Medical evaluation and management of male and female voiding dysfunction: a review.

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

The role of urodynamics in the surgical management of benign prostatic obstruction.

PURPOSE OF REVIEW: Benign prostatic obstruction (BPO) is a common cause of lower urinary tract symptoms (LUTS) in elderly men. However, such symptoms are often caused by primary detrusor overactivity or underactivity. Surgical management where BPO is absent or merely incidental has a lower chance of success, and exposes the patient to the potential complications of surgery. This review discusses the diagnostic challenges facing this common presentation. RECENT FINDINGS: Most evidence comes from small, historical prospective cohort studies. A Cochrane review found only two studies that met the prespecified inclusion criteria. It concluded that urodynamics changed decision-making regarding surgery for LUTS but it was not possible to determine whether this impacted upon outcome. A systematic review of several noninvasive alternatives to urodynamics could not recommend any of them over urodynamic pressure-flow study assessment. Further research is currently in progress, the 'UPSTREAM' study, which is a randomized, multicentre trial. Men are randomized to undergo investigation with clinical evaluation and uroflowmetry, or to additionally receive urodynamics. The primary aim is to determine the impact of urodynamics on the assessment pathway. SUMMARY: Assessment of BPO involves determining whether it has a contributory role in individual patients. This is a crucial factor in outcome, as surgery can give poor results if the symptoms are principally caused by detrusor dysfunction (overactivity or underactivity). Urodynamics can help determine this if undertaken to a suitable standard. Further research will identify the precise role of this test modality.

[Comparative analysis of the effectiveness of various techniques of endoscopic prostate enucleation in a single center]. / Sravnitel'nyi analiz éffektivnosti razlichnykh metodik éndoskopicheskoi énukleatsii prostaty.

AIM: To compare electro- and laser enucleation (thulium, holmium) of prostate hyperplasia. MATERIAL AND METHODS: 693 prostate hyperplasia patients were enrolled. 489 patients underwent holmium enucleation (HoLEP), 51 - monopolar enucleation, 153 - thulium enucleation (ThuLEP). Prostate volume was 91.7 (50-250) cm3. There were no significant differences in preoperative variables between both groups (I-PSS, QoL, Qmax, residual urine volume) (p>0.05). RESULTS: Mean time of HoLEP was 97.0±42.2 min, monopolar enucleation - 112.9±36.3 min, ThuLEP duration was significantly less (77.4±36.3 min, p<0.01). An efficacy of all methods was confirmed in 6 months after surgery by significant (p<0.01) improvement of functional parameters (I-PSS, QoL, Qmax, residual urine volume). CONCLUSION: High efficiency of thulium and holmium enucleation allows to consider them as 'gold standard' of prostate hyperplasia management. Despite higher incidence of complications an efficacy of monopolar enucleation is comparable to that in laser techniques.

Benign Prostatic Hyperplasia - An economic assessment of fixed combination therapy based on a literature review.

FederAnziani Senior Italia and SIU - Italian Society of Urology - have decided to work together to draft a document focussing on Benign Prostatic Hyperplasia (BPH), and to stress the importance of adherence with pharmacological treatment in this setting, from both a scientific and a patient standpoint. Starting from a literature search, the two associations analysed to what extent an increase in treatment adherence amongst these patients influences hospital savings and to what extent therapy persistence levels are affected by monotherapy rather than free drug combinations. These estimates were performed only on patients taking medicinal products belonging to the 5 α-reductase inhibitors (5ARI) class that, although not indispensable, are the compounds that bring the greatest benefits, especially in the elderly and for which we know that every additional 30 days of therapy reduced the likelihood of acute urinary retention (AUR) and surgery by 14% and 11% respectively *. The results show that the use of fixed combination therapy would involve an increase in persistence due to the lower rate of patients abandoning treatment over time. Each 30 day-increment of 5ARI therapy, i.e. for an expenditure of 10.6 million euros extra per year for 5ARI medication, savings of approximately 24.3 million euros in hospital costs could be achieved.

Clinical significance of prostatic-urethral angulation on the treatment outcome of patients with symptomatic benign prostatic hyperplasia treated with tamsulosin hydrochloride.

