Heesakkers2_EU_Genito.qxp 1/8/07 10:12 Page 63
The Complexities of Diagnosing and Treating Overactive Bladder in Men
improved volume to first detrusor contraction (VFC) (+59ml, 95%) and Well-designed Randomised Controlled Trials
maximum cystometric capacity (CMC) (+67ml, 95%) significantly. The Tolterodine and Tamsulosin in Men with LUTS including OAB
Tolterodine did not adversely affect urinary function in men with OAB and (TIMES) study was performed to evaluate the efficacy and safety of an
BOO. Urinary flow rate was unaltered, and there was no evidence of antimuscarinic, an alpha-blocker or both in men with LUTS that
clinically meaningful changes in voiding pressure. Tolterdine was well include OAB symptoms.
35
In this four-arm study, patients (n=879)
tolerated, suggesting it can safely be administered in men with BOO. were randomly assigned to receive placebo, tolterodine, tamsulosin or
both tolterodine and tamsulosin for 12 weeks. Tolterodine,
administered with tamsulosin, was an efficacious treatment.
As a result of the complex interplay
Compared with placebo, patients experienced significant reductions in
between overactive bladder and benign
urgency and frequency episodes. This led to significant improvements
in the total IPSS. The incidence of AUR was low and, in patients with
prostatic enlargement in male lower
PVR <200ml and maximum urinary flow rate (Qmax) >5ml/s, no
urinary tract symptoms, we stress the increase of PVR or decrease of Qmax was found. Tolterodin or
necessity for measured evaluation and
tamsulosin alone, however, was not sufficient to show significant
clinical efficacy.
treatment regarding this interaction.
Summary
In other studies, a sub-analysis of male patients with OAB in tolterodine We emphasise that male OAB symptoms are storage LUTS. They may
extended release (ER) proved that treatment with tolterodine was not occur with or without BOO, and are often found to be persistent after
associated with increased incidence of AUR.
32,33
The authors concluded interventions targeted at the prostate. As a result of the complex
that the available data might be considered promising and the use of interplay between OAB and BPE in male LUTS, we stress the necessity
anticholinergic drugs was demonstrated to be “quite safe”. However, of measured evaluation and treatment regarding this interaction. In
considering therapy with an alpha-blocker in combination with an spite of concern about the possible development of AUR while using
antimuscarinic, studies were methodologically insufficient to support the antimuscarinics, the first results of well-designed RCTs reveal that
clinical use of this combination therapy. Therefore, well-designed, large, these agents (with or without an alpha-blocker) do not adversely
double-blind, placebo-controlled, long-term, randomised controlled trials affect urinary function and can be safely administered in men
(RCTs) were needed.
34
with LUTS. ■
1. Irwin DE, Milsom I, Hunskaar S, et al., Population-based survey understanding, evaluation, and treatment of lower urinary tract placebo over 4 years. Characterization of patients and ultimate
of urinary incontinence, overactive bladder, and other lower symptoms in men: focus on the bladder, Eur Urol, 2006;49: outcomes.The PLESS Study Group, Eur Urol, 2000;37:528–36.
urinary tract symptoms in five countries: results of the EPIC 651–9. 26. McConnell JD, Roehrborn CG, Bautista OM, et al., The long-
study, Eur Urol, 2006;50:1306–15. 14. Dawson C , Whitfield H, ABC of Urology. Urological term effect of doxazosin, finasteride, and combination therapy
2. Abrams P, Cardozo L, Fall M, et al., The standardisation of emergencies in general practice, BMJ, 1996; 312:838–40. on the clinical progression of benign prostatic hyperplasia,
terminology of lower urinary tract function: report from the 15. Jacobsen SJ, Girman CJ, Guess HA, et al., Natural history of N Engl J Med, 2003;349:2387–98.
Standardisation Sub-committee of the International Continence prostatism: longitudinal changes in voiding symptoms in 27. Roehrborn CG, Alfuzosin 10 mg once daily prevents overall
Society, Neurol Urodyn, 2002;21:167–78. community dwelling men, J Urol, 1996;155:595–600. clinical progression of benign prostatic hyperplasia but not
3. Abrams P, Cardozo L, Fall M, et al., The standardisation of 16. Jacobsen SJ, Jacobson DJ, Girman CJ, et al., Natural history of acute urinary retention: results of a 2-year placebo-controlled
terminology in lower urinary tract function: report from the prostatism: risk factors for acute urinary retention, J Urol, study, BJU Int, 2006;97:734–41.
standardisation sub-committee of the International Continence 1997;158:481–7. 28. Emberton M, Definition of at-risk patients: dynamic variables,
Society, Urolog, 2003;61:37–49. 17. Verhamme KM, Dieleman JP, van Wijk MA, et al., Low BJU Int, 2006;97(Suppl. 2):12–159.
