Mauro Dicuio

Relationship Between Age, Prostate Volume, Prostate-specific Antigen, Symptom Score and Uroflowmetry in Men with Lower Urinary Tract Symptoms

Objectives: To estimate the relationship between age and the values of different diagnostic tests in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic enlargement (BPE) and to compare prostate growth curves between the normal population sample, healthy men and men with LUTS. Material and Methods: A series of 354 men (mean age 70.2 years; range 45-91 years) with LUTS due to BPE were stratified into seven age groups and reviewed retrospectively. All patients underwent a standard evaluation, involving determination of the International Prostate Symptom Score (IPSS), digital rectal examination, uroflowmetry, determination of the prostate-specific antigen (PSA) level and transrectal ultrasonography. Descriptive statistics were used to describe all the variables and Spearmans correlation test was used to evaluate the relationships between them. Results: The mean prostate volume was 40.1 (±23.9) cm[Formula: See Text] and mean PSA concentration 3.9 (±4.2) ng/ml. Both values increased progressively from 27.5 ml and 1.5 ng/ml, respectively in the <54 years age group to 48.2 ml and 5.4 ng/ml, respectively in the <80 years age group. However, in the 75-79 years age group there was a decrease in both prostate volume and symptom score; PSA concentration remained unchanged and maximal flow rate increased slightly. A statistically significant but weak correlation was found between prostate volume and age (r = 0.25, p < 0.0001) and between PSA and age (r = 0.28, p < 0.0001). Prostate volume correlated positively with serum PSA (r = 0.54, p < 0.0001). The correlations between maximum flow rate and age, prostate volume, PSA and IPSS were r = −0.21, p < 0.0001; r = −0.18, p < 0.0006; r = −0.29, p < 0.0001; and r = 0.14, p < 0.0098, respectively. Conclusions: These data confirm that prostate volume and serum PSA concentration are significantly correlated and increase with advanced age. The correlations between uroflowmetry (Qmax) and age, prostate volume, serum PSA and IPSS were also significant. However, there was no relationship between symptoms and objective measures of BPE. The increase in different parameters of the severity of benign prostatic hyperplasia with advanced age is not continuous. The prostate volume alone is not useful in the estimation of disease severity.

Testosterone treatment and cardiovascular and venous thromboembolism risk: what is ‘new’?

In men, testosterone (T) production declines as a function of ageing. Late-onset hypogonadism (LOH) is the most commonly used term to indicate this age-related condition. In LOH, the relative clinical significance and the potential benefit of testosterone treatment (TTh) are still the subject of strong criticisms in the scientific community. The debate is further complicated by the recent position statement of the US Food and Drug Administration (FDA) emphasizing that, in LOH, the benefits and safety of TTh have not been fully established. Hence, the FDA required a labeling change to inform patients about a possible increased cardiovascular (CV) risk of TTh. Similar considerations were previously released by the FDA and by Health Canada concerning a TTh-related venous thromboembolism (VTE) risk. In this review, we will summarize the available evidence concerning a possible link among TTh and CV and VTE risks. For this purpose, data derived from epidemiological studies analyzing relationships between the aforementioned risks and endogenous T levels will be analyzed. In addition, evidence deriving from interventional studies including pharmacoepidemiological and placebo-controlled randomized controlled trials (RCTs) will be examined. Our analysis shows that available data do not support an increased CV risk related to TTh. Similar considerations can be drawn for the relationship between TTh and VTE. The previously reported cases of TTh-related VTE were frequently related to a previously undiagnosed thrombophilia-hypofibrinolysis status. Hence, an anamnestic screening for thrombophilia before starting TTh is recommended, just as it is for the use of oral contraceptives.

Sexual dysfunction in subjects treated with inhibitors of 5α‐reductase for benign prostatic hyperplasia: a comprehensive review and meta‐analysis

Despite their efficacy in the treatment of benign prostatic hyperplasia, the popularity of inhibitors of 5α‐reductase (5ARIs) is limited by their association with adverse sexual side effects. The aim of this study was to review and meta‐analyze currently available randomized clinical trials evaluating the rate of sexual side effects in men treated with 5ARIs. An extensive Medline Embase and Cochrane search was performed including the following words: ‘finasteride’, ‘dutasteride’, ‘benign prostatic hyperplasia’. Only placebo‐controlled randomized clinical trials evaluating the effect of 5ARI in subjects with benign prostatic hyperplasia were considered. Of 383 retrieved articles, 17 were included in this study. Randomized clinical trials enrolled 24,463 in the active and 22,270 patients in the placebo arms, respectively, with a mean follow‐up of 99 weeks and mean age of 64.0 years. No difference was observed between trials using finasteride or dutasteride as the active arm considering age, trial duration, prostate volume or International Prostatic Symptoms Score at enrollment. Overall, 5ARIs determined an increased risk of hypoactive sexual desire [OR = 1.54 (1.29; 1.82); p < 0.0001] and erectile dysfunction [OR = 1.47 (1.29; 1.68); p < 0.0001]. No difference between finasteride and dutasteride regarding the risk of hypoactive sexual desire and erectile dysfunction was observed. Meta‐regression analysis showed that the risk of hypoactive sexual desire and erectile dysfunction was higher in subjects with lower Qmax at enrollment and decreased as a function of trial follow‐up. Conversely, no effect of age, low urinary tract symptom or prostate volume at enrollment as well as Qmax at end‐point was observed. In conclusion, present data show that the use of 5ARI significantly increases the risk of erectile dysfunction and hypoactive sexual desire in subjects with benign prostatic hyperplasia. Patients should be adequately informed before 5ARIs are prescribed.

