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Re: Elderly Men's Quality of Life and Lower Urinary Tract Symptoms: An Intricate Relationship
894
GERIATRICS
number of nocturnal voids (43% vs. 9%; P ⬍0.01), nocturnal urine volume (37% vs. 5%; P ⬍0.01), and increase in the mean duration of the first sleep period (52% vs. 19%, P ⬍0.01). Adverse events were mild. Conclusions: Staggered furosemide and desmopressin provide an effective and well-tolerated treatment for nocturia in the elderly. Editorial Comment: Nocturia is an important cause of interrupted sleep, particularly in older adults. The negative impact of sleep deprivation and nocturia may be especially pronounced in elderly patients. Prior research has linked nocturia with increased risk of falls, fractures and mortality in this older population. The causes of nocturia are often multifactorial, and treatment can be challenging for the clinician. The authors of this prospective randomized study examined the efficacy and safety of staggered dosing of furosemide and desmopressin compared to placebo in a group of older adults. The findings revealed that staggered dosing of these medications resulted in statistically better outcomes compared to placebo, as outlined in the abstract. Furosemide was administered 6 hours before planned bedtime to help reduce the potential contribution to nocturia from the medication. Only 2 patients experienced clinically significant hyponatremia. Methodological limitations of the study included a short duration of therapy (3 weeks), short followup (1 additional week) and lack of other comparator arms (desmopressin alone or furosemide alone). A total of 40 potential subjects withdrew during the desmopressin dose titration phase due to adverse events (11 patients), lack of response (12), no recurrence of diuresis (11) and other reasons (6). However, these preliminary results appear encouraging and suggest that additional research on the topic may be useful. Tomas L. Griebling, M.D., M.P.H.
Re: Elderly Men’s Quality of Life and Lower Urinary Tract Symptoms: An Intricate Relationship V. L. Pintarelli, L. F. Perchon, F. Lorenzetti, J. Toniolo Neto and M. Dambros Divisions of Geriatric Urology, Geriatrics and Gerontology, Federal University of São Paulo, São Paulo, Brazil Int Braz J Urol 2011; 37:758 –765.
Purpose: To evaluate the impact of lower urinary tract symptoms (LUTS) on the quality of life (QoL) in a group of elderly men. Materials and Methods: Observational clinical study contained 200 men recruited between March-September 2008 in the community and Urology and Geriatrics ambulatories. The data collected included health and sociodemographic conditions; the International Prostate Symptom Score (IPSS); an anxiety/depression inventory; the World Health Organization Quality of Life -Bref and -Old questionnaires (WHOQoL). Participants were classified according to IPSS: Group I (moderate/severe symptoms) and Group II (absence/mild symptoms) and 100 men were included in each group. Results: The groups were statistically similar in sociodemographic, morbidity, and anxiety/depression scores. Both QoL scales showed significant lower median scores in group I in all parameters, except the global subjective self-evaluation of QoL. The domains social and environmental relations presented the most significative differences (p ⬍ 0.0005) in both questionnaires, and final mean WHOQoL-OLD score was lower in group I (p ⬍ 0.0005). Conclusions: For elderly men, moderate to severe LUTS do significantly impact almost all parameters of QoL proposed by the WHO, especially social and environmental relations. Editorial Comment: Although multiple published studies have sought to examine the relationship between LUTS and QoL in men with benign prostatic hyperplasia, many have been criticized due to variable interpretations of what actually constitutes QoL. This observational study used 2 validated measures of QoL developed by WHO to examine this relationship in a cohort of elderly men. Subjects were stratified based on their degree of LUTS as measured by the IPSS. The finding of statistically similar results on the single QoL
GERIATRICS
895
item in the IPSS (the bother question) indicates that this tool by itself is not sensitive enough to reflect more subtle differences that could be more accurately measured using comprehensive scales. Social and environmental subscores of QoL were the most impacted by LUTS in this analysis. In a companion article the researchers examined these issues in relation to measures of androgen deficiency in the aging male syndrome.1 Using the Aging Male Symptoms scale, they found that the somatic and sexual subscores on the scale were most closely linked to negative QoL measures in the other instruments, particularly in men with moderate or severe LUTS. The findings highlight the importance of these genitourinary symptoms concerning QoL in elderly men. Tomas L. Griebling, M.D., M.P.H. 1. Perchon LF, Pintarelli VL, Bezerra E et al: Quality of life in elderly men with aging symptoms and lower urinary tract symptoms (LUTS). Neurourol Urodyn 2011; 30: 515.
Re: The Efficacy of Additive Tolterodine Extended Release for 1-Year in Older Men with Storage Symptoms and Clinical Benign Prostatic Hyperplasia S. D. Chung, H. C. Chang, B. Chiu, C. H. Liao and H. C. Kuo Division of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan Neurourol Urodyn 2011; 30:568 –571.