4. Mostwin JL, Karim OM, van Koeveringe G, Brooks EL, The incidence of acute urinary retention in the general male 29. Andersson KE, Yoshida M, Antimuscarinics and the overactive
guinea pig as a model of gradual urethral obstruction, J Urol, population: the triumph project, Eur Urol, 2005;47:494–8. detrusor--which is the main mechanism of action?, Eur Urol,
1991;145:854–8. 18. Roehrborn CG, McConnell JD, Saltzman B, et al., Storage 2003;43:1–5.
5. Steers WD, Pathophysiology of overactive bladder and urge (irritative) and voiding (obstructive) symptoms as predictors of 30. Reynard JM, Does anticholinergic medication have a role for
urinary incontinence, Rev Urol, 2002;4:S7–S18. benign prostatic hyperplasia progression and related outcomes, men with lower urinary tract symptoms/benign prostatic
6. Laniado ME, Ockrim JL, Marronaro A, et al., Serum prostate- Eur Urol, 2002;42:1–6. hyperplasia either alone or in combination with other agents?,
specific antigen to predict the presence of bladder outlet 19. Roehrborn CG, Malice M, Cook TJ, Girman CJ, Clinical Curr Opin Urol, 2004,14:13–16.
obstruction in men with urinary symptoms, BJU, 2004;94: predictors of spontaneous acute urinary retention in men with 31. Abrams P, Kaplan S, De Koning Gans HJ, et al. Safety and
1283–6. LUTS and clinical BPH: a comprehensive analysis of the pooled tolerability of tolterodine for the treatment of overactive
7. Fusco F, Groutz A, Blaivas JG, et al., Videourodynamic studies placebo groups of several large clinical trials, Urology, bladder in men with bladder outlet obstruction, J Urol,
in men with lower urinary tract symptoms: a comparison of 2001;58:210–16. 2006;175:999–1004.
community based versus referral urological practices, J Urol, 20. McConnell JD, Bruskewitz R, Walsh P, et al., The effect of 32. Roehrborn CG, Abrams P, Rovner ES, et al., Efficacy and
2001;166:910–13. finasteride on the risk of acute urinary retention and the need tolerability of tolterodine extended-release in men with
8. Lee JY, Kim HW, Lee SJ, et al., Comparison of doxazosin with for surgical treatment among men with benign prostatic overactive bladder and urgency urinary incontinence, BJU Intl,
or without tolterodine in men with symptomatic bladder outlet hyperplasia. Finasteride Long-Term Efficacy and Safety Study 2006;97:1003–6.
obstruction and an overactive bladder, BJU Int, 2004;94:817. Group, N Engl J Med, 1998;338:557–63. 33. Elinoff V, Bavendam T, Glasser DB, et al., Symptom-specific
9. De Groat WC, A neurologic basis for the overactive bladder, 21. Nickel CJ, Br J Urol, 1998;81:383–7. efficacy of tolterodine extended release in patients with
Urology, 1997;50:36–52. 22. Nickel CJ, et al., CMAJ, 1996;155:1251–9. overactive bladder: the IMPACT trial, Intl J Clin Pract,
10. Ziada A, Rosenblum M, Crawford ED, Benign prostatic 23. Marberger MJ, Long-term effects of finasteride in patients with 2006;60:745–51.
hyperplasia: an overview, Urology, 1999;53:1–6. benign prostatic hyperplasia: a double-blind, placebo- 34. Novara G, Galfano A, Ficarra V, Artibani W, Anticholinergic
11. Dmochowski RR, Staskin D, Overactive bladder in men: special controlled, multicenter study. PROWESS Study Group, Urology, drugs in patients with bladder outlet obstruction and lower
considerations for evaluation and management, Urology, 1998;51:677–86. urinary tract symptoms: A systematic review, Eur Urol,
2002;60(Suppl. A):56–62. 24. DeBruyne F, Barkin J, van Erps P, et al., Efficacy and safety of 2006;50:675–83.
12. Thomas AW, Cannon A, Bartlett E, et al., The natural history of long-term treatment with the dual 5 alpha-reductase inhibitor 35. Kaplan SA, Roehrborn CG, Rovner ES, , et al., Tolterodine and
lower urinary tract dysfunction in men: minimum 10-year dutasteride in men with symptomatic benign prostatic tamsulosin for treatment of men with lower urinary tract
urodynamic followup of transurethral resection of prostate for hyperplasia, Eur Urol, 2004;46:488–94. symptoms and overactive bladder: a randomized controlled
bladder outlet obstruction, J Urol, 2005;174:1887–91. 25. Roehrborn CG, Bruskewitz R, Nickel GC, et al., Urinary trial, JAMA, 2006;296:2319–28.
13. Chapple CR, Roehrborn CG, A shifted paradigm for the further retention in patients with BPH treated with finasteride or
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