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.