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Urology

Volume 8, Supplement 4, 2006

Volume 8, Supplement 4, 2006

Table of Contents

The Evolution of Alpha-Blockers for the Treatment of Benign Prostatic Hyperplasia Advances in Alpha-Blocker Therapy in the Management of Urological Disorders
Alpha-blockers have been evaluated for the treatment of benign prostatic hyperplasia (BPH) for 30 years, from early trials with the nonselective a-inhibitor phenoxybenzamine to short-acting (prazosin) then long-acting (terazosin, doxazosin, tamsulosin, alfuzosin) selective a1-antagonists. All of the a-blockers evaluated have demonstrated comparable effectiveness, and the evolution of a-blocker therapy for BPH has therefore focused primarily on improving convenience and tolerability. Although all of the long-acting a1-blockers are well tolerated, only tamsulosin and alfuzosin SR are administered without the requirement for dose titration. Alfuzosin has the additional advantage over tamsulosin of a lower incidence of ejaculatory dysfunction. Studies of subtype-selective a1-antagonists have not demonstrated superior efficacy or improved tolerability over the existing long-acting a1-blockers. [Rev Urol. 2006;8(suppl 4):S3-S9]
Update on the American Urological Association Guidelines for the Treatment of Benign Prostatic Hyperplasia Advances in Alpha-Blocker Therapy in the Management of Urological Disorders
The updated 2003 American Urological Association (AUA) Guidelines for the treatment of benign prostatic hyperplasia (BPH) are the culmination of an exhaustive effort predicated on scientifically accepted methods of reviewing the medical literature. In this second publication of the guidelines, a multidisciplinary panel reviewed a new meta-analysis of outcome data from the BPH literature from before and after 1994. The major differences between the 2 guidelines are the changes in our understanding of the biology of the prostate and the introduction of new therapies. The vast majority of randomized controlled trials, particularly with respect to minimally invasive therapies and progression of BPH, were performed after the release of the 1994 guidelines. Also, the most recent AUA panel carefully reviewed unpublished data to make the guidelines as timely as possible. Studies that were subsequently published included those on the value of combination medical therapy for BPH. The panel agreed on updated recommendations for the treatment of moderate-to-severe lower urinary tract symptoms associated with BPH, and diagnostic algorithms were revised. The durability and utility of the present guidelines should exceed that of its predecessor. [Rev Urol. 2006;8(suppl 4):S10-S17]
Current Concepts in Ejaculatory Dysfunction Advances in Alpha-Blocker Therapy in the Management of Urological Disorders
Although erectile dysfunction has recently become the most well-known aspect of male sexual dysfunction, the most prevalent male sexual disorders are ejaculatory dysfunctions. Ejaculatory disorders are divided into 4 categories: premature ejaculation (PE), delayed ejaculation, retrograde ejaculation, and anejaculation/anorgasmia. Pharmacologic treatment for certain ejaculatory disorders exists, for example the off-label use of selective serotonin reuptake inhibitors for PE. Unfortunately, the other ejaculatory disorders are less studied and not as well understood. This review revisits the physiology of the normal ejaculatory response, specifically explores the mechanisms of anejaculation, and presents emerging data. The neurophysiology of the ejaculatory reflex is complex, making classification of the role of individual neurotransmitters extremely difficult. However, recent research has elucidated more about the role of serotonin and dopamine at the central level in the physiology of both arousal and orgasm. Other recent studies that look at differing pharmacokinetic profiles and binding affinities of the 1-antagonists serve as an indication of the centrally mediated role of ejaculation and orgasm. As our understanding of the interaction between central and peripheral modulations and regulation of the process of ejaculation increases, the probability of developing centrally acting pharmaceutical agents for the treatment of sexual dysfunction approaches reality. [Rev Urol. 2006;8(suppl 4):S18-S25]
Alpha-Blockers for the Treatment of Prostatitis-Like Syndromes Advances in Alpha-Blocker Therapy in the Management of Urological Disorders
Prostatitis is a common medical diagnosis. The etiology of this symptomatic syndrome can be an acute or chronic bacterial infection, a noninfectious initiator (the most common cause), or iatrogenic heat or radiation; the syndrome may coexist with benign prostatic hyperplasia. Alpha-blockers have a role in the treatment of the prostatitis syndromes. In Category I, acute bacterial prostatitis, a-blockers have been shown to possibly ameliorate obstructive and irritative voiding symptoms. In Category II, chronic bacterial prostatitis, a-blockers seem to reduce the risk of clinical and bacteriological recurrence. In Category III, chronic pelvic pain syndrome, a-blockers improve symptoms and quality of life. Alpha-blockers also seem to ameliorate the symptoms and reduce the risk of acute urinary retention in patients who suffer from either heat- or radiation-induced prostatic inflammation. Alpha-blockers improve lower urinary tract symptoms, including pain, in patients who are diagnosed with both prostatitis and benign prostatic hyperplasia. Evidence has proven there is definitely a role for a-blockers in the management of the prostatitis syndromes. [Rev Urol. 2006;8(suppl 4):S26-S34]
The Use of Alpha-Blockers for the Treatment of Nephrolithiasis Advances in Alpha-Blocker Therapy in the Management of Urological Disorders
Medical expulsion therapy has been shown to be a useful adjunct to observation in the management of ureteral stones. Alpha-1-adrenergic receptor antagonists have been studied in this role. Alpha-1 receptors are located in the human ureter, especially the distal ureter. Alpha-blockers have been demonstrated to increase expulsion rates of distal ureteral stones, decrease time to expulsion, and decrease need for analgesia during stone passage. Alphablockers promote stone passage in patients receiving shock wave lithotripsy, and may be able to relieve ureteral stent–related symptoms. In the appropriate clinical scenario, the use of a-blockers is recommended in the conservative management of distal ureteral stones. [Rev Urol. 2006;8(suppl 4):S35-S42]