European Urology

Editorials

The presence of storage symptoms is extremely common in patients with bladder outlet obstruction (BOO). Questionnaire data from 1271 men with lower urinary tract symptoms (LUTS) indicated that many men have both storage and voiding symptoms [1]. The same study demonstrated that storage symptoms made up four of the five most bothersome LUTS. Daily practice has given a clear impression, confirmed by observational studies, that pharmacotherapies and surgical interventions that target the prostate may not alleviate overactive bladder (OAB) symptoms. In the April issue of European Urology, Chapple and Roehrborn [2] emphasised that male OAB symptoms are storage LUTS that may coexist with bladder prostatic hyperplasia (BPH), bladder prostatic enlargement (BPE), or BOO without being caused by the prostatic condition.

Hence, the idea arose of treating these patients with anticholinergic drugs, alone or in combination with α₁-receptor antagonists. Based on the physiology of α-adrenergic and muscarinic receptors, the inhibition of each one would be expected to be more beneficial than that of either alone because they would work on two components of detrusor function. However, lessons from the past have taught us to be cautious with “good” ideas. Are we convinced that the inhibitory effect of anticholinergic drugs on detrusor muscle contraction will never aggravate the voiding difficulties or cause urinary retention in men with OAB symptoms and possible BOO? Do we know that other side-effects, such as mouth dryness, will not induce in the long term a worse impact on quality of life than OAB symptoms? How much do we know about the efficacy and safety of antimuscarinics for the treatment of OAB in men, when used alone or in combination with α₁-receptor antagonists?

The article by Novara et al. published in this issue of European Urology [3] is timely in this respect. The authors reviewed the available evidence concerning the use of anticholinergic drugs in patients with LUTS due to or associated with BPH/BPE/BOO and concomitant OAB to assess whether the currently available data suggest a role for antimuscarinic drugs. They used a systematic review that identified a sparse literature, that is, four randomised controlled trials (RCTs), two prospective case series, and a few congress abstracts.

What did the authors find? Obviously, the answer requires extensive reading of the article. But even if it means to be a reductionist, here are the main ideas:

• •Among the rather meagre literature mentioned above, some randomised and prospective nonrandomised studies have not been published in peer-reviewed or indexed journals. The different studies did not use the same methodology nor the same judgement criteria.

• •Treatment duration was as a rule very short (1–3 mo) with virtually no follow-up.

• •Most of the studies found that anticholinergic drugs were associated with:

  • ∘a significant improvement in the International Prostate Symptom Score (IPSS) or nighttime frequency or quality-of-life score

  • ∘significant urodynamic alterations, mainly significant reductions in maximum detrusor pressure during micturition and filling phase

  • ∘mouth dryness and increase in postvoid residual urine with rare cases of consequent drop-out rate and acute urinary retention, however

  Thus, the available data may be considered promising and the use of anticholinergic drugs quite safe also in patients with voiding symptoms and urodynamically proven detrusor overactivity. Is this issue settled and does OAB in men (with or without BOO) equal the use of anticholinergic drugs (with or without α-blockers or 5α-reductase) as a standard in daily practice?

  I would totally agree with the authors’ reservations. First, the present evidence is extracted from a limited number of RCTs, most of them including methodologic or clinical weaknesses. Second, in all the published RCTs, detrusor overactivity and BOO were chosen as inclusion criteria, requiring urodynamic studies to be performed in all the patients. Consequently, their conclusions do not necessarily apply to patients in everyday clinical practice.

  Obviously, these considerations led the authors to this maybe well-worn but wise conclusion: “Well-designed, large, double-blind, placebo-controlled, long-term RCTs are needed to assess the safety and, above all, efficacy of antimuscarinic drugs, alone or in combination with alpha-blockers, in this category of patients.”

  References

  • [1] T.J. Peters, J.L. Donovan, H.E. Kay, et al.. The International Continence Society “Benign Prostatic Hyperplasia” Study: the bothersomeness of urinary symptoms. J Urol 157 (1997) (885 - 889)
  • [2] C.R. Chapple, C.G. Roehrborn. A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: focus on the bladder. Eur Urol 49 (2006) (651 - 659) Abstract, Full-text, PDF, Crossref.
  • [3] G. Novara, A. Galfano, V. Ficarra, W. Artibani. Anticholinergic drugs in patients with bladder outlet obstruction and lower urinary tract symptoms: a systematic review. Eur Urol 50 (2006) (675 - 683) Abstract, Full-text, PDF, Crossref.
  return to article outline

  Footnotes

  Centre Hospitalier Universitaire, Department Urologie, La Milétrie, 86000 Poitiers, France

  Tel. +33 5 4944 4477; Fax: +33 5 4944 3844.
  

  Article information

  PII: S0302-2838(06)00852-9
  DOI: 10.1016/j.eururo.2006.07.018
  © 2006 European Association of Urology. Published by Elsevier B.V.

  return to article outline
  Comment form

  Add a comment

  Your email address is only used for a confirmation mail and will not be used for other purposes.

  Name:

  Email:

  Comment:
  Next article

  Contents