Usefulness of a Prevoiding Transabdominal Sonographic Bladder Scan for Uroflowmetry in Patients Involved in Clinical Studies of Benign Prostatic Hyperplasia

Objective. Flow rate measurements in clinical studies require an amount of voided urine greater than 125 to 150 mL. Often patients do not void sufficient amounts of urine, and having them produce repeated flows is often difficult. Transabdominal sonographic scanning of the bladder is a simple method for estimating bladder volume. We determined by sonography the prevoiding bladder volume needed to void a sufficient amount of urine. Methods. Sixty‐seven patients with a mean age ± SD of 67.5 ± 8.0 years underwent free flow rate measurement. Bladder volume was measured by transabdominal sonography when the patient had the sensation to void and after uroflowmetry to calculate residual urine. Results. The voided volume was 220 ± 127 mL; the postvoiding residual urine volume was 92 ± 88 mL; and the bladder scan volume was 309 ± 158 mL. Among all patients, 23.9% had insufficient voided volumes of less than 125 mL in the flow rate measurements, and 31.3% had voided volumes of less than 150 mL. There was a strong correlation between the prevoiding measured volume and the voided volume (r = 0.836; P < .0001). Linear regression analysis of the flow rate recording yielded the following formula: voided volume = 11,766 + (0.673 × prevoiding volume). Conclusions. Bladder scanning before uroflowmetry is a useful test for reducing the amount of nonevaluable flow rate data. If a voided volume of greater than 125 mL (>150 mL) is required, the mandatory prevoiding bladder scan volume should be greater than 200 mL (>250 mL), which would decrease the number of noneligible flow rate recordings from 23.9% to 4.5% (31.3% to 4.5%).

30-MINUTES-TUMT

Introduction: Primary objective: to investigate if 30-MINUTES-TUMT can be performed under topical anesthesia and analgesics. Secondary objectives: to evaluate retrospectively analgesics and to study parameters connected with pain. Materials and Methods: Eighty-nine patients underwent TUMT. Patients were divided into four groups with different medications. Paracetamol and tolterodin-L-tartrate were administered in all groups. The first group was also given hydromorphone hydrochloride and atropine sulphate, the second group dextropropoxyphene, the third group morphine and diclofenac, and the fourth group morphine and dextropropoxyphene. Pain during TUMT was registered using the VAS scale. Results: Pain during TUMT was (VAS in mm), respectively, total-first-second-third-fourth group: at 5 min –30, 31, 12, 28, 35; at 15 min –30, 23, 16, 25, 34; at 25 min –30, 28, 18, 25, 35. All patients accepted the treatment. No significant difference between the different drug schedules was noticed. Conclusions: It is possible to treat patients with 30-MINUTES-TUMT with local anesthesia and analgesics. The pain can be accepted by all patients.

Cardiovascular impact of testosterone therapy for hypogonadism

ABSTRACT Introduction: Since 2010 some evidence supporting the possible increased cardiovascular (CV) risk related to testosterone treatment (TTh) has created much debate in the scientific community. Based on these results, the US Food and Drug Administration agency has questioned TTh for aging men recognizing its value only for classical hypogonadism due to genetic or organic causes. To better clarify this topic, we scrutinized and summarized, also by using meta-analytic methods, the data generated during the last 7 years, as derived from the analysis of randomized controlled trials (RCTs) on TTh and CV risk. Areas covered: Analysis included 31 RCTs published between 2010 and 2018. Retrieved trials included 2675 and 2308 patients in TTh and placebo groups, respectively. The analysis documented that TTh was not associated with an increased CV mortality or morbidity either when overall or major adverse CV events were considered. Expert commentary: Despite present evidence it is important to recognize that the duration of the available trials is short (lower that 3 years) limiting final conclusions on this topic. In particular, the available information on possible long-term effects of TTh on CV risk is limited. Long-term safety studies are advisable to better clarify these points.