Optimize medication for LUTS, PH docs urged

MANILA, Philippines - A great thing happened in the medical community recently. Thousands of Filipino doctors got to listen to leading American urologist and expert in the treatment of LUTS (Lower Urinary Tract Symptoms) Dr. Steven Kaplan as he talked in a conference called “The Great Pro Gathering.”

Dr. Kaplan is a Diplomate of the American Board of Urology and a Fellow of the American College of Surgeons. The conference was organized by Biomedis, Inc., a division of leading pharmaceutical and healthcare company United Laboratories (Unilab), and held at 1 Esplanade in Pasay City.

Two significant things happened at this event: one was that the conference was streamed live to four provinces in the country — Pampanga, Iloilo, Bacolod and Davao — benefitting hundreds of Filipino doctors outside the actual physical venue and, more importantly LUTS was put in the spotlight and in the awareness not just of medical practitioners but also the common people.

The conference was successful in its aim at leading to a better understanding of this diseases and its treatment.  For instance, people who experience difficulty urinating easily conclude that they have a Urinary Tract Infection (UTI) or a blockage caused by gallbladder stones.  But urologists warn of another set of urinary tract disorders that exhibit the same types of symptoms – LUTS or Lower Urinary Tract Symptoms.

LUTS is a set of storage, voiding and other similar symptoms affecting the urinary tract in 40 percent of older men.  It is usually characterized by incontinence (inability to hold/control urination), extreme pain during urination and similar other symptoms.

The most common cause of LUTS is Benign Prostatic Hyperplasia (BPH), a condition characterized by the enlargement of the size of the prostate. BPH is a non-cancerous enlargement of the prostate gland among males.  Various theories have been proposed for this occurrence namely: hormonal changes (testosterone), late activation of growth factors, delayed apoptosis and blood vessel injury.  But they remain just theories. 

What is certain is that the prostate glands of the great majority of men begin to enlarge at age 40.  And as they advance in years, a significant number of these men will develop LUTS such as hesitancy (a delay in the initiation of urination), weak flow of urine, a sensation of inadequate emptying of the bladder (feeling of residual urine after voiding), urgency, frequency and nocturia (frequency at night).

LUTS secondary to BPH, though not life-threatening, certainly affects the quality of life of the aging male as he copes with these bothersome symptoms.  LUTS prevents these men from engaging in their regular activities because of the fear of being caught in embarrassing and compromising situations.  LUTS limits their mobility and may even result in frustrations and withdrawal.

Dr. Kaplan, whom the Weill Cornell Medical College website, calls “a recognized authority on the study of benign diseases of the prostate and female urology,” is a member of more than 30 professional organizations and holds several leadership positions at both The New York Presbyterian Hospital and the American Urologic Association and is a member of the World Health Organization Committee on treating BPH.

He emphasized in his talk in the Philippines the need to optimize medication for BPH since he thinks there isn’t a one-fits-all treatment to the disease.

“It’s cheaper in the long run to do the right thing from the beginning. Yes, it may be cheaper to have a single mode of treatment in the short-term scale but then if it fails, then you will have to start all over again. In the end, it is best to do the right thing from the very beginning,” he said.

Two types of medications are commonly used in the treatment of BPH - 5a-reductase inhibitors (5ARI) and alpha blockers. Among the 5ARI’s, Finasteride and Dutasteride are the most popular, while Tamsulosin is the most common among alpha blockers.  5ARI inhibits the growth of the prostate while alpha blockers relaxes the muscles and muscle fibres in the prostate (in the case of BPH) to make it easier to urinate. 

There are three common treatment methods for BPH: single medication of either Finasteride or Dutasteride or a combination of either of the two with an alpha blocker.

Dr. Kaplan believes that while combination therapy is efficacious, it must be considered only in advanced cases of BPH especially since it brings also a combination of side effects such as sexual and other adverse drug effects.

Although he believes that Finasteride and Dutasteride are both efficacious in decreasing prostate size in BPH, Dr. Kaplan warned that based on research data, Dutasteride causes sexual side effects. Dr. Kaplan also mentioned in his talk that there were cardiac failure incidents in a study using Dutasteride although no causal relationship was established. There were no increased cardiac events for Finasteride in clinical trials using the drug.

 â€œConsidering the sexual side effects of Dutasteride plus the fact that Finasteride is just as effective, I think I will have to opt for Finasteride first before Dutasteride,” said Dr. Kaplan. “If I am going to have to resort to a combination medication, I would have to do a combination of Finasteride and an alpha blocker, given the side-effects of Dutasteride and more stable studies on Finasteride,” he added.

Although BPH in itself is not found to lead to cancer, it greatly affects the lifestyle of patients, many of whom suffer from almost unbearable symptoms including difficulty in urinating, extreme pain in the lower urinary tract area and incontinence.

 â€œThere’s no evidence that having BPH in itself increases the risk [of developing cancer].  Obviously, both of them go up with the increase in age but does not converge with the other,” clarified Dr. Kaplan.

 â€œIt’s more of a problem about the quality of life.  For some people getting up at night [because of urinating problems] affects their quality of life.  People who sleep less have a higher rate of depression and a higher rate of mortality.  The condition is benign; it’s not life threatening but it is lifestyle threatening and for a lot of people, it’s a problem,” he explained.