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Overactive bladder in the male patient: Bladder, outlet, or both?

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Abstract

Generations of urologists have presumed that the cause of lower urinary tract symptoms (LUTS) in men is infravesical (prostatic) obstruction. When symptoms such as urinary urgency and frequency can’t easily be explained directly by obstruction, secondary effects of obstruction on the bladder are identified as causative factors. Although to some extent this explanation may still be accurate, emerging concepts in the pathophysiology of LUTS in men may be at odds with these traditional explanations. The idea that primary bladder pathology may explain the symptom complex in at least one subset of men with LUTS has both experimental and clinical support. This review discusses the physiologic and clinical observations used to explain the mechanisms underlying LUTS. Specifically, this review focuses on two data sets: one supporting infravesical obstruction as the causative factor for LUTS, and another positing that a primary bladder abnormality is responsible.

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References and Recommended Reading

  1. Madersbacher S, Hidinger G, Temml C, Schmidbauer CP: Prevalence of lower urinary tract symptoms in Austria as assessed by an open survey of 2,096 men. Eur Urol 1998, 24:136–141.

    Article  Google Scholar 

  2. Yalla SV, Sullivan MP, Lecamwasam HS, et al.: Correlation of American Urological Association symptom index with obstructive and nonobstructive prostatism. J Urol 1995, 153:674–680.

    Article  PubMed  CAS  Google Scholar 

  3. Blaivas JG: Pathophysiology and differential diagnosis of benign prostatic hypertrophy. Urology 1988, 32(Suppl 6):5–11.

    PubMed  CAS  Google Scholar 

  4. Milsom I, Abrams P, Cardozo L, et al.: How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int 2001, 87:760–766. This article reports on a population-based survey of men and women older than 40 years of age, aimed at assessing the prevalence of symptoms associated with OAB. Of over 16,000 people interviewed, 16.6% were found to have symptoms of OAB with only minor differences noted between men and women. Advancing age was associated with an increased likelihood of symptoms. Among patients younger than 75 years of age, 40% had never spoken with a physician about their symptoms.

    Article  PubMed  CAS  Google Scholar 

  5. Andersen JT, Nordling J, Walter S: Prostatism I: the correlation between symptoms, cystometric, and urodynamic findings. Scand J Urol Nephrol 1979, 13:229–236.

    Article  PubMed  CAS  Google Scholar 

  6. Andersen JT, Jacobsen O, Worm-Petersen J, et al.: Bladder function in healthy elderly males. Scand J Urol Nephrol 1978, 12:123–127.

    PubMed  CAS  Google Scholar 

  7. Christensen MM, Bruskewitz RC: Clinical manifestations of benign prostatic hyperplasia and indications for therapeutic intervention. Urol Clin North Am 1990, 17:509–516.

    PubMed  CAS  Google Scholar 

  8. Finkbeiner A, Lapides J: Effect of distension on blood flow in dog’s urinary bladder. Invest Urol 1974, 12:210–212.

    Article  PubMed  CAS  Google Scholar 

  9. Lin ATL, Chen MT, Yang CH: Blood flow of the urinary bladder effects of outlet obstruction and correlation with energetic metabolism. J Urol 1993, 149:285–292.

    Google Scholar 

  10. Lemack GE, Burckard F, Zimmern PE, et al.: Physiologic sequelae of partial infravesical obstruction in the mouse: role of inducible nitric oxide synthase. J Urol 1999, 161:1015–1022.

    Article  PubMed  CAS  Google Scholar 

  11. Uvelius B, Arner A: Changed metabolism of detrusor muscle cells from obstructed rat urinary bladder. Scand J Urol Nephrol 1997, 184(Suppl):59–65.

    CAS  Google Scholar 

  12. Wang P, Zweier JL: Measurement of nitric oxide and peroxynitrite generation in the postischemic heart. J Biol Chem 1996, 271:29223–29230.

    Article  PubMed  CAS  Google Scholar 

  13. Elbadawi A, Yalla SV, Resnick NM: Structural basis of geriatric voiding dysfunction. IV. Bladder outlet obstruction. J Urol 1993, 150:1681–1695.

    PubMed  CAS  Google Scholar 

  14. Speakman MJ, Brading AF, Gilpin CJ, et al.: Bladder outflow obstruction: a cause of denervation supersensitivity. J Urol 1987, 138:1461–1466.

    PubMed  CAS  Google Scholar 

  15. Seki N, Karim OM, Mostwin JL: The effect of experimental urethral obstruction and its reversal on changes in passive electrical properties of detrusor muscle. J Urol 1992, 148:1957–1961.

    PubMed  CAS  Google Scholar 

  16. Levin RM, Yu H-J, Kim K-B: Effects of outlet obstruction on glucose metabolism of the rabbit urinary bladder. Scand J Urol Nephrol 1997, 184 (Suppl):43–50.