Aim: To determine the efficacy of tolterodine extended release (ER) treatment for 1 year in older men with benign prostatic hyperplasia (BPH) and storage symptoms treated with alpha-blockers and/or 5-alpha-reductase inhibitors (5ARI). Methods: Men aged over 70 years with BPH/bladder outlet obstruction (BOO) and clinical storage symptoms were randomly treated with or without tolterodine ER in combination with alpha-blockers and/or 5ARI for 12 months. Among them, 50 patients (group 1) received additive tolterodine extended release (ER) 4 mg q.d., another 87 patients (group 2) did not. All patients had a baseline and 12th month post-treatment evaluation, which comprised of uroflowmetry, post-void residual (PVR) volume, International Prostate Symptom Score (IPSS), and quality of life index (QoL-I), transrectal ultrasound of the prostate and serum prostate specific antigen. Results: One hundred thirty-seven of 153 enrolled patients with a mean age of 74.9 years completed the study. Treatment benefit demonstrated in both groups included deceased total, voiding and storage IPSS scores, increased peak urinary flow rate and deceased QoL-I. Inter-group difference was only observed on the storage domain of IPSS score (P ⫽ 0.012). The mean PVR after treatment did not significantly differ between two groups. Two patients of group 1 and three of group 2 developed acute urinary retention. Among group 1, six patients discontinued tolterodine ER for intolerable dry mouth; among group 2, three patients reported dizziness. Conclusions: This longer comparative study indicated that additive treatment with tolterodine ER in older men with BPH/BOO and significant storage symptoms is a beneficial and safe therapeutic option. Editorial Comment: The role of detrusor overactivity in men with symptomatic BPH and lower urinary tract symptoms has gained increasing attention in recent years. There is a growing body of evidence that storage and voiding components may contribute to overall symptoms experienced by men with this condition. This finding partly explains why treatments traditionally used for BOO, such as the alpha-antagonists and 5ARIs, may not help relieve all lower urinary tract symptoms in men. This study examined use of tolterodine in conjunction with alpha-antagonists (with or without a 5ARI) compared to not receiving tolterodine. No patients were treated with a 5ARI alone. Men receiving combination therapy with tolterodine experienced better overall outcomes, including a statistically significant improvement in the storage domain on the IPSS, compared to the other group. Strengths of the study include the use of urodynamics to confirm the diagnosis, inclusion only of participants older than 70 years and
GERIATRICS
number of nocturnal voids (43% vs. 9%; P ⬍0.01), nocturnal urine volume (37% vs. 5%; P ⬍0.01), and increase in the mean duration of the first sleep period (52% vs. 19%, P ⬍0.01). Adverse events were mild. Conclusions: Staggered furosemide and desmopressin provide an effective and well-tolerated treatment for nocturia in the elderly. Editorial Comment: Nocturia is an important cause of interrupted sleep, particularly in older adults. The negative impact of sleep deprivation and nocturia may be especially pronounced in elderly patients. Prior research has linked nocturia with increased risk of falls, fractures and mortality in this older population. The causes of nocturia are often multifactorial, and treatment can be challenging for the clinician. The authors of this prospective randomized study examined the efficacy and safety of staggered dosing of furosemide and desmopressin compared to placebo in a group of older adults. The findings revealed that staggered dosing of these medications resulted in statistically better outcomes compared to placebo, as outlined in the abstract. Furosemide was administered 6 hours before planned bedtime to help reduce the potential contribution to nocturia from the medication. Only 2 patients experienced clinically significant hyponatremia. Methodological limitations of the study included a short duration of therapy (3 weeks), short followup (1 additional week) and lack of other comparator arms (desmopressin alone or furosemide alone). A total of 40 potential subjects withdrew during the desmopressin dose titration phase due to adverse events (11 patients), lack of response (12), no recurrence of diuresis (11) and other reasons (6). However, these preliminary results appear encouraging and suggest that additional research on the topic may be useful. Tomas L. Griebling, M.D., M.P.H.
Re: Elderly Men’s Quality of Life and Lower Urinary Tract Symptoms: An Intricate Relationship V. L. Pintarelli, L. F. Perchon, F. Lorenzetti, J. Toniolo Neto and M. Dambros Divisions of Geriatric Urology, Geriatrics and Gerontology, Federal University of São Paulo, São Paulo, Brazil Int Braz J Urol 2011; 37:758 –765.
