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BACKGROUND & OBJECTIVE: Urinary system stone disease is a common entity. Small renal stones are preferably treated using Extracarporeal Shock Wave Lithotripsy (ESWL) technique. Passage of stone fragments result in pain, hematuria and urinary tract obstruction. This can be avoided by the use selective α-1 receptor antagonists like Tamsulosin. However, their efficacy remains a matter of debate. In this study the role of selective α-1 blocker was evaluated in facilitating spontaneous expulsion of renal stone fragments after ESWL. The objective of our study was to find out the Efficacy of Tamsulosin (Selective α-1 blocker) in facilitating the transit of stone fragments (4-7mm) after ESWL. Follow up X-ray KUB was used to confirm the stone clearance. Efficacy was measured in terms of stone expulsion rate. METHODOLOGY: It was randomized controlled trial including 150 patients coming to outpatient department of Urology Lahore General Hospital, Lahore from January 25, 2010­ to July 25, 2010. Total 150 patients with renal stones broken down into fragments (4-7mm) after ESWL were enrolled using non-probability purposive sampling technique. Patients were categorized into group A and B. Patients of group A received cap. Tamsulosin 0.4mg along with Tab. Diclofenac sodium 50mg. Whereas, patients belonging to group B received only diclofenac sodium 50 mg twice daily. Patients underwent ESWL every three weeks, in case of non-fragmentation, to the maximum of 4 sessions. All the patients were followed with X Ray KUB for stone clearance. The data of all patients was incorporated into pre designed Performa. Statistical evaluation of clinical variables done in terms of efficacy i.e. stone clearance. RESULTS: Stone clearance rate of patients in group A was 86.6% as compared to only 76% in group B. Usage of selective α-1 blockers in group A enhanced the stone clearance rate as compared to group B. However this difference was statistically insignificant (p-value-0.094). CONCLUSION: There was increased stone clearance in alpha one blocker group but not statistically significant. Further studies with larger sample size are required to evaluate the role of Selective α-1 blockers (Tamsulosin) after ESWL.

Introduction: The immediate postoperative hemodynamic alterations occurring after carotid endarterectomy (CEA) is called postendarterectomy hypertension (PEH). PEH results in prolonged hospital admission, increased peri-operative morbidity, and mortality. The exact causes of the PEH whether it is due to carotid sinus denervation or due to the increased norepinephrine production in cerebral and peripheral circulation remain unclear. Materials and Methods: A prospective analysis of 62 patients who underwent CEA from 2018 to 2019 were carried out by dividing into two groups based on the technique of surgery (conventional CEA [c-CEA], n = 31; eversion CEA [e-CEA], n = 31), and the effect of four class of drugs mainly beta blockers (βBs), calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), and alpha blockers (αBs) were studied for the prevention of PEH. Results: 72.6% of patients developed PEH irrespective of the technique of surgery (e-CEA n = 25 c-CEA n = 20; P = 0.15). The mean postoperative dose of antihypertensive drugs (Mpostoperative) were found significantly increased compared to mean preoperative dose (Mpreoperative) in all PEH patients among βB? group (Mpreoperative 18.95 mg vs. Mpostoperative 45.76 mg; P = 0.00); CCB group (preoperative Mpreoperative 6.21 mg vs. Mpostoperative 9.79 mg; P = 0.01); ARB group (Mpreoperative 14.03 mg vs. Mpostoperative 38.23 mg; P = 0.01); but those patients with preoperative αBs have well controlled BP in the postoperative period without significant change in mean dosage; αB (Mpreoperative 0.16 mg vs. Mpostoperative 3.74 mg: P = 0.27). Conclusions: This study indirectly showed that fluctuations of sympathetic system are happening in both e- and c-CEA irrespective of the technique of surgery. These fluctuations were better controlled in patients who had adequate sympathetic blockade preoperatively. In other words, αB can be considered a drug of choice for PEH.

Purpose: The aim of this meta-analysis was to evaluate the efficacy and safety of imidafenacin for overactive bladder (OAB) induced by benign prostatic hyperplasia (BPH) in men receiving alpha-blocker monotherapy.Methods: We performed a systematic research of the PubMed, Embase, and Cochrane Library databases, and searched for studies about alpha-blocker with or without imidafenacin treatment for OAB in patients with BPH. We also investigated the original references of the included texts.Results: Four randomized controlled trials including 779 participants with BPH (389 in the alpha-blocker+imidafenacin group and 390 in the alpha-blocker only group) were studied. The main efficacy endpoint was the Overactive Bladder Symptom Score, which showed a mean difference of -1.88 (95% confidence interval, -2.32 to -1.44; P

