A 59-year-old man with a history of benign prostatic hyperplasia and lower urinary tract symptoms comes for care. He has been receiving doxazosin at a dose of 4 mg daily (his only medication) for the past 2 years, with minimal improvement. He continues to have nocturia, a weak urinary stream, and urinary frequency (voiding eight times per day). How would you manage this case?
"Benign prostatic hyperplasia (BPH) and related lower urinary tract symptoms (LUTS) are a common problem of male aging . LUTS consists of both irritative and obstructive voiding symptoms [1,2]. In men greater than seventy years old, the prevalence of LUTS may be as high as 30% . "
[Show abstract][Hide abstract] ABSTRACT: Background
Obstructive voiding symptoms (OVS) are common following prostate cancer treatment with radiation therapy. The risk of urinary retention (UR) following hypofractionated radiotherapy has yet to be fully elucidated. This study sought to evaluate OVS and UR requiring catheterization following SBRT for prostate cancer.
Patients treated with SBRT for localized prostate cancer from February 2008 to July 2011 at Georgetown University were included in this study. Treatment was delivered using the CyberKnife® with doses of 35 Gy-36.25 Gy in 5 fractions. UR was prospectively scored using the CTCAE v.3. Patient-reported OVS were assessed using the IPSS-obstructive subdomain at baseline and at 1, 3, 6, 9, 12, 18 and 24 months. Associated bother was evaluated via the EPIC-26.
269 patients at a median age of 69 years received SBRT with a median follow-up of 3 years. The mean prostate volume was 39 cc. Prior to treatment, 50.6% of patients reported moderate to severe lower urinary track symptoms per the IPSS and 6.7% felt that weak urine stream and/or incomplete emptying were a moderate to big problem. The 2-year actuarial incidence rates of acute and late UR ≥ grade 2 were 39.5% and 41.4%. Alpha-antagonist utilization rose at one month (58%) and 18 months (48%) post-treatment. However, Grade 3 UR was low with only 4 men (1.5%) requiring catheterization and/or TURP. A mean baseline IPSS-obstructive score of 3.6 significantly increased to 5.0 at 1 month (p < 0.0001); however, it returned to baseline in 92.6% within a median time of 3 months. Late increases in OVS were common, but transient. Only 7.1% of patients felt that weak urine stream and/or incomplete emptying was a moderate to big problem at two years post-SBRT (p = 0.6854).
SBRT treatment caused an acute increase in OVS which peaked within the first month post-treatment, though acute UR requiring catheterization was rare. OVS returned to baseline in > 90% of patients within a median time of three months. Transient Late increases in OVS were common. However, less than 10% of patients felt that OVS were a moderate to big problem at two years post-SBRT.
"The clinical relevance of BPH/BPE is underscored by the fact that up to 50% of elderly men develop lower urinary tract symptoms due to BPH/BPE, and that trans urethral resection of the prostate (TURP) remains the gold-standard therapy against BPH, with a lifetime risk for surgery of around 25–30%12. BPH/BPE originates in the transition zone of the prostate and consists of a nodular overgrowth of the epithelium and fibromuscular tissue within transitional zone and periurethral areas12. Although the pathogenesis of BPH/BPE is poorly understood and thought to be multifactorial, prostate tissue-remodeling in the transition zone is characterized by: (i) hypertrophic basal cells, (ii) altered secretions of luminal cells leading to calcification, clogged ducts and inflammation, (iii) lymphocytic infiltration with production of proinflammatory cytokines, (iv) increased radical oxygen species (ROS) production that damages epithelial and stromal cells, (v) increased basic fibroblast growth factor (bFGF) and transforming growth factor beta 1 (TGF-β1) production leading to stromal proliferation, transdifferentiation and extracellular matrix production, (vi) altered autonomous innervation that decreases relaxation and leads to a high adrenergic tonus, and (vii) altered neuroendocrine cell function and release of neuroendocrine peptides2. "
[Show abstract][Hide abstract] ABSTRACT: In the light of increasing evidence that benign prostatic hyperplasia is associated with cardiovascular disease, we have investigated the relationship between prostatic blood flow and prostatic hyperplasia in the spontaneously-hypertensive-rat (SHR). Twelve-week-old male SHRs were treated with nicorandil for six weeks. Wistar-Kyoto rats were used as controls. Six weeks after nicorandil treatment, blood pressure and the prostatic blood flow were estimated, and tissue levels of malondialdehyde, HIF-1α, TGF-β1, bFGF, dihydrotestosterone, and α-SMA were measured. SHRs showed significant increases in blood pressure, tissue levels of malondialdehyde, HIF-1α, TGF-β1, bFGF, α-SMA and a significant decrease in the prostatic blood flow. Although treatment with nicorandil failed to alter the blood-pressure and α-SMA, it significantly ameliorated the increased levels of malondialdehyde, HIF-1α, TGF-β1, and bFGF. There were no significant differences in tissue levels of dihydrotestosterone among any groups. These data indicate that development of prostatic hyperplasia may be associated with prostatic hypoxia, which nicorandil prevents via its effect to increase the blood flow.
[Show abstract][Hide abstract] ABSTRACT: Self-report assessment of lower urinary tract symptoms (LUTS) is complicated by the many tools that are available. The International Prostate Symptom Score (IPSS) is widely used and highly recommended in review articles and practice guidelines. This review focuses on work completed since 2011 using the IPSS and other tools. The focus of the review is on the merits and weakness of existing tools, as well as a discussion of how to move the field forward, given that there is already a strong base of questionnaires. Some specific trends in health measurement include the use of item response theory and computer adaptive testing, but it is unclear to what extent they will be adopted within urology. Many current studies in urology are making use of single items to assess important symptoms of interest, such as nocturia and incontinence, so future work might seek to catalogue best-in-class, single-question items.
Current Urology Reports 10/2012; 13(6). DOI:10.1007/s11934-012-0286-5 · 1.51 Impact Factor
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