OBJECTIVES: To evaluate the impact of the prostatic-urethral angulation (PUA) on the treatment efficacy of selective alpha-1A receptor blocker in male patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: A total of 80 patients with LUTS/BPH and with mean age 53.3 ± 6.3 (range 47-70) were included in our prospective comparative study. The patients were classified into 2 groups as a consecutive cases 40 in each one depending on the PUA either ≤ 35° (group A) or > 35° (group B). PUA and different prostatic parameters were measured using transrectal ultrasound. Prostate-specific antigen (PSA), the International Prostate Symptom Score and quality of life score (IPSS/QoL score), maximum flow rate (Qmax), and postvoid residual (PVR) volume were compared between the groups. The clinical significance of PUA was evaluated after 8 weeks of medical treatment with tamsulosin hydrochloride 0.4 mg daily. RESULTS: Baseline evaluation (pre-treatment) for both groups were comparable to each other with no clinically significant difference regarding age, PSA, IPSS/QoL score, Q(max) and PVR volume (P-value > 0.05). Comparison of parameters after 8 weeks showed that tamsulosin hydrochloride improved the total IPSS and all subscores (P < 0.001), QoL (P = 0.001), Q(max) (P = 0.002), and PVR (P = 0.04) in group A (Table 1). CONCLUSION: Tamsulosin hydrochloride appears to be less effective in improving IPSS/Qol score, Qmax and PVR in patients with lager PUA. The PUA might be a predictor for the treatment efficacy of α-blockers and more studies are warranted in the future before the final conclusion.

Painful Bladder Filling and Painful Urgency are Distinct Characteristics in Men and Women with Urological Chronic Pelvic Pain Syndromes: A MAPP Research Network Study.

PURPOSE: We describe bladder associated symptoms in patients with urological chronic pelvic pain syndromes. We correlated these symptoms with urological, nonurological, psychosocial and quality of life measures. MATERIALS AND METHODS: Study participants included 233 women and 191 men with interstitial cystitis/bladder pain syndrome or chronic prostatitis/chronic pelvic pain syndrome in a multicenter study. They completed a battery of measures, including items asking whether pain worsened with bladder filling (painful filling) or whether the urge to urinate was due to pain, pressure or discomfort (painful urgency). Participants were categorized into 3 groups, including group 1-painful filling and painful urgency (both), 2-painful filling or painful urgency (either) and 3-no painful filling or painful urgency (neither). RESULTS: Of the men 75% and of the women 88% were categorized as both or either. These bladder characteristics were associated with more severe urological symptoms (increased pain, frequency and urgency), a higher somatic symptom burden, depression and worse quality of life (3-group trend test each p<0.01). A gradient effect was observed across the groups (both>either>neither). Compared to those in the neither group men categorized as both or either reported more frequent urological chronic pelvic pain syndrome symptom flares, catastrophizing and irritable bowel syndrome, and women categorized as both or either were more likely to have a negative affect and chronic fatigue syndrome. CONCLUSIONS: Men and women with bladder symptoms characterized as painful filling or painful urgency had more severe urological symptoms, more generalized symptoms and worse quality of life than participants who reported neither characteristic, suggesting that these symptom characteristics might represent important subsets of patients with urological chronic pelvic pain syndromes.

Evaluation and management of post-transurethral resection of the prostate lower urinary tract symptoms.

Transurethral resection of the prostate (TURP) continues to be the most common treatment in the operative management of benign prostatic hypertrophy (BPH). Several other modalities have shown equivalence to TURP. However, even after surgical treatment, up to one third of patients have bothersome lower urinary tract symptoms (LUTS). This review discusses the pathophysiology, evaluation, and management options for patients with LUTS after TURP.

Benign prostatic hyperplasia evaluation and management by urologists and primary care physicians: practice patterns from the observational BPH registry.

