Sequential administration enhances the effect of apomorphine SL in men with erectile dysfunction.

The response to Uprima (apomorphine sublingual, (apo SL)) has been well documented in conventional clinical trials. Apo SL produces a predictable, consistent and durable response across a wide variety of patients. The positive reinforcement of a successful outcome should further support clinical benefit. Apo SL with its rapid onset affords a greater opportunity for spontaneity, which can be an important factor in influencing patient choice. It is recognised that patient counselling and the setting of realistic expectations are vital to a successful outcome. The impact of persisting with sequential treatment on outcome has been calculated from the clinical data. While apo SL is effective de novo in 50% of single doses, additional benefit is observed with repeat dosing. Full benefit may not be achieved until four or more treatments have been taken in an optimal setting. The data also confirm that 3 mg has superior activity. Patients should therefore be encouraged to try a minimum of 4 doses at 3 mg.

Combination of symptom score, flow rate and prostate volume for predicting bladder outflow obstruction in men with lower urinary tract symptoms.

PURPOSE: The severity of lower urinary tract symptoms associated with benign prostatic enlargement correlates poorly with bladder outlet obstruction. Since urodynamic studies are presumed to be relatively complex, invasive and not cost-effective, they are not routinely performed by physicians treating men with lower urinary tract symptoms. As a result, a large number of patients are treated for bladder outlet obstruction when in fact obstruction may not be present. Since other noninvasive methods have not been effective for predicting bladder outlet obstruction, we investigated whether a combination of prostate volume, uroflowmetry and the American Urological Association (AUA) symptom index would be reliable for predicting this condition. MATERIALS AND METHODS: We prospectively evaluated 204 men with a mean age plus or minus standard deviation of 66.7 +/- 7.5 years who presented with lower urinary tract symptoms. Each patient completed an AUA symptom index questionnaire and underwent uroflowmetry, post-void residual urine volume measurement, pressure flow study and transrectal ultrasound of the prostate to estimate prostatic volume. We constructed receiver operating characteristics curves using various threshold values for maximum urine flow and prostate volume. Threshold values for maximum urine flow and prostate volume were used alone and combined with the AUA symptom index for predicting bladder outlet obstruction. We selected a cutoff value for maximum urine flow of 10 or less ml. per second and prostate volume of 40 gm. or greater, and used these values with an AUA symptom index of greater than 20 to predict bladder outlet obstruction in the group overall. RESULTS: Differences in the mean symptom index score in men with and without bladder outlet obstruction were not statistically significant. There was no obstruction in 19%, 28.9% and 35% of those with severe, moderate and mild symptoms, respectively. The selected cutoff values of maximum urine flow, prostate volume and symptom score combined correctly predicted obstruction in all 39 patients. Therefore, our combination of cutoff values proved to be highly accurate for predicting bladder outlet obstruction. Sensitivity, specificity, and positive and negative predictive values were 26%, 100%, 100% and 32%, respectively. CONCLUSIONS: Our study showed that combining the AUA symptom index, maximum urine flow and prostate volume reliably predicted bladder outlet obstruction in a small subset of patients only. Although bladder outlet obstruction was correctly predicted by our threshold values of AUA symptom index, maximum urine flow and prostate volume in only 39 men (26%) with obstruction, these patients represent a substantial group in any large urological practice treating male lower urinary tract symptoms.

Transurethral needle ablation of the prostate: a urodynamic based study with 2-year followup.

PURPOSE: We evaluated the efficacy of transurethral needle ablation of the prostate for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (BPH). This study was urodynamic based with 2-year followup to determine whether transurethral needle ablation of the prostate could reduce bladder outlet obstruction and, if so, whether the effect was durable. MATERIALS AND METHODS: A total of 47 patients with symptomatic BPH underwent transurethral needle ablation of the prostate under local anesthesia and intravenous sedation. All patients were evaluated subjectively using the American Urological Association symptom index and the quality of life score. Patients were evaluated objectively with uroflowmetry, post-void residual volume and pressure-flow studies. All patients underwent subjective and objective evaluation before treatment. Followup was conducted at 1, 3, 6, 12 and 24 months after treatment. Short and long-term complications were assessed. RESULTS: At 6-month followup there was 71% improvement in mean cases (22.4 to 6.6, 42 patients symptom index, p < 0.05), and 66% improvement in mean quality of life score (4.6 to 1.56, 42 patients, p < 0.05). Maximum flow rate, post-void residual volume and detrusor pressure at maximum flow rate also showed statistically significant improvements throughout the study. At 12-month followup there was a 55% increase in maximum flow rate (6.6 to 10.23 ml. per second, 29 patients, p < 0.05). A 37% reduction in mean detrusor pressure at maximum flow rate (92.4 cm. to 58 cm. water, 31 patients, p < 0.05) was recorded at 24-month followup, thus indicating that transurethral needle ablation of the prostate can lower bladder pressure-significantly. Post-void residual volume decreased from a pretreatment mean of 76.1 ml. to a mean of 36.9 ml. (31 patients, p < 0.05) at 24 months. Short-term complications (3 months) included transient posttreatment urinary retention in 8 patients (17%), duration 1 to 9 days, mild to moderate transient frequency dysuria all patients which resolved in more than 90% by 5 weeks and epididymitis in 1. A patient questionnaire was used to evaluate changes in sexual function and there were no reports of disturbances in erectile function or retrograde ejaculation. There were no long-term complications. However, 6 patients (12.7%) had persistent bothersome symptoms during the followup period and underwent transurethral prostate resection. Further analysis of this subset of patients with respect to pretreatment evaluation and transurethral needle ablation procedure did not reveal significant differences between them and patients with successful outcomes. CONCLUSIONS: Transurethral prostate resection is a safe and effective technique for treating lower urinary tract symptoms related to benign prostatic hyperplasia. The technique can be performed in the office as an outpatient, or as a same day surgical procedure, using topical anesthesia with intravenous sedation, if necessary. In the majority of patients subjective and objective improvements were sustained for the duration of this study, which included 2-year followup with pressure-flow studies.