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Re: Pelvic Floor Symptoms and Bone Mineral Density in Women Undergoing Osteoporosis Evaluation
GERIATRICS
156
placebo subgroup the relative reduction in urgency was 45.1% for drug and 47.3% for placebo, a treatment difference favoring placebo! For incontinence the mean reduction for the high treatment, low placebo subgroup was 78.6% for drug and 35.5% for placebo, a treatment difference of 41.4%. Within the low treatment, high placebo group essentially all of the relative reduction in incontinence for drug was associated with placebo effect. So conceivably one could choose a “good” or “bad” population for a drug trial! Alan J. Wein, MD, PhD (hon.)
Re: Long-Term Durability of the Response to Desmopressin in Female and Male Nocturia Patients K. V. Juul, B. M. Klein and J. P. Nørgaard Ferring International PharmaScience Center, Copenhagen, Denmark Neurourol Urodyn 2013; 32: 363e370.
Abstract available at http://jurology.com/ Editorial Comment: Desmopressin clearly decreases nocturnal urine production and, therefore, nocturia episodes. The question is whether the changes over placebo in (1) the number of nocturia episodes, (2) time of first awakening (hours of uninterrupted sleep) and (3) percent of patients with greater than 50% reduction in nocturnal episodes result in a meaningful improvement in quality of life with an acceptably low risk of safety issues, the latter of which are seemingly confined to the risk of hyponatremia. Alan J. Wein, MD, PhD (hon.)
Geriatrics Re: Pelvic Floor Symptoms and Bone Mineral Density in Women Undergoing Osteoporosis Evaluation H. E. Richter, S. L. Morgan, J. L. Gleason, J. M. Szychowski, P. S. Goode and K. L. Burgio University of Alabama at Birmingham, Birmingham, Alabama Int Urogynecol J 2013; 24: 1663e1669.
Abstract available at http://jurology.com/ Editorial Comment: Rates of osteopenia and osteoporosis increase with advancing age, and are higher in women than in men. In recent years there has been increased awareness of these conditions and an emphasis on screening and prevention. This study identified clinical associations between these skeletal disorders and genitourinary problems, including urinary and fecal incontinence. Study design precluded identification of causality or directionality of effect. It is unclear if there is an actual pathophysiological connection between these conditions. However, the results indicate that consideration of osteopenia and osteoporosis may be warranted in elderly women presenting with symptoms of pelvic floor dysfunction. Similarly older women with issues related to bone health may have genitourinary conditions requiring treatment. This study highlights the need to include assessment of these issues as part of geriatric health care for women. Tomas L. Griebling, MD, MPH
BENIGN PROSTATIC HYPERPLASIA
157
Suggested Reading Chen B and Yeh J: Alterations in connective tissue metabolism in stress incontinence and prolapse. J Urol 2011; 186: 1768.
Benign Prostatic Hyperplasia Re: Intravesical Prostatic Protrusion Can Be a Predicting Factor for the Treatment Outcome in Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction Treated with Tamsulosin A. A. Cumpanas, M. Botoca, R. Minciu and V. Bucuras Department of Urology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania Urology 2013; 81: 859e863.
Abstract available at http://jurology.com/ Editorial Comment: I had the pleasure of meeting Professor Foo in Singapore last year when I was a visiting professor there. As usual, I learned a lot! Most notably, Foo had been extensively evaluating the role of intravesical prostatic protrusion (IPP) as a method to predict the degree of bladder outlet obstruction and the response to surgical therapy. The data are quite compelling. Tan and Foo1 and other investigators have contributed a significant noninvasive proxy for bladder outlet obstruction and a potential predictor of medical and surgical success. Since that time, we have been using IPP as part of every transrectal ultrasound we perform and have found similar results. One can almost predict which patients will have urinary retention and which will have a good surgical outcome. To supplement this concept, the authors of this study use IPP as a predictor of which patients may fail alpha-blocker therapy. They report that response to tamsulosin using predetermined criteria (International Prostate Symptom Score decrease of 35% and 3 points, and peak flow rate increase of 25% and 1.6 ml per second) was significantly less in men with a baseline IPP of less than 10 mm. This finding makes intuitive sense, as men with middle lobe obstruction seem to be a different breed than those with simple bilobar hypertrophy. In general, men with IPP greater than 10 mm tend to have worse symptoms and worse bladder outlet obstruction and are more likely to go into urinary retention but most importantly seem to respond best to surgical intervention. Steven A. Kaplan, MD 1. Tan YH and Foo KT: Intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urinary retention. J Urol 2003; 170: 2339.
Re: Predictors of Successful First-Line Antimuscarinic Monotherapy in Men with Enlarged Prostate and Predominant Storage Symptoms C. H. Liao, Y. C. Kuo and H. C. Kuo Department of Urology, Cardinal Tien Hospital and School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan Urology 2013; 81: 1030e1033.
