Reply by the author

REFERENCE 1. Brubaker L: Urgency: the cornerstone symptom of overactive bladder. Urology 64(suppl 6A): 12–16, 2004.

Jane M. Meijlink, B.A. Hons., MITI, MCIJ International Interstitial Cystitis Patient Network Foundation Rotterdam, The Netherlands doi:10.1016/j.urology.2005.01.064

REPLY BY THE AUTHOR: These insightful comments have captured the difficulty with the definition of urgency. I agree that an improved definition of urgency will follow more discussion bolstered by scientific study. We must keep in mind that this is a symptom, and the definition of urgency must be applicable in whatever clinical situation the symptom is present, including such entities as urinary tract infection. When we are able to refine this definition, we can advance our knowledge of bladder sensation in health and disease.

Linda Brubaker, M.D. Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Loyola University Medical Center Maywood, Illinois Note: L. Brubaker is a paid consultant to Pfizer, and is a member of the medical advisory board for Pfizer. doi:10.1016/j.urology.2005.02.008

Initial, Long-Term, and Durable Responses to Terazosin, Placebo, or Other Therapies for Chronic Prostatitis/Chronic Pelvic Pain Syndrome TO THE EDITOR:

We read with interest the long-term results of a wellconducted, double-blind, placebo-controlled study plus open-label phase to evaluate the initial and durable response rate to terazosin and placebo in 79 patients with chronic prostatitis/chronic pelvic pain syndrome (CP/ CPPS) (National Institutes of Health category III prostatitis).1 They presented again the initial response rate in the 43 patients who were randomized and completed 14 weeks of terazosin therapy,2 but then analyzed the durable response rate at the 38-week visit in the 23 initial terazosin responders. Nonresponders and responders to terazosin with subsequent relapse were then treated with terazosin or other medications (open label), and the long-term response was evaluated at a median of 38 weeks (range 34 to 42), regardless of any additional treatment. It is difficult to draw significant conclusions from the open-label phase of the study, because, as the authors admitted, it was underpowUROLOGY 66 (1), 2005

ered to detect differences in this group of retreated patients and was confounded by other drug treatments. We agree with the authors that the 14-week initial treatment with terazosin might have been too short. Indeed, in the study by Mehik et al.,3 alfuzosin treatment gave the greatest response rate at the end of the 6 months, confirming that the length of the treatment correlates with its efficacy and showing that the plateau, in terms of efficacy, can be reached only with longer treatment. These results show that alpha-blockers can benefit some patients with CP/ CPPS, but additional studies are needed to determine the subset of patients most likely to respond, the optimal drug/ dose to use, and the optimal treatment duration. Alpha-blockers have been proposed for the treatment of CP/CPPS since a voiding dysfunctional explanation for this syndrome was hypothesized in the early 1980s.4,5 This theory was recently confirmed by others.6 Moreover, CP/CPPS was recently associated with anatomic alterations such as bladder neck hypertrophy.7 On the basis of these hypotheses, we would expect a temporary effect limited to the duration of the therapy or perhaps slightly longer, but not a durable effect sustained over time. Cheah et al.1 stated that their findings suggest the benefit of terazosin treatment is sustained over time. A durable response occurred in 18 (78%) of 23 initial responders to terazosin but also in one half of the 12 initial responders to placebo, and this difference was not statistically significant.1 In contrast, we agree with the results reported by Mehik et al.3 In their study, after the treatment was stopped, a significant deterioration in symptoms occurred in the alfuzosin-treated patients.3 Interestingly, at the end of the 12-month study, the control/standard group had better symptom reduction than the alfuzosin group.3 From this study, we would conclude that the efficacy of alpha-blockers is limited to the active phase of administration and then the symptoms return gradually and probably would have reached baseline 8 to 10 months after the therapy was stopped. On the basis of their experience in the field, we would be grateful if Cheah et al.1 could draw a scientifically sound explanation for their conclusions on the durable effect of terazosin treatment. REFERENCES 1. Cheah PY, Liong ML, Yuen KH, et al: Initial, long-term, and durable responses to terazosin, placebo, or other therapies for chronic prostatitis/chronic pelvic pain syndrome. Urology 64: 881– 886, 2004. 2. Cheah PY, Liong ML, Yuen KH, et al: Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized, placebo controlled trial. J Urol 169: 592–596, 2003. 3. Mehik A, Alas P, Nickel JC, et al: Alfuzosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, double-blind, placebo-controlled, pilot study. Urology 62: 425– 429, 2003. 4. Barbalias GA, Meares EM Jr, and Sant GA: Prostatodynia: clinical and urodynamic characteristics. J Urol 130: 514 –517, 1883. 5. Kirby LS, Lowe D, Bultitude MI, et al: Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis. BJU Int 54: 729 –731, 1982. 6. Mehik A, Hellström P, Nickel JC, et al: The chronic prostatitis-chronic pelvic pain syndrome can be characterized by prostatic tissue pressure measurements. J Urol 167: 137–140, 2002. 231