Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

PRIORITY PRESS - 66th Annual Meeting of the Canadian Urological Association / First CUA Primary Care Meeting

Montreal, Québec / June 18-21, 2011

Chief Medical Editor: Dr. Léna Coïc, Montreal, Québec

Incontinence Management

Urinary incontinence may result from bladder overactivity and/or dysfunction or weakening of the urinary sphincter or pelvic floor muscles (stress incontinence). Functional incontinence (e.g. secondary to confusion caused by a medication) is also observed fairly frequently in aging individuals. Most cases can be managed in the primary care setting, indicated Dr. Luc Valiquette, Professor of Surgery and Urology, Université de Montréal, Québec. Referral to a urologist may be needed in cases of non-response or complications.

Medications shown to ease stress incontinence include a-adrenergic agents and duloxetine (not indicated in Canada). About 1 in 3 patients can achieve relief with regular Kegel exercises and/or physiotherapy with biofeedback aimed at strengthening pelvic floor muscles. Advanced treatments include injection of collagen or microplastic into the bladder; however, these are expensive and have inconsistent, sometimes temporary effects. Surgical techniques to support the bladder neck have improved, especially for female patients, Dr. Valiquette noted.

Combining education and lifestyle changes with anticholinergic agents is effective in the large majority of patients with overactive bladder, noted Dr. Valiquette. “So especially in older individuals, we encourage both treatments.” In refractory cases, bladder injection of botulinum toxin, neuromodulation or surgery may be considered.

BPH Treatment: When and How

As set out in new evidence-based guidelines, screening for lower urinary tract symptoms, benign prostatic hypertrophy (BPH) and prostate cancer should be mandatory for all men aged =50, remarked Dr. François Bénard, Associate Professor and Director of Urology, Université de Montréal. Prostate-specific antigen (PSA) should be measured in patients who are BPH-symptomatic. When screening for prostate cancer, PSA should also be measured in patients with a life expectancy of at least 10 years.

BPH causes a steady increase in prostate volume over time, which in turn reduces urinary flow and leads to other symptoms. Pharmacologic treatment is generally indicated if the prostate size is at least 30 g and PSA is at least 1.5 ng/mL, noted Dr. Bénard. “The larger the prostate, the greater the PSA; the older the patient, the greater the risk of progression,” he stated. A decision on the need for treatment is also influenced by the impact of symptoms on the patient’s quality of life, assessment of which is aided by the International Prostatic Symptom Score questionnaire.

For patients with relatively small prostates who are not overly troubled by their symptoms, reassurance and lifestyle measures may be sufficient, Dr. Bénard commented. For patients with greater discomfort, a-blockers have a rapid muscle-relaxant effect although they have no effect on prostate volume or PSA. As suggested by the MTOPS study results (N Engl J Med 2003;349:2387-98), treatment with a-blockers “starts to fail” after approximately 3 years, noted Dr. Larry Goldenberg, Professor and Head, Department of Urologic Sciences, University of British Columbia, Vancouver. In the COMBAT study (Eur Urol 2010;57:123-31), conducted in patients with moderate to severe prostate enlargement treated with the a-blocker tamsulosin, the incidence of acute urinary retention was about 5% at 4 years.

In contrast with a-blockers, 5-a reductase inhibitors address both symptoms and the natural history of BPH, reducing prostate volume by approximately 20% to 30% in 1 year and decreasing PSA by 40% to 50% within 6 months. In turn, they reduce the risk of urinary retention and surgery, “which are the true signals of progression,” noted Dr. Goldenberg.

In patients at relatively high risk, combination therapy ensures both rapid symptom relief and reduced BPH progression, Dr. Goldenberg remarked. The COMBAT trial demonstrated that a course of treatment with tamsulosin and dutasteride substantially reduced the incidence of acute urinary retention (Figure 1) and surgery. The PROACT study (Can Urol Assoc J 2008;2:16-21) indicated that after about 6 to 9 months of combination therapy, it may be possible to stop the a-blocker and continue the 5-a reductase inhibitor, if the prostate volume has been reduced, Dr. Bénard remarked.

Figure 1.

Chemoprevention

Despite an overall reduction in risk, debate continues as to whether 5-a reductase inhibition may raise the likelihood of higher-grade prostate cancers. In the PCPT and REDUCE trials (N Engl J Med 2003;349:215-24, 2010;362:1192-202), the medications lowered the risk of prostate cancer (Gleason score =6 only) by 24% to 25% compared with placebo; an increase in higher-grade tumours was observed. Some research suggests the increase was the result of concentrated biopsy sampling in prostates that had reduced in size.

Based on its own analysis of biopsy data from the studies, the FDA in the US has stated that 5-a reductase inhibitors appear to prevent mostly “insignificant” tumours; as a result, it does not support their widespread use for chemoprevention. This position is “countervalent to the predominant feeling in the urology community,” commented Dr. Peter Scardino, Head, Prostate Cancer Program, Memorial Sloan-Kettering Cancer Center, New York.

Erectile Dysfunction: The Heart of the Problem

As the majority of patients with erectile dysfunction (ED) have at least 1 comorbidity affecting the cardiovascular (CV) system, there is now an established link between ED and overall health, noted Dr. Serge Carrier, Associate Professor of Surgery and Urology Program Director, McGill University, Montreal. “We must recognize that ED is truly a marker or predictor of CV disease. ED is only the tip of the iceberg. If there is vascular pathology in the penis, that cannot be the only site in the body affected.”

Damage to the penile endothelium may be caused by risk factors such as diabetes, hypertension, smoking and hyperlipidemia. “This is the common factor. Damage to the endothelium is truly the beginning of CV disease. Why is the penis the first victim? Because the penile arteries are 2 to 3 times smaller than those of the heart,” Dr. Carrier explained. In 1 study, ED preceded overt CV symptoms by about 3 years (Eur Urol 2003;44:360-4). A Canadian study has shown that the greater the severity of ED, the greater the severity of associated CV disease (Arch Intern Med 2006;166:213-9). Longer duration of ED may also be a marker of CV disease severity. “However, even when ED is minor, there is an influence,” Dr. Carrier remarked.

Phosphodiesterase-5 inhibitors are safe and effective for ED management, he continued. An agent for daily administration may be more effective than or preferable to those taken as-needed. Moreover, patients with diabetes, in whom gastric transit and drug absorption take longer than average, may benefit from daily-administration medication. In patients who have BPH, who may be more likely to experience ED, these agents have beneficial effects on urinary symptoms similar to those of a-blockers. A daily-use medication may simplify treatment of both problems, Dr. Carrier suggested.

Summary

Urological issues become increasingly common in the middle-aged to elderly population. Although media reports and advertising or public service announcements about BPH, ED and incontinence and their therapies have also become commonplace, patients with urinary complaints may still be embarrassed and reluctant to report them. These problems may also be dismissed by patients as inconveniences of aging. In fact, they can have long-term implications for health and quality of life. Primary care practitioners are encouraged to screen or question patients at risk to ensure pathology is detected, risk factors are addressed and appropriate care is offered.