Alpha blockers are characterize as one of the most therapies that used for treatment of several condition such as Raynaud's disease, hypertension, scleroderma , and one of the most treatments for treated continuing pelvic pain syndrome- continuing prostatitis and also be used to treat anxiety and panic disorder such as generalized anxiety, posttraumatic stress disorder (Raskind, et al.,2003) . This study was conducted at the laboratory of department of biology, faculty of science/university of Kufa , 40 male rats that was used. The present study was conducted to investigate the effect of Prazosin hydrochloride on some organs in male rats (Rattus norvegicus), after administration of prazosin hydrochloride at three doses (25,50,75) mg/kg b.wt. for eight-weeks, prazosin revealed significant decreased at (p ˂0.05) the hemoglobin concentration, red blood cell account, packed cell volume , and erythropoietin hormone but a significant increased at (P˂0.05) in the levels of erythrocyte sedimentation rate of the blood, when compred with control group,the levels of HDL showed significant increment at (P˂0.05) in group that gives low dose (50 and 75)mg/kg b.wt. when compared with control, but significant decline at (P˂0.05) in the levels of very low density lipoprotein in group that gives low dose of prazosin (25)mg/kg b.wt. when equaled with control group, the levels of LDL and VLDL revealed significant decreased at (P˂0.05) in groups that gives moderate and high doses.

BACKGROUND The selective alpha-blockers are widely used in the clinical treatment for ureteral stones as MET (Medical Expulsive Therapy). American Urological Association and European Association of Urology, strongly recommend that patients with ureteral stones be alpha-blockers to promote stone passage. Due to the physiological effect of alpha-blockers on the ureter, researchers hypothesized that the use of alphablockers before ureteroscopy may help during the Ureteroscopic procedures, making it easier and safer. One critical step in doing ureteroscopy is directing scope into vesicoureteral junction as most of the time its non-dilated and this is place injury and later stricture chances are high which lead to failure of treatment.3 But in literature, there is a discrepancy with this hypothesis as some studies have failed to demonstrate the benefits of technical ease and lower complication rate with alpha-blocker being used in the preoperative period. METHODS We conducted a cross sectional study in the department of urology from January 2019 to January 2020. 30 patients of ureteric calculus on alpha-blocker therapy and 30 patients of BPH on alpha-blocker ± 5 alpha reductase therapy were included for study. During URSL (Ureteroscopic Lithotripsy) we used 6 / 7.5 fr URS (Ureterorenoscope), ease of admitting URS in vesicoureteral junction noted. The need for ureteral dilator for admitting URS, presence of mucosal injury, and bleeding or false passage noted as difficulty in instrumentation. And documentation of finding done in excel. RESULTS Out of 60 patients, 24 (40 %) patients didn’t need dilatation of ureteric orifice and Ureteroscopy was done easily among which 8 (33.33 %) were BPH patient and 16 (66.66 %) were ureteric calculus patient this difference is statistically significant with p-value 0.010. 36 (60 %) patients needed dilatation of ureteric orifice to facilitate URS of which 22 (61.11 %) patients were from the BPH group and 14 (38.88 %) are ureteric calculus group. The study shows a statistically significant difference with p-value 0.029. CONCLUSIONS Our study demonstrates that alpha-blockers failed to show a statistically significant difference in relaxation of the ureteric orifice in non-ureteric calculus patients. Further large group, multi-centric studies are required to find a definitive role for alpha blockers prior to URS. KEYWORDS BPH, Silodosin, Ureteroscopy, Ureteric Orifice, Alpha Blocker, Alpha 1a, Medical Expulsion Therapy

Introduction Combination therapy with an alpha blocker (AB) plus an antimuscarinic (AM) is recommended for men with moderate‐to‐severe mixed lower urinary tract symptoms (LUTS) when monotherapy is not effective in relieving storage symptoms. This study compared treatment persistence and adherence with an AB plus AM fixed‐dose combination (FDC) vs an AB plus AM free‐dose combination in men with LUTS in Spain. Methods Retrospective study using the Spanish IQVIA Cegedim Electronic Medical Records database. Men prescribed AB plus AM combination therapy were included in an FDC or free‐dose combination cohort based on their index treatment. Treatment persistence was the time from index date to first discontinuation of ≥1 of the two index drugs over 12 months. Adherence was measured using the fixed medication possession ratio (MPR). Results Of 3114 patients identified, 999 were included (FDC, n = 790; free‐dose combination, n = 209). Median (95% CI) persistence was longer in the FDC (125 [109‐151] days) than in the free‐dose combination (31 [31‐36] days) cohort (hazard ratio [HR], 2.9; 95% CI, 2.4‐3.4; P 80 vs

Objective: The purpose of this study is to know the differences in effectiveness between SAB administration with combination 5-ARI administration assessed by IPSS evaluation in BPH LUTS patients. Material & Methods: This observational analytic with a cross-sectional design study had been done to 50 BPH LUTS patients that obtained at Paru Jember, Bina Sehat Jember, and Bhayangkara Bondowoso Hospital. These samples had got by simple random sampling method and include in inclusion with exclusion criteria freely. Results: This comparison study between the type of medical therapy administration and total IPSS decrease, IPSS-voiding decrease, IPSS-storage decrease, IPSS-QoL, and prostate volume give significancies as follows: p=0.002; p