PURPOSE: We examined the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia by physician specialty (urologist vs primary care physician). MATERIALS AND METHODS: The BPH Registry and Patient Survey is a longitudinal, observational, disease registry cohort of patients enrolled from January 2004 to February 2005 in the United States. The survey examines patient outcomes and physician practice patterns in the management of lower urinary tract symptoms associated with clinical benign prostatic hyperplasia. It includes 402 urologist and primary care physician practices throughout the United States. Included in this study were 6,924 men with lower urinary tract symptoms/benign prostatic hyperplasia managed by watchful waiting or medical therapy. Data were collected on demographics, clinical characteristics and lower urinary tract symptoms/benign prostatic hyperplasia management using physician and patient completed forms. Multivariate analysis was done by physician specialty. RESULTS: Based on multivariate analysis urologists were more likely than primary care physicians to perform urinalysis (OR 3.9), serum prostate specific antigen (OR 1.2) and post-void residual urine (OR 18.9) measurement, uroflowmetry (OR 17.3), prostate ultrasound (OR 7.7) and biopsy (OR 3.5), renal ultrasound (OR 4.0) and cystoscopy (OR 4.6) but less likely to measure creatinine (OR 0.1). Men seeing urologists were twice as likely as men seeing primary care physicians to be treated with benign prostatic hyperplasia medical therapy vs watchful waiting. Significant differences by physician specialty were also observed for specific benign prostatic hyperplasia medical therapies. CONCLUSIONS: Significant differences in practice patterns were observed between primary care physicians and urologists in the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia. These data establish valuable benchmarks and identify possible interventions that may improve the standard of care.

Diagnostic value of International Prostate Symptom Score voiding-to-storage subscore ratio in male lower urinary tract symptoms.

AIMS: To investigate the diagnostic value of the International Prostate Symptom Score (IPSS) voiding-to-storage subscore ratio (IPSS-V/S) in male lower urinary tract symptoms (LUTS). METHODS: A total of 253 men with LUTS were enrolled from January 2005 to July 2010. The voiding (IPSS-V) and storage IPSS (IPSS-S) subscores were recorded separately by the patients themselves. The IPSS-V/S was calculated and compared among various aetiologies based on videourodynamic studies. Receiver operating characteristics (ROC) curves were constructed for comparing the diagnostic value of various non-invasive methods for predicting failure to voiding and storage lower urinary tract dysfunction (LUTD). RESULTS: Patients with failure to voiding LUTD, including benign prostatic obstruction (n = 72), bladder neck dysfunction (n = 19), urethral stricture (n = 3) and poor relaxation of the urethral sphincter (n = 32), had mean IPSS-V/S scores > 1. In contrast, patients who were urodynamically normal (n = 2) or had failure to storage LUTD, including idiopathic detrusor overactivity (n = 84), increased bladder sensation (n = 37), and detrusor overactivity and impaired contractility (n = 4), had IPSS-V/S scores ≤ 1. When IPSS-V/S was used to differentiate male LUTS, failure to voiding LUTD was found in 81.2% of patients with IPSS scores > 1, while failure to storage LUTD was found in 75.7% of patients with IPSS-V/S ≤ 1. The area under ROC curve of IPSS-V/S was higher than for other non-invasive methods for predicting failure to voiding and storage LUTD. CONCLUSION: Measuring IPSS subscores and calculating IPSS-V/S is a simple and useful method to differentiate failure to voiding and failure to storage LUTD in men with LUTS. IPSS-V/S may provide a guide for the initial treatment, especially for primary care physicians without access to urological studies.

Change in International Prostate Symptom storage subscore after long-term medical therapy in BPH patients: finasteride and alpha-blocker combination therapy in men with moderate-to-severe LUTS/BPH in Korea.

OBJECTIVE: To evaluate the efficacy and the change of International Prostate Symptom Score (IPSS) storage subscore after combination therapy (α-blocker and finasteride) in patients with lower urinary tract symptoms (LUTS) consistent with moderate-to-severe benign prostatic hyperplasia (BPH) and compared with α-blocker-only treatment. METHODS: A total of 1315 patients seen in 5 urology centers in Korea from January 2001 to August 2007, with LUTS secondary to BPH were enrolled. Patients were divided into 4 groups according to treatment pattern (α-blocker monotherapy vs combination therapy) and IPSS storage subscores (≥6 vs <6). The changes from baseline in prostate volume, prostate-specific antigen concentration, IPSS, and Q(max.) were analyzed. We also determined the statistical differences among 4 groups in the IPSS, Q(max.), quality of life score (QoL), and prostate volume. RESULTS: Of the 1315 men, 217 (16.5%) completed the month 48 visit. All groups showed significant improvements in the IPSS total score, IPSS voiding subscores, and QoL at 1 year. However, the high storage subscore group at baseline showed a significantly higher improvement in IPSS total scores and IPSS voiding subscores compared with the low storage subscore group at year 4. IPSS storage subscores were improved only in patients with high storage subscores at baseline, especially in combination treatment group. The mean change in QoL score from baseline to year 4 was significantly improved in high storage subscore groups. CONCLUSIONS: Data from this retrospective analysis suggest that long-term combination treatment would be beneficial, especially to patients with severe storage symptoms at baseline.