    CAS  Google Scholar 

  17. Cher ML, Abernathy BB, McConnell JD: Smooth muscle myosin heavy-chain isoform expression in bladder-outlet obstruction. World J Urol 1996, 14:295–300.

    Article  PubMed  CAS  Google Scholar 

  18. Gosling JA, Gilpin SA, Dixon JS: Decrease in the autonomic innervation of human detrusor muscle in outflow obstruction. J Urol 1986, 136:501–504.

    PubMed  CAS  Google Scholar 

  19. Dupont MC, Persson K, Spitskergent D, et al.: The neuronal response to bladder outlet obstruction, a role for NGF. Adv Exp Med Biol 1995, 385:41–54.

    PubMed  CAS  Google Scholar 

  20. Abrams P, Farrar DJ, Turner-Warwick RT: The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients. J Urol 1979, 121:640–642.

    PubMed  CAS  Google Scholar 

  21. Hyman MJ, Groutz A, Blaivas JG: Detrusor instability in men: correlation of lower urinary tract symptoms with urodynamic findings. J Urol 2001, 166:550–552.

    Article  PubMed  CAS  Google Scholar 

  22. Knutson T, Edlund C, Fall M, Dahlstrand C: BPH with coexisting overactive bladder dysfunction: an everyday urological dilemma. Neurourol Urodyn 2001, 20:237–247. One hundred sixty-two men with LUTS were evaluated urodynamically, of whom 55% had BPO alone and 45% had coexisting BOO and DO. Men with DO were more likely to be older, have BOO, and had higher prostate-specific antigen levels. Symptom scores, Qmax, flow rate, and residual volume did not differ between the groups.

    Article  PubMed  CAS  Google Scholar 

  23. Eckhardt M, van Venrooij G, Boon T: Interactions between prostate volume, filling cystometric estimated parameters, and data from pressure-flow studies in 565 men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Neurourol Urodyn 2001, 20:579–590. Five hundred sixty-five men with LUTS were assessed with UDS, of whom 53% were confirmed to have obstruction and 46% had DO. Increasing grades of obstruction were associated with increasing likelihood of DO. Patients with DO were older than those without, although age was not correlated with BOO in this study.

    Article  PubMed  CAS  Google Scholar 

  24. Dorflinger T, Frimodt-Moller P, Bruskewitz R: The significance of uninhibited detrusor contractions in prostatism. J Urol 1985, 133:819–821.

    PubMed  CAS  Google Scholar 

  25. Cucchi A: Different voiding dynamics in stable and unstable bladders with and without outlet obstruction. Neurourol Urodyn 1998, 17:473–481.

    Article  PubMed  CAS  Google Scholar 

  26. Abrams P, Farrar D, Turner-Warwick R: The results of symptomatic and urodynamic analysis of 152 patients. J Urol 1979, 121:640–642.

    PubMed  CAS  Google Scholar 

  27. Chai T, Gemalmaz H, Anderson K, et al.: Persistently increased voiding frequency despite relief of bladder outlet obstruction. J Urol 1999, 161:1689–1693.

    Article  PubMed  CAS  Google Scholar 

  28. Gormley E, Griffiths D, McCracken P, et al.: Effect of transurethral resection of the prostate on detrusor instability and urge incontinence in elderly males. Neurourol Urodyn 1993, 12:445–453.

    Article  PubMed  CAS  Google Scholar 

  29. Thomas A, Abrams P: Lower urinary tract symptoms, benign prostatic obstruction, and the overactive bladder. BJU Int 2000, 85(Suppl 3): 57–71. This study presents the results of a long-term urodynamic follow-up of men with LUTS who were either followed with observation or treated with TURP. DO was noted in the majority of men after longterm follow-up (more than 13 years), even after TURP. Men with detrusor underactivity also developed DO in nearly 40% of cases.

    PubMed  Google Scholar 

  30. Sirls L, Ganabathi K, Zimmern P, et al.: Transurethral incision of the prostate: an objective and subjective evaluation of long-term efficacy. J Urol 1993, 150:1615–1621.

    PubMed  CAS  Google Scholar 

  31. Chalfin S, Bradley W: The etiology of detrusor hyperreflexia in patients with infravesical obstruction. J Urol 1982, 127:938–942.

    PubMed  CAS  Google Scholar 

  32. Sugiyama T, Park Y, Hanai T, et al.: Why is transurethral microwave thermotherapy (TUMT) positively effective? Int Urol Nephrol 1998, 30:293–300.

    Article  PubMed  CAS  Google Scholar 

  33. De Nunzio C, Laurenti C, Minardi V, et al.: Evolution of detrusor hyperactivity after watchful waiting, medical therapy and surgery in patients with obstructive BPH: a long term follow-up [abstract]. J Urol 2002, 167:986.

    Google Scholar 

  34. Knutson T, Schafer W, Fall M, et al.: Can urodynamic assessment of outflow obstruction predict outcome from watchful waiting? Scand J Urol Nephrol 2001, 35:463–469.