Background: Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting middle-aged men. This condition can be symptomatic or asymptomatic. Up to 15-25% of men aged 50-65 years have lower urinary tract symptoms (LUTS). Aim of the Work: To compare between the effect of alpha blocker (Tamsulosin 0.4 mg once at night) and a combination of alpha blockers (Tamsulosin 0.4 mg once at morning) and PDE5 inhibitors (Sildenafil 25 mg at night) in treatment of benign prostatic hyperplasia patients through evaluation of IPSS and post-voiding residual urine and uroflometry before and after treatment. Patients and Methods: This was a prospective study done on 30 patients fulfilling inclusion criteria at Eldemerdash hospital between 1-9-2017 till 1-9-2018 and this study has two phases: Phase (1): included 30 patients complaining of LUTS 2ry to BPH assessed by uroflowmetry and IPSS and post voiding residual urine.Before taking any drugs and after treatment by alpha blocker (tamsulosin 0.4mg capsule once daily at night) for 3 months. Phase (2): included the same 30 patients after treatment by phase (2) of alpha blocker (Tamsulosin 0.4 capsule once daily in the morning) and PDEI (sildenafil 25mg once daily in the night) for 3 months. These patient also assessed by IPSS, uroflowmetry and PVR urine. Results: The results of this study showed that there was a significant improvement after phase 1 treatment in IPSS, also there was a significant improvement after phase 2 more than phase 1. The PVRU and Q max was significantly improve after phase 1 but the change after phase 2 was insignificant. Conclusion: Sildenafil citrate in combination with tamsulosin improved LUTS more than tamsulosin monotherapy with the merit of a comparable safety profile in patients with LUTS/BPH.

Introduction Erectile dysfunction (ED) is a prevalent medical condition that affects millions of men globally. A number of pharmacological and complementary options are used in the management of ED, including Coenzyme Q10 (CoQ10). Oxidative stress has been linked to the progression of ED, and Co Q10 protects against oxidative damages and improves erectile function as well as the activity of antioxidant enzymes. This study aimed to determine the efficacy of CoQ10 in the treatment of erectile dysfunction in hypertensive males. Method An open-labeled parallel arm interventional study was conducted in the cardiology unit of Hayatabad Medical Complex Hospital, Peshawar, Pakistan, from March 2020 to March 2021. Hypertensive male patients (n = 230) were randomly allocated to either receiving 200-gram CoQ10 daily along with their current antihypertensive therapy (n=104) or anti-hypertensive treatment only (n=105). The patient's erectile function was assessed at baseline and three months using the International Index of Erectile Function Test (IIEF-5) during the study period. Result Of the total 230, 209 (90.87%) patients were included in the final analysis. There were no significant differences in demographics, history of illness, co-morbid conditions, and current medication of both groups. After three months, 21 (20.1%) participants scored more than 17 in the IIEF-5 and no longer had ED. Overall, no significant difference was found in the mean IIEF-5 score between the study group and control group (14.41 ± 4.49 Vs. 15.61 ± 4.82; p=0.06). However, in subgroup analysis, significant improvement in the study group was seen in participants with mild ED (p=0.03). Conclusion With the demonstration of its efficacy in hypertensive patients with mild ED, co-enzyme Q10 supplementation can be proposed as a potential candidate in patients with long-term hypertension and can play a role in erectile dysfunction.

INTRODUCTION AND OBJECTIVE:Prostatic urethral lift (PUL) is a widely utilized minimally invasive treatment for benign prostatic hypertrophy (BPH) indicated in men with prostates less than 80 grams ...

Benign prostatic hyperplasia (BPH) is a histologic diagnosis describing proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The prevalence and severity of lower urinary tract symptoms (LUTS) in aging men are progressive and impact the health and welfare of society. This revised Guideline provides a useful reference on effective evidence-based management of male LUTS/BPH. See the accompanying algorithm for a summary of the procedures detailed in the Guideline (figures 1 and 2[Figure: see text][Figure: see text]).The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible English language studies published between January 2008 and April 2019, then updated through December 2020. Search terms included Medical Subject Headings (MeSH) and keywords for pharmacological therapies, drug classes, and terms related to LUTS or BPH. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]).Nineteen guideline statements pertinent to evaluation, work-up, and medical management were developed. Appropriate levels of evidence and supporting text were created to direct both primary care and urologic providers towards streamlined and suitable practices.The work up and medical management of BPH requires attention to individual patient characteristics, while also respecting common principles. Clinicians should adhere to recommendations and familiarize themselves with standards of BPH management.

