Introduction
Extension of the lifetime in developed countries results in the increase in the prevalence of benign prostatic hyperplasia (BPH) and related, so called non-neurogenic lower urinary tract symptoms (LUTS) [1]. Progressive prostate enlarging impairs the outflow of urine from the bladder, known as bladder outlet obstruction (BOO), followed by hypertrophy and overactivity of the detrusor muscle [2]. BOO impairs both emptying and storage of urine in the bladder, that are manifested by weakness of the urine stream, incomplete emptying, frequent urination, urgency, and nocturia, in the absence of urinary tract infection and other urethro-vesical dysfunctions. The occurrence of symptoms deteriorate, to a various extend, the quality of life including sleep disorders, anxiety, embarrassment associated with the disease, reduced mobility, as well as impairment of sexual activity and satisfaction with sexual relations [3, 4, 5, 6].
The majority of men with non-neurogenic LUTS can be treated conservatively. The European Association of Urology (EAU) in 2000 developed guidelines (and updated them in 2019) on the management of non-neurogenic male LUTS including publications from 2017 [7]. According to these guidelines, pharmacotherapy in BPH should not be offered to men with mild/moderate LUTS, minimally bothered by their symptoms (watchful waiting). While the therapy (monotherapy) with selective α1-alpha- antagonists (ARAs) should be initiated in those with moderate-to-severe symptoms. ARAs are effective in reducing LUTS and increasing the peak urinary flow rate, but neither reduce prostate volume, nor prevent acute urinary retention (AUR). 5-α reductase inhibitors (5αRIs) should be offered in monotherapy or in combination with ARAs, to men with moderate-to-severe symptoms and an increased risk of disease progression (prostate volume > 40 mL). These drugs have delayed onset of action and may reduce libido, deteriorate potency and cause ejaculation disorders, but increase the peak urinary flow rate, decrease prostate volume and the risk of AUR as well as the need for surgery. In addition, in men with bladder storage symptoms, but without increased void residual volume (> 150 mL), the guidelines recommend the use of muscarinic receptor antagonists (MRAs). These drugs can significantly improve urgency, urinary incontinence, and increased daytime frequency. Finally, the guidelines recommend the use of tadalafil as the only phosphodiesterase 5 (PDE5) inhibitor with some potency to improve LUTS and urinary flow rate, and β3-adrenoceptors agonist (mirabegron) in men with moderate-to-severe LUTS who have mainly bladder storage symptoms, as an alternative of MRAs due to better patients adherence.
Pharmacotherapy for non-neurogenic LUTS, should be individualized taking into account not only the severity and structure but also dominance of certain symptoms, as well as prostate volume, co-morbidities and patient expectations and preferences. In patients with mostly storage LUTS, the first-line treatment should be lifestyle advice and behavioural modifications (restriction of caffeine, alcohol and fluid intake at the evening, weight reduction in overweight and obese, training of bladder control strategies) [8]. If not effective, MRAs and β3-adrenoceptors agonists, alone or in combination with ARAs [9, 10, 11] are more effective than other pharmacological strategies. While in men with concomitant voiding LUTS in course of BPO, ARAs and 5αRIs allow the improvement in the storage symptoms [12].
A survey performed among Polish urologists, shortly after the publication of the 2013 edition of EAU guidelines, showed that 10% urologists start pharmacotherapy in patients with minimal-to-moderate LUTS. ARAs were the first line treatment option both for patients with (48.8% urologists) and without (84.8% urologists) benign prostate enlargement (BPE) while only 17.1% urologists were choosing 5αRIs in monotherapy, and 29.6% prescribed them with ARAs as the primary treatment. MRAs were an acceptable treatment option for storage LUTS in the opinion of 83.7% of urologists [13]. This survey assessed the urologists declarations concerning therapy, but did not verify their daily prescribing practice.
The aim of this study was to to analyze pharmacotherapy of storage symptoms in men with BPE, and their compliance with guidelines.