    Article  PubMed  CAS  Google Scholar 

  35. Kageyama S, Watanabe T, Kurita Y, et al.: Can persisting detrusor hyperreflexia be predicted after transurethral prostatectomy for benign prostatic hypertrophy? Neurourol Urodyn 2000, 19:223–240.

    Article  Google Scholar 

  36. Lepor H, Williford WO, Barry MJ, et al.: The impact of medical therapy on bother due to symptoms, quality of life and global outcome, and factors predicting response. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. J Urol 1998, 160:1358–1367.

    Article  PubMed  CAS  Google Scholar 

  37. Gerber G, Kim J, Contreras B, et al.: An observational urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin. Urology 1996, 47:840–844.

    Article  PubMed  CAS  Google Scholar 

  38. Gleason D, Bottaccini M: Effect of terazosin on urine storage and voiding in the aging male with prostatism. Neurourol Urodyn 1994, 13:1–12.

    Article  PubMed  CAS  Google Scholar 

  39. Chapple C, Carter P, Christmas T, et al.: A three month doubleblind study of doxazosin as treatment for benign prostatic bladder outlet obstruction. Br J Urol 1994, 74:50–56.

    PubMed  CAS  Google Scholar 

  40. Kirby R, Coppinger S, Corcoran M, et al.: Prazosin in the treatment of prostatic obstruction. A placebo-controlled study. Br J Urol 1987, 60:136–142.

    Article  PubMed  CAS  Google Scholar 

  41. Serels S, Stein M: Prospective study comparing hyoscyamine, doxazosin, and combination therapy for the treatment of urgency and frequency in women. Neurourol Urodyn 1998, 17:31–36.

    Article  PubMed  CAS  Google Scholar 

  42. Schwinn D: The role of _1-adrenergic receptor subtypes in lower urinary tract symptoms. BJU Int 2001, 88(Suppl 2):27–34. Outstanding review of the pharmacology of α-receptors, and their role in lower urinary tract function and pathology from a leader in the field.

    Article  PubMed  CAS  Google Scholar 

  43. Blue D, Zinner N, Grino P, et al.: R0700004, a selective _1a-adrenoreceptor antagonist, does not improve lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2002, 167:1044a.

    Google Scholar 

  44. Chapple C: Pharmacotherapy for benign prostatic hyperplasia: the potential for _1-adrenoreceptor subtype-specific blockade. Br J Urol 1998, 81(Suppl 1):34–47.

    PubMed  CAS  Google Scholar 

  45. Hiebel J, Ruffolo R Jr: Recent advances in the identification of _1- and _2-adrenoceptor subtypes: therapeutic implications. Exp Opin Invest Drugs 1997, 6:367–387.

    Article  Google Scholar 

  46. Saito M, Longhurst P, Tammela T, et al.: Effects of partial outlet obstruction of the rat urinary bladder on micturition characteristics, DNA synthesis and the contractile response to field stimulation and pharmacological agents. J Urol 1993, 150:1045–1051.

    PubMed  CAS  Google Scholar 

  47. Perlberg S, Caine M: Adrenergic response of bladder muscle in prostatic obstruction. Its relation to detrusor instability. Invest Urol 1982, 20:524–527.

    CAS  Google Scholar 

  48. Smith D, Chapple C: In vitro response of human bladder smooth muscle in unstable obstructed male bladders: a study of pathophysiological causes. Neurourol Urodyn 1994, 13:414–415.

    Google Scholar 

  49. Hampel C, Dolber P, Savic S, et al.: Changes in _1-adrenoceptor (AR) subtype gene expression during bladder outlet obstruction of rats. J Urol 2000, 163:228.

    Google Scholar 

  50. Ishizuka O, Pandita R, Mattiasson A, et al.: Stimulation of bladder activity by bolume, L-dopa, and capsaicin in normal conscious rats-effects of spinal _1-adrenoceptor blockade. Naunyn Schmiedebergs Arch Pharmacol 1997, 355:787–793.

    Article  PubMed  CAS  Google Scholar 

  51. Andersson K-E: _1-adrenoceptors and bladder function. Eur Urol 1999, 36(Suppl 1):96–102.

    Article  PubMed  CAS  Google Scholar 

  52. Price D: Potential mechanisms of action of superselective _1-adrenoceptor antagonists. Eur Urol 2001, 40(Suppl 4):5–11.

    Article  PubMed  CAS  Google Scholar 

  53. Abrams P, Kaplan S, Millard R: Tolterodine treatment is safe in men with bladder outlet obstruction (BOO) and symptomatic detrusor overactivity (DO) [abstract]. Neurourol Urodyn 2001, 20:547–548.

    Google Scholar 

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Abdel-Aziz, K.F., Lemack, G.E. Overactive bladder in the male patient: Bladder, outlet, or both?. Curr Urol Rep 3, 445–451 (2002). https://doi.org/10.1007/s11934-002-0095-3

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