Olulade Ayodele,1 Howard J Cabral,2,3 David McManus,4 Susan Jick1,5 1Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA; 2Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; 3Biostatistics and Research Design Program, Boston University Clinical and Translational Science Institute, Boston, MA, USA; 4Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; 5Boston Collaborative Drug Surveillance Program, Lexington, MA, USACorrespondence: Susan JickBoston Collaborative Drug Surveillance Program, Lexington, MA, USATel +1 781 862-6660Email sjick@bu.eduBackground: Many men receive 5-alpha reductase inhibitors (5ARIs) for ongoing treatment of benign prostatic hyperplasia (BPH). The increased risk of cardiovascular complications with 5ARIs has been documented in BPH studies and the occurrence of cerebral venous thrombosis, presumably due to increased estrogen level following 5ARI use, was described in multiple case reports. The objective of this study was to determine if 5ARIs with or without alpha blockers (AB) were associated with an increased risk of venous thromboembolism (VTE) in males with BPH.Methods: We conducted a nested case–control study among a population of men ages 40– 79 who received at least one 5ARI or AB prescription for treatment of BPH between 1995 and 2015 in the UK-based Clinical Practice Research Datalink GOLD. Cases of incident VTE (pulmonary embolism [PE] or deep venous thrombosis [DVT]) and matched controls were identified from this population. We used descriptive analyses and conditional logistic regression to evaluate the risk of VTE in users of 5ARIs compared to users of ABs.Results: For 5ARI only users, the adjusted odds ratios (aORs), (95% CI) for VTE were 1.51 (0.98– 2.32) in current 5ARI users and 1.23 (0.70– 2.17) in recent/distant past, compared to AB only users. However, the aOR (95% CI) in men who had 50 or more current 5ARI prescriptions compared to users of ABs only was higher: 2.29 (1.14– 4.63). For 5ARI with AB use, the aORs, (95% CI) for VTE were 1.16 (0.64– 2.10) in current 5ARI+AB users and 1.93 (0.71– 5.25) in recent/distant past, compared to AB only users. The aOR (95% CI) in men who had 50 or more current 5ARI+AB prescriptions compared to users of ABs only was 1.65 (0.64– 4.26).Conclusion: Current use of 5ARI, particularly long-term use, is associated with an increased risk of incident idiopathic VTE compared to patients treated with AB use only.Keywords: 5ARI, BPH, VTE, alpha blocker

Background: Extracorporeal Shock Wave Lithotripsy (ESWL) is a noninvasive technique for the treatment of kidney stones. Most ESWL is carried out when the stone is present in the renal pelvis.Aim of Study: To evaluate the efficacy of alpha blocker (tamsulosin) to enhance stone fragments clearance from urinary tract after ESWL on renal pelvic stones.Methods: This is prospective randomized study which was carried out at Urology Department Ain Shams University Hospital during the period from August 2017 till July 2018. After hospital ethical committee approval, a total of 56 patients fulfilling inclusion criteria with symptomatic single renal pelvic radiopaque stone £1cm were included in this study. All patients underwent ESWL therapy for their stone. Patients were randomized into two groups; group A (received tamsu-losin 0.4mg) and group B (received placebo).Results: After two weeks of follow up PUT was done and revealed post ESWL SFR (stone free rate) on placebo group was 86.9% and SFR on tamsulosin group was 92.5% (p-value=0.2) (no statistically significant difference) on the other hand post ESWL pain was significantly more among group B (placebo group) of 73.9% compared to group A (tamsulosin group) of 3.7% (p-value=0.0023), and Dizziness in tamsulosin group was 18.5% of the group patients experienced it while none of the placebo group complained of that, (p-value= 0.003).Conclusion: When the stones were (£10mm, no improve-ment was seen in the success rates by adding Medical Expulsive Therapy (MET) in the form of alpha blocker than placebo, as has been reported in other studies, but post ESWL pain is less with adding tamsulosin.

Objective: To evaluate real-world persistence and adherence in patients with benign prostate hyperplasia (BPH) receiving a fixed-dose combination of dutasteride plus tamsulosin (DUT-TAM FDC) versus α-blocker plus 5-α reductase inhibitor (AB/5ARI) free-combination therapy. Materials and methods: This retrospective, observational cohort study utilized the German IMS LRx (IQVIA) database. Patients ≥ 45 years old with BPH receiving DUT-TAM FDC or AB/5ARI free-combination therapy from July 1, 2011 to November 30, 2017 were included. Data were analyzed for 48 months from index date (date of first prescription). Persistence, measured as time to discontinuation (defined as a 90-day gap in therapy), was evaluated using Kaplan-Meier curves (log-rank tests). Adherence, measured as medication possession ratio (MPR), was based on a comparison of mean prescribing duration and expected treatment duration. Results: A total of 141,667 patients were included (DUT-TAM FDC, n = 86,057; free AB/5ARI: n = 55,610). Small differences in persistence were observed between treatment arms. At month 12, 41.8% of DUT-TAM FDC-treated and 41.0% of AB/5ARI free-combination therapy-treated patients were persistent; at month 24, 28.2% and 27.1% were persistent, respectively. A higher proportion of DUT-TAM FDC-treated patients had MPR ≥ 0.80, ≥ 0.75 and ≥ 0.70 compared with AB/5ARI free-combination therapy (p < 0.0001). Conclusion: Small differences observed in persistence between treatment arms may not translate to meaningful clinical relevance. Adherence was significantly better in the FDC arm, which may be clinically relevant as improved adherence is associated with better outcomes. Persistence and adherence to BPH therapy in Germany is low; further studies exploring the reasons behind this are required.

