The management of lower urinary tract symptoms in menBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3861 (Published 24 June 2014) Cite this as: BMJ 2014;348:g3861
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We read the article by Hollingsworth JM et alwith great interest. This informative paper comprehensively reviewed the published literature about benign prostatic hyperplasia (BPH), including prevalence, diagnosis, treatment and recommendations form the major clinical guidelines. As urologists, we are most interested in the optimal treatment for BPH patients.
To date pharmacological therapy has become the mainstay of treatment for BPH. More than ten classes of medicines, including terazosin, doxazosin, tamsulosin, alfuzosin, silodosin, finasteride, dutasteride, tadalafil and various phytotherapies, are now available for prescription. On one hand, these medicines provide multiple treatment options for BPH. This could be particularly import for patients who are not sensitive to certain BPH medicines, or those with certain comorbidities such as erectile dysfunction. On the other hand, the variety of BPH medicines also results in considerable difficulties for clinicians to prescribe the best agent because currently the comparative effects of different BPH agents is still not fully investigated. According to evidence based medicine, medical decisions should be made based on evidence, clinical expertise, and the needs and wishes of patients. In our clinical practice in the West China Hospital, one of the largest hospitals in China, some α-blockers like doxazosin are our common prescribed drugs. This is because these drugs are relatively cheap, and seem to be more effective, or at least equally effective as other medicines by our past experience. Our experience is partly supported by some published trials [3-7] although a systematic evaluation of the comparative efficacy and safety of various BPH medicines is still lacking.
In Hollingsworth JM et al’s review, comparisons between some medicines, such as 5α-reductase inhibitors vs. terazosin, were reported. However, comparisons among many other agents were not fully discussed. We noticed that this review was carried out based on a systematic search of electronic databases. A summary of the latest evidence regarding the comparative effects of various BPH medicines would be very useful for clinicians. If possible, a secondary quantitative synthesis of trial data using pairwise meta-analysis or mixed-treatment comparison would provide clinicians with even stronger evidence. We believe most urologists would be applauded for that.
Competing interests: No competing interests
1. Rees J, Bultitude M, Challacombe B. The management of lower urinary tract symptoms in men. BMJ 2014;348:g3861.
2. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.
3. Chung MS, Lee SH, Lee DH, Chung BH. Comparative Rapid Onset of Efficacy between Doxazosin Gastrointestinal Therapeutic System and Tamsulosin in Patients with Lower Urinary Tract Symptoms from Benign Prostatic Hyperplasia: A Multicentre, Prospective, Randomised Study. Int J Clin Pract 2012;65:1193-9.
4. Zhang K, Yu W, Jin J, et al. Effect of Doxazosin Gastrointestinal Therapeutic System 4 mg vs Tamsulosin 0.2 mg on Nocturia in Chinese Men With Lower Urinary Tract Symptoms: A Prospective, Multicenter, Randomized, Open, Parallel Study. Urology 2011;78:636-40.
5. Pompeo AC, Rosenblatt C, Bertero E, et al. A randomised, double-blind study comparing the efficacy and tolerability of controlled-release doxazosin and tamsulosin in the treatment of benign prostatic hyperplasia in Brazil. Int J Clin Pract 2006;60:1172-7.
6. Kirby RS, Quinn S, Mallen S, Jensen D. Doxazosin controlled release vs tamsulosin in the management of benign prostatic hyperplasia: an efficacy analysis. Int J Clin Pract 2004;58:6-10.
7. Tsujii T. Comparison of prazosin, terazosin and tamsulosin in the treatment of symptomatic benign prostatic hyperplasia: A short-term open, randomized multicenter study. International Journal of Urology 2000;7:199-205.
Competing interests: No competing interests
Included in the causes of nocturia in men in this article is sleep disturbance. The most common causes of sleep disturbance in this group are pain and obstructive sleep apnoea (OSA). Nocturia is one of the commonest complaints in our OSA patients1. Many have already been investigated in urology clinics and are on ineffective medical treatments. Nocturia is also often blamed for the excessive daytime sleepiness resulting from OSA. The nocturia almost always resolves once the OSA is treated.
Any investigation of nocturia should include questions about snoring and witnessed apnoeas. It would be even better to use a questionnaire like the STOP BANG series of 8 questions2. The Epworth Sleepiness Scale should not be used. Those patients scoring highly should be investigated for OSA.
The British Lung Foundation have recently run a campaign to increase awareness of OSA as it is generally believed that we have only found 20% of the patients suffering with OSA. Understanding the link between nocturia (and also nocturnal gastro-oesophageal reflux) should result in more of these patients being identified and progressing down the correct diagnostic pathway.
David Dawson consultant anaesthetist,
lead clinician for sleep medicine,
Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6RJ email@example.com
(1) Tandeter H, Gendler S, Dreiher J, Tarasiuk A. Nocturic episodes in patients with benign prostatic enlargement may suggest the presence of obstructive sleep apnea. J Am Board Fam Med 2011; 24(2):146-151.
(2) Cowan DC, Allardice G, Macfarlane D, Ramsay D, Ambler H, Banham S et al. Predicting sleep disordered breathing in outpatients with suspected OSA. BMJ Open 2014; 4(4):e004519.
Competing interests: Medical Adviser to Philips Respironics