Phytotherapy Adds to the Therapeutic Armamentarium for the Treatment of Mild-To-Moderate Lower Urinary Tract Symptoms in Men.

BACKGROUND: Practice guidelines hardly recommend herbal extracts for male lower urinary tract symptoms (LUTS). However, many patients are unsatisfied with first-line synthetic drugs and often prefer herbal medicines because of good tolerability. To improve the decision-making process, which should consider the patients' expectations, it is crucial to reflect on the role of phytotherapy in the treatment of LUTS. We (panel experts) reflected on current guideline recommendations and real practice across various European countries and debated the potential role of plant extracts with a focus on pumpkin seed soft extract investigated over 12 months in two randomised placebo-controlled trials. SUMMARY: Most guidelines give no clear recommendations on phytotherapy due to the heterogeneity of clinically investigated extracts. Nevertheless, plant extracts are prescribed to patients with mild-to-moderate LUTS. Also, self-medicating patients often handle their complaints with herbal products. Many patients aim to avoid synthetic drugs for fear of sexual functional side effects and a negative impact on their quality of life. For the elderly, vasoactive comedications might become an issue. When taking plant extracts, patients experience an acceptable symptomatic relief similar to that achieved with synthetics but without side effects. Key Messages: In shared decision-making for purely symptomatic treatment, a low risk of side effects takes priority. We propose to consider patient preferences in the treatment of mild-to-moderate LUTS in men with a low risk of disease progression. We found a consensus that pumpkin seed soft extract adds to the therapeutic armamentarium for patients who cannot or do not want to apply synthetic drugs.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients: Part 1.

OBJECTIVES: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, -EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: We provide 75 recommendations and 68 statements in the updated evidence- and consensus-based national clinical guideline. The diagnostics part covers practical recommendations on cystitis and pyelonephritis for each defined patient group. Clinical examinations, as well as laboratory testing and microbiological pathogen assessment, are addressed. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.

BACKGROUND: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Long-term results after acute therapy of obstructive pyelonephritis.

INTRODUCTION: To evaluate therapeutic results till 5 years after therapy of obstructive pyelonephritis (OPN) emphasizing regular follow-up. MATERIAL AND METHODS: During 5 years, 57 patients with OPN were treated. The patients' charts were reviewed retrospectively for clinical data. These were completed by a questionnaire. RESULTS: In the group of 57 patients (average age 56 years), about two third were women. Urolithiasis (65%) and tumors (21%) were the main causes of obstruction; fever (91%) and loin pain (86%) the main symptoms. Three fourth of the patients showed renal insufficiency and nearly 50% anemia. E. coli and Proteus spp. were the dominating organisms. Sonography detected obstruction in 93% cases. In one third of cases, CT scan was added; 81% percutaneous nephrostomy and 19% ureteral stenting were the initial methods of urinary drainage. During therapy, 23% nephrectomies (19% complete, 4% partial) were performed. Long-term follow-up showed 11% recurrent OPN and 33% recurrent UTI. CONCLUSIONS: After diagnosis of OPN, primary nephrostomy or ureteral stenting and antibiotic therapy are the first measures. If recurrent urinary tract infections or OPN occur, long-term follow-up and low-dose antibiotic prophylaxis may be discussed.

Effects of pumpkin seed in men with lower urinary tract symptoms due to benign prostatic hyperplasia in the one-year, randomized, placebo-controlled GRANU study.

INTRODUCTION: The German Research Activities on Natural Urologicals (GRANU) study was a randomized, partially blinded, placebo-controlled, parallel-group trial that investigated the efficacy of pumpkin seed in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH/LUTS). SUBJECTS AND METHODS: A total of 1,431 men (50-80 years) with BPH/LUTS were randomly assigned to either pumpkin seed (5 g b.i.d.), capsules with pumpkin seed extract (500 mg b.i.d.) or matching placebo. The primary response criterion was a decrease in International Prostate Symptom Score (IPSS) of ≥5 points from baseline after 12 months. Secondary outcome measures included IPSS-related quality of life, IPSS single items and diary-recorded nocturia. RESULTS: After 12 months, the response rate (intention-to-treat/last-observation-carried-forward approach) did not differ between pumpkin seed extract and placebo. In the case of pumpkin seed (responders: 58.5%), the difference compared with placebo (responders: 47.3%) was descriptively significant. The study products were well tolerated. Overall, in men with BPH, 12 months of treatment with pumpkin seed led to a clinically relevant reduction in IPSS compared with placebo. CONCLUSION: In order to fully justify a recommendation for the use of pumpkin seed to treat moderate LUTS, these findings need to be substantiated in a confirmatory study or systematic review.