Alpha-blockers (ABs) are commonly prescribed as part of a multidrug regimen in the management of hypertension. We set out to assess the risk of hypotension and related adverse events with AB use compared with other blood pressure (BP) lowering drugs using a population-based, retrospective cohort study of women (≥66 years) between 1995 and 2015 in Ontario, Canada. Cox proportional hazards examined the association of AB use and hypotension and related events (syncope, fall, and fracture) compared with other BP lowering drugs matched via a high dimensional propensity score. The primary outcome was a composite of hospitalizations for hypotension and related events (syncope, fractures, and falls) within 1 year. From 734 907 eligible women, 14 106 were dispensed an AB (mean age, 75.7; standard deviation 6.9 years, median follow-up 1 year) and matched to 14 106 dispensed other BP lowering agents. The crude incidence rate of hypotension and related events was 95.7 (95% CI [confidence interval], 90.4–101.1, events 1214 [8.6%]) with AB and 79.8 (95% CI, 74.9–84.7 per 1000 person-years, events 1025 [7.3%]) with other BP lowering medications (incident rate ratio, 1.20; 95% CI, 1.10–1.30). The risk was higher for hypotension (hazard ratio, 1.71; 95% CI, 1.33–2.20) and syncope (hazard ratio, 1.44; 95% CI, 1.18–1.75) with no difference in falls, fractures, adverse cardiac events, or all-cause mortality. Treatment of hypertension in women with ABs is associated with a higher risk of hypotension and hypotension-related events compared with other BP lowering agents. Our findings suggest that ABs should be used with caution, even as add on therapy for hypertension.

Objective To investigate the effects of alpha blocker treatment on the placement of ureteral access sheaths (UAS) during retrograde intrarenal surgery (RIRS). Material and methods This study was a retrospective analysis of prospectively collected data. Patients who underwent RIRS due to renal stones between November 2015 and December 2017 were seperated into two groups. Age, gender, body mass index (BMI), stone size, laterality, hydronephrosis degree, and renal stone density were recorded. Tamsulosin (0.4 mg/day) was prescribed to the study group (n=25) 2 weeks before the operation. The control group (n=25) underwent the operation without any additional treatment. All the operations were performed using a 7.5 Fr flexible ureteroscope and 9.5/11.5 Fr (Cook, Blooming, USA) UAS. Results Two patients in the study group were excluded from the study as they suffered from dizziness and retrograde ejaculation. No statistically significant difference was found between the patients in the study group (n=23) and control group (n=25) in terms of age, gender, BMI, stone size, laterality, hydronephrosis, and renal stone density (p=0.470, p=0.536, p=0.456, p=0.102, p=0.555, p=0.732, and p=0.317, respectively). The UAS could be successfully placed on the first attempt in 15 (65.2%) patients in the study group and 11 (44%) patients in the control group during the first attempt itself. Even though the successful UAS placement rate was higher in the study group, no statistically significant values were observed (p=0.141). Conclusion The data obtained from the present study showed that the use of alpha blockers prior to RIRS did not improve the UAS placement rates. It is considered that studies conducted on more patients might be able to achieve significant values.

Patient: Male, 65-year-old Final Diagnosis: Xanthogranulomatous prostatitis Symptoms: Constipation • pelvic pain • tenesmuss • urinary retention Medication: — Clinical Procedure: Biopsy Specialty: General and Internal Medicine • Psychiatry • Urology Objective: Unusual clinical course Background: Xanthogranulomatous prostatitis is rare, with no more than 10 to 15 cases reported to date. The presentation typically includes lower urinary tract or lower urinary tract infection symptoms. The present case report describes a 65-year-old man diagnosed with xanthogranulomatous prostatitis after a prolonged course of atypical symptoms. Symptom remission was achieved with low-dose Cymbalta and 6 weeks of ciprofloxacin. Case Report: A 65-year-old man had a 1-year history of pelvic floor disorder, including treatment-resistant tenesmus and rectal and perineal pain. The patient eventually developed a reduced urinary steam with urinary retention. On digital rectal examination, his prostate was non-tender and had significant firmness on the left side. Magnetic resonance imaging of the prostate with and without contrast showed a Prostate Imaging-Reporting and Data Stem 5 lesion involving the left peripheral zone of the prostate with diffuse enhancement and low signal throughout the gland. Suspicious adjacent lymphadenopathy also was present. The patient’s prostate-specific antigen level was within the normal range at 2.4 ng/mL. All 13 left prostatic biopsy specimens showed acute and chronic inflammatory changes with prominent xanthogranulomatous features and without evidence of necrosis. All of the patient’s symptoms, including pain, resolved after he started taking Cymbalta and completed a 6-week course of ciprofloxacin. Conclusions: The present case report describes an atypical presentation of xanthogranulomatous prostatitis, which started with symptoms of pelvic floor disorder that preceded urinary symptoms by at least 1 year. The patient’s symptoms improved after he started taking Cymbalta and completed a 6-week course of ciprofloxacin, 500 mg twice daily, and without concurrent treatment with an alpha blocker, corticosteroids, or pelvic floor therapy.

Ejaculatory dysfunction is not only psychologically distressing but can become a significant obstacle for men who wish to conceive. Dysfunction comes in the form of anejaculation, reduced ejaculation, retrograde ejaculation, painful ejaculation, or premature ejaculation. Most treatments for lower urinary tract symptoms related to benign prostatic hyperplasia, which commonly occurs in aging men, carry significant risks of absent, reduced, or retrograde ejaculation. This review focuses on such risks that accompany both the medical and surgical management of lower urinary tract symptoms/benign prostatic hyperplasia and how these risks impact male fertility.