Effects of tadalafil on lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with or without erectile dysfunction.

OBJECTIVES: To compare the safety and efficacy of the daily erectogenic therapy, tadalafil, on lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) in men with or without comorbid erectile dysfunction (ED). METHODS: Following a 4-week placebo run-in period, men with moderate-to-severe BPH-LUTS were randomized to placebo or tadalafil 2.5, 5, 10, or 20 mg once daily for 12 weeks. International Prostate Symptom Scores (IPSS), IPSS quality of life, and BPH Impact Index were measured every 4 weeks. Safety was mainly assessed via spontaneous reports of adverse events. Data from men with (n=716) or without (n=340) ED at baseline were compared in posthoc analyses. RESULTS: Men with ED were older and had more frequent hypertension, hyperlipidemia, coronary artery disease, and diabetes at baseline compared with men without ED. After 12 weeks, changes in IPSS in men with ED (least squares mean change from baseline, placebo: -2.4; tadalafil 2.5, 5, 10, 20 mg: -4.3, -4.8, -5.3, -5.6) and without ED (-2.4, -3.2, -5.3, -5.1, -4.5) were not significantly different (subgroup/interaction P values: .352/.644). Similar effects were observed for IPSS quality of life (with ED: -0.6, -0.9, -0.9, -1.0, -1.1; without ED: -0.6, -0.7, -0.9, -0.8, -0.8; 0.090/0.773) and BPH Impact Index (with ED: -0.7, -0.9, -1.3, -1.3, -1.4; without ED: -1.0, -0.7, -1.3, -1.3, -1.2; 0.753/0.852). Tadalafil was generally well tolerated, and men with or without ED had similar tolerability profiles. CONCLUSIONS: Changes in BPH-LUTS after 12 weeks of treatment with placebo or various doses of once daily tadalafil were similar in men with or without comorbid ED.

Symptomatic and quality of life response to tolterodine in subgroups of men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia.

OBJECTIVES: To investigate the symptomatic and quality of life (QoL) response to treatment with tolterodine extended release (ER) in subgroups of male patients with Overactive Bladder Syndrome (OAB) and LUTS suggestive of non-obstructive benign prostatic hyperplasia (BPH) according to age, symptom severity, diabetes mellitus status, and concomitant treatment for LUTS. METHODS: Patients treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of > or =6 weeks duration, and presumed non-obstructive BPH (Q (max) > or = 15 ml/s) were observed for 12 weeks in a non-interventional study. Patients completed the International Prostate Symptom Score (IPSS) and Overactive Bladder Questionnaire (OAB-q) at baseline and after 12 weeks. RESULTS: 52.4% of 741 patients were aged < or =65 years; 4, 64, and 32% had mild, moderate, and severe symptoms, respectively, according to IPSS; 14% had diabetes mellitus, and in 42% tolterodine was added to alpha blockers. In the various subgroups, mean IPSS total scores improved by 2.8-11.1 points, IPSS QoL scores by 1.8-2.4 points, and all OAB-q subscores by more than 14 points. Only IPSS and OAB-q baseline scores had a relevant impact on changes during treatment, benefits were greatest in patients with more severe symptoms and bother. CONCLUSIONS: In men with symptoms of OAB and LUTS suggestive of non-obstructive BPH of all IPSS severity classes, aged < or =65 years or above, with or without concomitant diabetes or alpha-blockers, symptoms and QoL improved markedly during treatment with tolterodine ER.

Prostate cancer detection by TURP after repeated negative saturation biopsy in patients with persistent suspicion of cancer: a case-control study on 75 consecutive patients.

To evaluate prostate cancer (PCa) detection after repeated negative saturation biopsy, 75 patients, aged 53-78 years, underwent transurethral resection of prostate (TURP) because of persistent suspicion of cancer; median PSA was 11.8 ng ml(-1) and 58 men complained lower urinary tract symptoms (LUTS). In 12 (16%) and 3 (4%) men a T1a and T1b PCa was found with median PSA and Gleason score equal to 14.2 vs 23.6 ng ml(-1) and 5.6 vs 7 ng ml(-1). In case of persistent suspicion of PCa after repeated negative saturation biopsy, TURP may be proposed, aside from the coexistence of LUTS, to rule out a PCa, in younger patients with high PSA values (> or =20 ng ml(-1)).