[Interstitial cystitis/bladder pain syndrome (IC/BPS)]. / Interstitielle Zystitis/Blasenschmerzsyndrom (IC/BPS).

BACKGROUND: In this review, aspects of interstitial cystitis/bladder pain syndrome (IC/BPS) are presented against the background of the German S2k guideline on this disease. OBJECTIVE: Quite often this disease, characterized by bladder or lower abdominal pain (permanent or intermittent) and pollakisuria without pathogenic bacteria in the urine culture, is diagnosed much too late. MATERIALS AND METHODS: The debate on disease definition, aspects on pathophysiology and epidemiology are presented. For diagnosis, disease severity must be determined and relevant differential diagnoses like bladder cancer must be excluded. Conservative measures (clothing, food, sexuality, sport, bladder training, sufficient fluid intake, prevention of hypothermia) are effective especially in early stages of the disease. Combination drug therapy with mucosa stabilizing, anti-inflammatory, psychotropic, and pain-reducing drugs should be adjusted individually. Inpatient rehabilitation, hydrodistension, laser- and electrocoagulation, neuromodulation (sacral or pudendal) or hyperbaric oxygen therapy may help after pharmacotherapy failure. Cystectomy and urinary diversion are used in irreversible shrunken urinary bladder. RESULTS: If all treatment modalities are consequently used, many patients may reach a state that is more bearable. CONCLUSION: With a high level of suffering in many patients with IC/BPS, all available treatment modalities should be known and used.

[Rehabilitation of patients with interstitial cystitis/bladder pain syndrome (IC/BPS)]. / Rehabilitation von Patienten mit Interstitieller Cystitis/Bladder Pain Syndrom (IC/BPS).

After unsuccessful outpatient conservative treatment or invasive inpatient treatment and after cystectomy in interstitial cystitis/bladder pain syndrome (IC/BPS), an inpatient discipline-specific urological rehabilitation (rehab) should be proposed according to the German guideline on IC/BPS. During rehab, diagnostic results will be completed. Multimodal therapy includes the optimisation of lifestyle and medication. Intensive psychotherapy may frequently improve the processing of the disease. Various forms of exercise therapy and physical therapy with water applications, thermotherapy, several forms of massage and electrical or magnetic therapies as well as nutritional advice frequently alleviate complaints in IC/BPS. The different therapies are modified during rehab, if necessary. Social medicine evaluation and advice, e.g. on grade of handicap or ability to work, are also important issues in rehab. Two-thirds of patients show an essential improvement after rehab, which lasts for a prolonged period in about 50% of patients.

Effect of a Herbal Therapy on Clinical Symptoms of Acute Lower Uncomplicated Urinary Tract Infections in Women: Secondary Analysis from a Randomized Controlled Trial.

Background: Antibiotics are commonly used as first-line treatment for acute lower uncomplicated urinary tract infections (uUTIs). However, antimicrobial resistance is a growing global problem and efficacious nonantibiotic treatment options are urgently needed. METHODS: A secondary analysis was conducted with data from a randomized, controlled, double-blind trial comparing a fixed combination of extracts of restharrow root, Java tea, and goldenrod herb (Aqualibra®) to placebo in 200 women with acute lower uUTI. Symptom scores reported in the original trial were reanalyzed and adjusted to the definitions of the Acute Cystitis Symptom Score (ACSS). RESULTS: Based on a subgroup of patients with evaluable microbiologic data (n = 122), the decrease of the mean sum-score of three typical ACSS-adjusted symptoms showed significant superiority of the herbal preparation over placebo already after one day of treatment (p = 0.0086); on Day 7, the average difference was -1.9 score points (p < 0.0001). The superior efficacy of the herbal preparation on Day 1 was mainly driven by a difference in response rates of the symptom 'dysuria' (group difference: -29.4%, p = 0.0042). Furthermore, significantly fewer patients in the verum group required antibiotic therapy (15.3% vs. 49.2%, p = 0.0001). These results were confirmed in the intention-to-treat (ITT) population (n = 200). CONCLUSIONS: A fixed combination of extracts of restharrow root, Java tea, and goldenrod herb was superior to placebo regarding symptom relief and prevention of antibiotic use in women with lower uUTI. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04032574.