Abstract available at http://jurology.com/ Editorial Comment: It is somewhat remarkable that a class of medical therapy previously thought to be verboten in men with lower urinary tract symptoms, ie antimuscarinics, is now approved in virtually every urological guideline for benign prostatic hyperplasia. It seems reasonable that men with predominantly storage symptoms, ie frequency, urgency, etc, would benefit from antimuscarinic
156
placebo subgroup the relative reduction in urgency was 45.1% for drug and 47.3% for placebo, a treatment difference favoring placebo! For incontinence the mean reduction for the high treatment, low placebo subgroup was 78.6% for drug and 35.5% for placebo, a treatment difference of 41.4%. Within the low treatment, high placebo group essentially all of the relative reduction in incontinence for drug was associated with placebo effect. So conceivably one could choose a “good” or “bad” population for a drug trial! Alan J. Wein, MD, PhD (hon.)
Re: Long-Term Durability of the Response to Desmopressin in Female and Male Nocturia Patients K. V. Juul, B. M. Klein and J. P. Nørgaard Ferring International PharmaScience Center, Copenhagen, Denmark Neurourol Urodyn 2013; 32: 363e370.
Abstract available at http://jurology.com/ Editorial Comment: Desmopressin clearly decreases nocturnal urine production and, therefore, nocturia episodes. The question is whether the changes over placebo in (1) the number of nocturia episodes, (2) time of first awakening (hours of uninterrupted sleep) and (3) percent of patients with greater than 50% reduction in nocturnal episodes result in a meaningful improvement in quality of life with an acceptably low risk of safety issues, the latter of which are seemingly confined to the risk of hyponatremia. Alan J. Wein, MD, PhD (hon.)
Geriatrics Re: Pelvic Floor Symptoms and Bone Mineral Density in Women Undergoing Osteoporosis Evaluation H. E. Richter, S. L. Morgan, J. L. Gleason, J. M. Szychowski, P. S. Goode and K. L. Burgio University of Alabama at Birmingham, Birmingham, Alabama Int Urogynecol J 2013; 24: 1663e1669.
Abstract available at http://jurology.com/ Editorial Comment: Rates of osteopenia and osteoporosis increase with advancing age, and are higher in women than in men. In recent years there has been increased awareness of these conditions and an emphasis on screening and prevention. This study identified clinical associations between these skeletal disorders and genitourinary problems, including urinary and fecal incontinence. Study design precluded identification of causality or directionality of effect. It is unclear if there is an actual pathophysiological connection between these conditions. However, the results indicate that consideration of osteopenia and osteoporosis may be warranted in elderly women presenting with symptoms of pelvic floor dysfunction. Similarly older women with issues related to bone health may have genitourinary conditions requiring treatment. This study highlights the need to include assessment of these issues as part of geriatric health care for women. Tomas L. Griebling, MD, MPH
BENIGN PROSTATIC HYPERPLASIA
157
Suggested Reading Chen B and Yeh J: Alterations in connective tissue metabolism in stress incontinence and prolapse. J Urol 2011; 186: 1768.
Benign Prostatic Hyperplasia Re: Intravesical Prostatic Protrusion Can Be a Predicting Factor for the Treatment Outcome in Patients with Lower Urinary Tract Symptoms Due to Benign Prostatic Obstruction Treated with Tamsulosin A. A. Cumpanas, M. Botoca, R. Minciu and V. Bucuras Department of Urology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania Urology 2013; 81: 859e863.
Abstract available at http://jurology.com/ Editorial Comment: I had the pleasure of meeting Professor Foo in Singapore last year when I was a visiting professor there. As usual, I learned a lot! Most notably, Foo had been extensively evaluating the role of intravesical prostatic protrusion (IPP) as a method to predict the degree of bladder outlet obstruction and the response to surgical therapy. The data are quite compelling. Tan and Foo1 and other investigators have contributed a significant noninvasive proxy for bladder outlet obstruction and a potential predictor of medical and surgical success. Since that time, we have been using IPP as part of every transrectal ultrasound we perform and have found similar results. One can almost predict which patients will have urinary retention and which will have a good surgical outcome. To supplement this concept, the authors of this study use IPP as a predictor of which patients may fail alpha-blocker therapy. They report that response to tamsulosin using predetermined criteria (International Prostate Symptom Score decrease of 35% and 3 points, and peak flow rate increase of 25% and 1.6 ml per second) was significantly less in men with a baseline IPP of less than 10 mm. This finding makes intuitive sense, as men with middle lobe obstruction seem to be a different breed than those with simple bilobar hypertrophy. In general, men with IPP greater than 10 mm tend to have worse symptoms and worse bladder outlet obstruction and are more likely to go into urinary retention but most importantly seem to respond best to surgical intervention. Steven A. Kaplan, MD 1. Tan YH and Foo KT: Intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urinary retention. J Urol 2003; 170: 2339.
Re: Predictors of Successful First-Line Antimuscarinic Monotherapy in Men with Enlarged Prostate and Predominant Storage Symptoms C. H. Liao, Y. C. Kuo and H. C. Kuo Department of Urology, Cardinal Tien Hospital and School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan Urology 2013; 81: 1030e1033.
Abstract available at http://jurology.com/ Editorial Comment: It is somewhat remarkable that a class of medical therapy previously thought to be verboten in men with lower urinary tract symptoms, ie antimuscarinics, is now approved in virtually every urological guideline for benign prostatic hyperplasia. It seems reasonable that men with predominantly storage symptoms, ie frequency, urgency, etc, would benefit from antimuscarinic