Purpose: To evaluate the impact of lower urinary tract symptoms (LUTS) on the quality of life (QoL) in a group of elderly men. Materials and Methods: Observational clinical study contained 200 men recruited between March-September 2008 in the community and Urology and Geriatrics ambulatories. The data collected included health and sociodemographic conditions; the International Prostate Symptom Score (IPSS); an anxiety/depression inventory; the World Health Organization Quality of Life -Bref and -Old questionnaires (WHOQoL). Participants were classified according to IPSS: Group I (moderate/severe symptoms) and Group II (absence/mild symptoms) and 100 men were included in each group. Results: The groups were statistically similar in sociodemographic, morbidity, and anxiety/depression scores. Both QoL scales showed significant lower median scores in group I in all parameters, except the global subjective self-evaluation of QoL. The domains social and environmental relations presented the most significative differences (p ⬍ 0.0005) in both questionnaires, and final mean WHOQoL-OLD score was lower in group I (p ⬍ 0.0005). Conclusions: For elderly men, moderate to severe LUTS do significantly impact almost all parameters of QoL proposed by the WHO, especially social and environmental relations. Editorial Comment: Although multiple published studies have sought to examine the relationship between LUTS and QoL in men with benign prostatic hyperplasia, many have been criticized due to variable interpretations of what actually constitutes QoL. This observational study used 2 validated measures of QoL developed by WHO to examine this relationship in a cohort of elderly men. Subjects were stratified based on their degree of LUTS as measured by the IPSS. The finding of statistically similar results on the single QoL
GERIATRICS
895
item in the IPSS (the bother question) indicates that this tool by itself is not sensitive enough to reflect more subtle differences that could be more accurately measured using comprehensive scales. Social and environmental subscores of QoL were the most impacted by LUTS in this analysis. In a companion article the researchers examined these issues in relation to measures of androgen deficiency in the aging male syndrome.1 Using the Aging Male Symptoms scale, they found that the somatic and sexual subscores on the scale were most closely linked to negative QoL measures in the other instruments, particularly in men with moderate or severe LUTS. The findings highlight the importance of these genitourinary symptoms concerning QoL in elderly men. Tomas L. Griebling, M.D., M.P.H. 1. Perchon LF, Pintarelli VL, Bezerra E et al: Quality of life in elderly men with aging symptoms and lower urinary tract symptoms (LUTS). Neurourol Urodyn 2011; 30: 515.
Re: The Efficacy of Additive Tolterodine Extended Release for 1-Year in Older Men with Storage Symptoms and Clinical Benign Prostatic Hyperplasia S. D. Chung, H. C. Chang, B. Chiu, C. H. Liao and H. C. Kuo Division of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan Neurourol Urodyn 2011; 30:568 –571.
Aim: To determine the efficacy of tolterodine extended release (ER) treatment for 1 year in older men with benign prostatic hyperplasia (BPH) and storage symptoms treated with alpha-blockers and/or 5-alpha-reductase inhibitors (5ARI). Methods: Men aged over 70 years with BPH/bladder outlet obstruction (BOO) and clinical storage symptoms were randomly treated with or without tolterodine ER in combination with alpha-blockers and/or 5ARI for 12 months. Among them, 50 patients (group 1) received additive tolterodine extended release (ER) 4 mg q.d., another 87 patients (group 2) did not. All patients had a baseline and 12th month post-treatment evaluation, which comprised of uroflowmetry, post-void residual (PVR) volume, International Prostate Symptom Score (IPSS), and quality of life index (QoL-I), transrectal ultrasound of the prostate and serum prostate specific antigen. Results: One hundred thirty-seven of 153 enrolled patients with a mean age of 74.9 years completed the study. Treatment benefit demonstrated in both groups included deceased total, voiding and storage IPSS scores, increased peak urinary flow rate and deceased QoL-I. Inter-group difference was only observed on the storage domain of IPSS score (P ⫽ 0.012). The mean PVR after treatment did not significantly differ between two groups. Two patients of group 1 and three of group 2 developed acute urinary retention. Among group 1, six patients discontinued tolterodine ER for intolerable dry mouth; among group 2, three patients reported dizziness. Conclusions: This longer comparative study indicated that additive treatment with tolterodine ER in older men with BPH/BOO and significant storage symptoms is a beneficial and safe therapeutic option. Editorial Comment: The role of detrusor overactivity in men with symptomatic BPH and lower urinary tract symptoms has gained increasing attention in recent years. There is a growing body of evidence that storage and voiding components may contribute to overall symptoms experienced by men with this condition. This finding partly explains why treatments traditionally used for BOO, such as the alpha-antagonists and 5ARIs, may not help relieve all lower urinary tract symptoms in men. This study examined use of tolterodine in conjunction with alpha-antagonists (with or without a 5ARI) compared to not receiving tolterodine. No patients were treated with a 5ARI alone. Men receiving combination therapy with tolterodine experienced better overall outcomes, including a statistically significant improvement in the storage domain on the IPSS, compared to the other group. Strengths of the study include the use of urodynamics to confirm the diagnosis, inclusion only of participants older than 70 years and