Background and purpose Some groups of cardiovascular drugs (beta-blocking drugs, Ca antagonists, antiarrhythmics) are listed as potentially worsening myasthenia. An empirical basis for alternative recommendations for antihypertensive and antiarrhythmic therapy in myasthenia patients has not yet been provided. Methods From the World Health Organization pharmacovigilance database, we retrieved total and myasthenia-related counts of adverse drug reactions for various groups of drugs used in cardiovascular disease and drugs with related mechanism of action used in other indications. We calculated the reporting odds ratio as a measure of a disproportional fraction of myasthenia-related events among all events. A 95% confidence interval of reporting odds ratio (ROR) >1 was taken as an indication for a higher risk. Because our approach involves a considerable number of tests, this situation is referred to as a signal that requires additional confirmation. Results A signal for an increased risk was noted for tizanidine, for alpha-blocking drugs, for beta-blocking drugs, and for Ca antagonists. ROR indicated a lower-than-average risk for salbutamol, angiotensin receptor antagonists, oral anticoagulants, thrombocytic function inhibitors, and heparins. Conclusions Angiotensin receptor antagonists, angiotensin-converting enzyme inhibitors, and diuretics seem to be safe in antihypertensive therapy. Surprisingly, and yet requiring confirmation by case reports, alpha receptor-blocking drugs seem to carry a risk of myasthenia worsening. Amiodarone seems to be a safe alternative in antiarrhythmic therapy in patients with myasthenia.

PURPOSE/OBJECTIVE(S) Little is known about optimal dose constraints when high dose rate (HDR) brachytherapy is used as monotherapy for prostate cancer. Most dose constraints for HDR monotherapy were extrapolated from predictors of toxicity when HDR brachytherapy was combined with external beam radiotherapy as a boost. We sought to determine clinical and dosimetric predictors of toxicity and health related quality of life (HRQOL) in men treated with HDR brachytherapy as monotherapy. MATERIALS/METHODS Eligible patients were treated with single fraction HDR brachytherapy as monotherapy on two prospective clinical trials at a single institution. Patients in the first trial (HDR-mono) received a single fraction of 19 Gy without a dominant intraprostatic lesion (DIL) boost, and patients from the second trial (MARS) received 19 Gy in a single fraction with an MRI-guided DIL boost to ≥ 23 Gy. ADT was not used. Univariable and multivariable logistic regression was used to evaluate clinical (age, IPSS score, prostate volume, alpha blocker use at baseline, and receipt of a DIL boost) and dosimetric (prostate V100, V150, V200, D90, Urethral Dmax and D10, and Rectal Dmax and V80) predictors of CTCAE v4 acute/late toxicity and HRQOL changes measured with expanded prostate index composite (EPIC). Three classifications of late minimally clinically important changes (MCICs) were evaluated: small (> 0.5 standard deviation [SD]), moderate (> 1.0 SD) and severe (> 2.0 SD) declines compared to baseline. RESULTS 147 patients were included (87 from HDR-mono, 60 from MARS). Median follow-up was 62.8 months. Only increasing prostate size predicted acute GU toxicity ≥ grade 2 (OR 1.05, 95% CI 1.01-1.09, P = 0.021). On multivariable regression, predictors of late GU toxicity ≥ grade 2 were not receiving a DIL boost (OR 3.78, 95% CI 1.88-7.83, P < 0.001) and higher baseline IPSS score (OR 1.89, 95% CI 1.89-3.18, P = 0.015). Rectal and urethral dose constraints were not associated with late GU/GI toxicity ≥ grade 2. Contrary to our hypothesis, small (OR 0.91, 95% CI 0.81-0.98, P = 0.032) and moderate (OR 0.91, 95% CI 0.80-0.98, P = 0.037) urinary MCICs were less frequent in those with higher urethral Dmax. No impact of urethra D10 on urinary MCICs was seen. Rectal Dmax and V80 did not predict bowel MCIC changes at any threshold. CONCLUSION We were unable to identify dose constraints that were predictive of late toxicity or relevant HRQOL changes in single fraction HDR brachytherapy. This suggests dose parameters used in these trials were safe, and that minor variability in plan dosimetry likely has little clinical significance. While increasing urethral Dmax paradoxically predicted for less frequent urinary MCICs, we do not believe this finding is clinically relevant. Further research exploring optimal dose constraints to be used in HDR brachytherapy as monotherapy for prostate cancer is warranted.

