medical examination remains.     

前列腺增生与老年2型糖尿病患者心血管疾病危险因素的相关性分析

目的探讨2型糖尿病老年患者前列腺增生与血脂、血压等心血管危险因素的相关性。方法将已诊断的766例2型糖尿病老年患者分为轻、中、重三组,记录其甘油三酯、低密度脂蛋白及高密度脂蛋白等情况。采用单因素和多因素分析对资料进行分析对比。结果老年2型糖尿病患者前列腺增生的程度与吸烟、年龄、低密度脂蛋白、血压增高显著相关（OR值分别为1．895、2．067、2．123和2．826,P均〈0．05）。结论高血压、吸烟、年龄等心血管疾病危险因素可以加重老年2型糖尿病患者的前列腺增生程度。     

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.