Diarrhea and flatulence are major bowel disorders after radical cystectomy: Results from a cross-sectional study in bladder cancer patients.

OBJECTIVES: We had previously demonstrated changes in defecation after radical cystectomy (RC). Reports addressing long-term bowel disorders following RC are rare. This cross-sectional study evaluates long-term bowel issues in a large cohort. MATERIAL AND METHODS: A questionnaire assessing changes in bowel function (diarrhea, constipation, urge to defecate, sensation of incomplete defecation, and flatulence) and its effect on quality of life was developed based on the gastrointestinal quality of life index and distributed in collaboration with the German bladder cancer support group. There were 431 evaluable questionnaires. For the analyses, we focused on patients that had the RC>1 year ago (n = 324). RESULTS: Current bowel problems were reported by 42.6% of patients. The most frequent bowel problems were flatulence (48.8%), diarrhea (29.6%), and sensation of incomplete defecation (22.5%). In cases of bowel problems, 39.7% and 59.8% of the patients indicated life restriction and dissatisfaction, respectively. Prevalence of diarrhea and flatulence were significantly higher>12 (vs. ≤12) months following RC. Both symptoms significantly correlated with younger age at RC, life restriction, lower quality of life, lower health state, and lower energy level. Additionally, diarrhea significantly correlated with pouches as urinary diversion (vs. ileal conduit or ureterocutaneostomy) and higher dissatisfaction level. CONCLUSIONS: To our knowledge this is the largest cohort evaluating long-term bowel symptoms after RC. Diarrhea is a prominent symptom after RC with a high impact on daily life that leads to dissatisfaction. A better understanding of long-term bowel symptoms could be translated into optimized surgical procedures, postoperative medication/nutrition, and patient education.

Activity of the antiseptic polyhexanide against gram-negative bacteria.

The activity of the antiseptic polyhexanide was tested against 250 gram-negative clinical isolates, that is, 50 isolates each of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Moraxella catarrhalis, and Haemophilus influenzae. Minimal inhibitory concentrations (MICs) and minimal bactericidal concentrations (MBCs) were determined by using a serial broth microdilution technique according to DIN 58940. Time-kill studies were performed for reference stains E. coli ATCC 25922, K. pneumoniae ATCC 4352, P. aeruginosa ATCC 15442, M. catarrhalis ATCC 43617, and H. influenzae ATCC 49247. All tested isolates had MICs and MBCs within a range of 1-32 mg/L and were regarded as susceptible to polyhexanide. The highest values were found for P. aeruginosa and H. influenzae with MICs and MBCs of 32 mg/L. Addition of up to 4% albumin to the test medium did not change MICs and MBCs. Time-kill studies of the reference strains showed reduction rates from 3 log10 colony forming units (CFU)/ml to more than 5 log10 CFU/ml for 200 and 400 mg/L polyhexanide within 5-30 min. Testing of polyhexanide in combination with antibiotics showed indifference with amoxicillin, cefotaxime, imipenem, gentamicin, and ciprofloxacin; no antagonism was found. As no resistance and no antagonism with antibiotics were detected, polyhexanide is regarded as suitable agent for topical eradication of gram-negative bacteria.

Calculi in hydrocele: incidence and results of infrared spectroscopy analysis.

Trauma, inflammation, or necrosis in the scrotal cavity may lead to depositing of organic material in hydrocele fluid with consecutive calcification if the fluid is oversaturated. During a period of 25 years, 2 scrotal calculi (calculous material in hydrocele fluid) in 2 of 42 patients (4.8%) were found during surgery on symptomatic hydroceles by the first author. In these symptomatic cases, infrared spectroscopy revealed carbonate apatite as the causative mineral. The appearance of scrotal calculi in hydrocele does not change the treatment or prognosis of hydroceles. However, if the calculous material is attached to the visceral or parietal part of the tunica vaginalis and does not change position during sonography with different postures, tumor growth may be a problem. An inguinal approach for operation should be chosen in such situations. Infrared spectroscopy can be used to determine the mineralogy of scrotal calculi. Carbonate apatite, the predominantly found mineral in scrotal calculi, can precipitate in an alkaline milieu.