Delayed double-J ureteric stent (DJ) removal may cause severe morbidity. We aimed to identify high-risk patients for forgotten DJs to prevent iatrogenic injury and improve safety. Data of patients with DJs placed after ureterorenoscopic lithotripsy (URSL) between 2000 and 2013 from the National Health Insurance Database in Taiwan were included. Forgotten DJs were defined as indwelling DJs for > 6 months after URSL, which is approximately two times longer than the expiratory duration. Age at stenting, sex, socioeconomic status, specialty of stenting physician, comorbidities, postoperative emergency room visiting and abdominal plain x-ray filming frequencies, and alpha blocker use for > 7 days after stenting were analysed. Of 13,058 patients, 12,969 (99.31%) had timely removed DJs while 89 (0.68%) had forgotten DJs. Per a univariate analysis, patients with forgotten DJs were older, female, and of low socioeconomic status, and the use of more than one DJ for one URSL, placement by non-urologists, and less frequent postoperative abdominal plain x-ray filming and postoperative alpha blocker use were risk factors. Per a multivariate analysis, elderly patients (Odds ratio [OR] = 3.37, 95% confidence interval (CI) 1.36–8.32, p = 0.0085), DJ placement by non-urologists (OR = 9.63, 95% CI 6.09–15.24, p

Objective To evaluate the efficacy and safety of adjunctive alpha-blocker therapy before ureteroscopy in the management of ureteral stones. Methods The databases MEDLINE®, EMBASE and The Cochrane Controlled Trail Register of Controlled Trials were searched between January 1980 and June 2019 to identify randomized controlled trials (RCTs) that referred to the use of alpha-blockers as adjunctive therapy before ureteroscopy for the treatment of ureteral stones. Odds ratios (ORs) with 95% confidence intervals (CIs) were used for dichotomous outcomes; and mean difference (MD) with 95% CIs were used to report continuous outcomes. Results The analysis included five RCTs with a total of 557 patients. Compared with placebo, patients that received adjunctive alpha-blockers had significantly higher successful access to the stone (OR 5.44; 95% CI 2.99, 9.88), a significantly higher stone-free rate at the end of week 4 (OR 3.75; 95% CI 2.20, 6.39), significantly less requirement for balloon dilatation (OR 0.26; 95% CI 0.15, 0.44) and a significantly lower risk of complications (OR 0.25; 95% CI 0.15, 0.42). There was no significant difference in the operation time between the two groups (MD –3.33; 95% CI –7.03, 0.37). Conclusions Adjunctive alpha-blocker therapy administered before ureteroscopy was effective in the management of ureteral stones with a lower risk of complications than placebo treatment.

Chronic anogenital pruritus can significantly impair affected patients’ quality of life by disrupting their sleep, mood, sexual function, and personal relationships. Although a significant portion of these patients can be managed with hygiene measures, topical therapy, oral anti-pruritics, and allergen avoidance after patch testing, guidelines to treat patients who do not respond to standard therapy have yet to be established. We describe the therapeutic response of a case of anogenital pruritus recalcitrant to multiple topical and systemic therapies. Treatment of this patient with dupilumab, an interleukin-4 receptor alpha blocker, resulted in clinical remission at 1 year from the initiation of the therapy, without significant adverse effects. Keywords: Atopic dermatitis, allergic contact dermatitis, dupilumab, pruritus ani, itch, genital pruritus

Background: Benign Prostatic Hyperplasia (BPH) is a condition intimately related to ageing. Although it is not life threatening, its clinical manifestation as Lower Urinary Tract Symptoms (LUTS) reduces the patient's quality of life.Aim of the Study: To determine prostate and bladder sonographic parameters that can predict the outcome of patients with LUTS/BPH treated by alpha 1a adrenoreceptor blocker monotherapy.Patients and Methods: Fifty patients complaining of LUTS/BPH were prospectively enrolled. Transrectal Ultra-sonography (TRUS) was done to all patients. Tamsulosin 0.4mg oral tablet was given to all patients once daily for 3 months then the response to treatment on the basis of Inter-national Prostatic Symptom Score (IPSS), Quality of Life (QoL) score and maximum urine flow rate (Qmax) was eval-uated. The impacts of baseline parameters on treatment out-come were statistically analyzed.Results: 45 patients completed the study. From them 15 patients (33.3%) had ineffective treatment. Pre treatment IPSS storage subscore, Qmax and TRUS measured parameters [Bladder Wall Thickness (BWT), Intravesical Prostatic Pro-trusion (IPP) and ultrasound estimated bladder weight (UEBW)] were the independent predictors of treatment failure. Receiver Operator characteristic (ROC) curves for parameters (BWT, UEBW and IPP) showed that Areas Under Curve (AUC) were (0.870, 0.908 and 0.836 respectively) at cut-off values of 9mm, 36g and 8.2mm. Using these cut-off values, the Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 75.0% and 97.6%; 72.4% and 96.0%; 67.5% and 95.0% for BWT, UEBW and IPP, respectively. Combination of these sono-morphologic parameters increased their positive predictive value to 76.39%.Conclusion: Combined use of sonographic parameters BWT, UEBW and IPP can predict alpha blocker monotherapy failure in BPH patients which aid in determining therapeutic plan and the need for further medical therapy or surgical intervention.

