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    • Voiding symptoms may influence health care seeking behavior

    2018-11-06

    Voiding symptoms may influence health care-seeking behavior through QOL impairment in Japanese men. The QOL score revealed more pronounced differences between men admitted to clinics and entacapone settings than did the IPSS category. The Core Lower Urinary Tract Symptom Score questionnaire is more comprehensive than the IPSS questionnaire for symptom assessment in men with various diseases/conditions, although both questionnaires can capture LUTS with a potential negative impact on QOL.
    Prediction of symptomatic progression A systematic review of the placebo arm of clinical trials related to BPH revealed that disease progression was relative to increased PV and decreased Qmax. In addition, disease progression increased the risk of acute urinary retention (AUR) and surgery. Progression may be associated with a higher IPSS, lower Qmax, increased postvoid residual urine (PVR), and enlarged PV. According to the Medical Therapy of Prostatic Symptoms study (MTOPS), the clinical progression of the placebo arm (n = 737) was 17%, AUR was 2%, and invasive therapy for BPH was 5%. The results from this study suggested that the risk factors for clinical progression may include age ≥62 years, prostate volume ≥31 mL, prostate specific antigen ≥1.6 ng/mL, Qmax <10.6 mL/s, and PVR ≥39 mL. However, medical practitioners often encounter patients with several unfavorable conditions and not with a single risk factor. In a comprehensive analysis of expert opinions, considerable PVR (>150 mL), poor Qmax (<10 mL/s), and severe symptoms (total IPSS = 20–35 points) were the most dominant factors predicting an elevated risk of disease progression. Enlarged prostate and high prostate specific antigen value were good clinical predictors of AUR and BPH-related surgery. In addition, high PVR should be reconsidered as a predictor of BPH progression because of evidence from the results of population-based, longitudinal studies and analysis of the placebo arm of controlled studies.
    Natural history of BPH after diagnosis The best method to evaluate the natural history of BPH after diagnosis is to understand the fate of a watchful–waiting or placebo treatment group. In a community-based, longitudinal study followed for 12 years, an average increase in the IPSS of 0.18 points/yr (0.05 points for men in their 50s to 0.44 points for men in their 70s) was observed. Qmax decreased 2%/yr, and median prostate growth decreased 1.9%/yr. In addition, the accumulative incidence of AUR was 2.7% when monitored for over 4 years. In the placebo-controlled arm of the MTOPS study, evidence revealed that symptom deterioration (IPSS ≥ 4 points) was the most prevalent progression event (79.5%), with an accumulative incidence of 14% over a mean follow-up period of 4.5 years. After diagnosis of BPH, self-management intervention, including lifestyle modification and specific behavioral changes, such as decreasing fluid intake at bedtime and avoiding consumption of caffeine and alcohol, may be the most suitable management strategies that offer an enhanced clinical response. However, the failure rate at 3 months, 6 months, and 12 months is higher in watchful–waiting patients (40.3% vs. 9.6%; 58.2% vs. 17.8%; and 65.7% vs. 24.6%, respectively) than in patients receiving active management. This evidence indicates that BPH results in a deteriorated clinical or symptomatic natural progression, and early treatment may benefit the patients with bothersome symptoms of BPH. The Prowess Study revealed that patients with moderate symptoms of BPH show a significantly greater improvement with finasteride therapy than those in the placebo group. The PV decreased 15.3% in the treatment group compared with that in the placebo group, in which PV increased approximately 8.9% after 24 months. A nationally representative database study reported that in addition to α-blocker therapy, each 30-day delay in the treatment with 5-α-reductase inhibitors may increase overall clinical progression (21.1%), AUR (18.6%), and likelihood of prostate-related surgery (26.7%) within 6 months of follow-up. This result indicates that even after receiving early treatment with α-blockers, patients have an elevated risk of symptomatic progression if they cannot reduce the prostate size. In the Veterans Affairs Cooperative Study, 24% watchful–waiting patients underwent surgery within 3 years of waiting for assignment. Based on the natural history after diagnosis of BPH with or without medical treatment, monitoring clinical progression should help raise awareness among clinicians and patients, who should also remain informed, particularly those receiving watchful–waiting treatment.