Background: Tamsulosin is an a-1A-specific blocker which induces selective relaxation of ureteral smooth muscle with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen and facilitates stone expulsion.Aim of the Study: In this prospective randomized study we aimed to assess the efficacy of use of alpha blocker (tamsulosin Hcl 0.4mg) on the outecome of ureteroscopic lithotripsy for distal ureteric stone.Patients and Methods: In a prospective study by a rand-omized controlled clinical trial, which was performed from September 2016 to March 2017, about 50 patients underwent ureteroscopic lithotripsy with the pneumatic wolf lithotripsy. The patients were randomly divided into 2 groups: The study group including 25 patients, received tamsulosin with our traditional treatment (hydration and analgesic when required), and the control group with 25 patients who received placebo with traditional treatment. Patients prospectively will be evaluated for stone clearing rate by imaging at morning of URSL and at the end of 2nd week including: (KUB and pelvi abdominal ultrasound)and they will be evaluated for number of colic episodes, analgesic consumption and post-operative complications (haematuria and UTI).Results: The results showed that tamsulosin treatment group had short time of the procedure, easy extraction of the stone fragments, had low expulsion time, low urinary tract symptoms, least analgesic needs and low adverse effects.Conclusions: Administration of a-1A-specific antagon istmade the procedure of short time, easy extraction of the stone fragments reduced analgesic dosage and colic episodes, rate of adverse effects after ureteroscopic lithotripsy of lower ureteral stones and decreased gravel expulsion time after URSL.

Objective: To evaluate the efficacy of tamsulosin in the treatment of distal ureteric calculi. Materials and Methods: Forty patients, who meet the in­clusion criteria, were selected for the prospective study. All these patients re­ceived tamsulosin 0.4 mg once before bed time for fourteen days to observe the effectiveness, side effects and stone expulsion rate. Results: The average time of stone expulsion was 8.03±2.80 days. The successful medical expul­sion was seen in 82.50%. About 7.5% complained of dizziness and headache, 2.5% complained of fatigue and postural hypotension. Conclusion: The use of tamsulosin was safe, effective and was associated with fewer side effects. Successful stone expulsion rate was observed in in selected cases.

Purpose To evaluate the efficacy of an alpha-1 adrenergic receptor (α1-AR) blocker for the treatment of female voiding dysfunction (FVD) through a pressure-flow study. Methods This was a randomized, double-blind, placebo-controlled trial. Women aged ≥18 years with voiding symptoms, as defined by an American Urological Association symptom score (AUA-SS) ≥15 and a maximum flow rate (Qmax) 100 mL and/or a postvoid residual (PVR) volume >150 mL, were randomly allocated to either the alfuzosin or placebo group. After 8 weeks of treatment, changes in the AUA-SS, Bristol female lower urinary tract symptoms (BFLUTS) questionnaire, Qmax/PVR, and voiding diary were compared between groups. Patients’ satisfaction with the treatment was compared. Patients were categorized into 3 groups according to the Blaivas-Groutz bladder outlet obstruction (BOO) nomogram: none, mild, and moderate to severe. Subgroup comparisons were also made. Results Of a total of 187 women, 154 (79 alfuzosin, 75 placebo) were included in the analysis. After 8 weeks of treatment, the AUA-SS decreased by 7.0 in the alfuzosin group and by 8.0 in the placebo group. Changes in AUA-SS subscores, BFLUTS (except the I-sum), the voiding diary, and Qmax/PVR were not significantly different between groups. Approximately 54% of the alfuzosin group and 62% of the placebo group were satisfied with the treatment. No significant difference was observed between groups according to the presence or grade of BOO. Conclusions Alfuzosin might not be more effective than placebo for treating FVD. The presence or the grade of BOO did not affect the results. A further study with sufficient power is needed to determine the efficacy of α1-AR blockers for the treatment of FVD.

Purpose: To determine changes in autonomic nervous system activity after treatment in men with lower urinary tract symptoms (LUTS), we evaluated changes in patients' symptoms, uroflowmetry, and heart rate variability (HRV) after treatment with alpha-blockers for 12 weeks. Materials and Methods: Ninety-five men who had LUTS (International Prostate Symptom Score [IPSS] ≥8) were included in this study. We divided them into two groups on the basis of a low frequency/high frequency (LF/HF) ratio of 1.6. After treatment with Xatral XL (Handok Inc., Korea) 10 mg for 3 months, we rechecked their IPSS, uroflowmetry, HRV and compared these with the baseline measurements. Results: Fifty-four men were assigned to the low LF/HF group (group A: LF/HF ≤1.6) and 41 men to the high LF/HF group (group B: LF/HF >1.6). At baseline and 12 weeks, none of the parameters differed significantly between the groups except for HF, which is one of the parameters of HRV. IPSS, the IPSS-voiding subscore, and the IPSS-storage subscore decreased and maximal uroflow increased significantly after 12 weeks of treatment. Whereas the baseline LF/HF ratio increased from 0.89±0.407 to 1.80±1.804 after treatment in group A, it decreased from 3.93±5.471 to 1.79±1.153 in group B. Conclusions: The efficacies of Xatral XL were clear in both groups. We found that the LF/HF ratio in the two groups merged to a value of approximately 1.79 after treatment. We suggest that this could be a clue to the importance of balance in autonomic nervous system activity in men with LUTS.