Is There a Role for a-Blockers for the Treatment of Voiding Dysfunction Unrelated to Benign Prostatic Hyperplasia?

TAMSULOSIN FOR THE TREATMENT OF BPH Is There a Role for
-Blockers for the Treatment of Voiding Dysfunction Unrelated to Benign Prostatic Hyperplasia? Victor W. Nitti, MD Department of Urology, New York University School of Medicine, New York, NY
-Adrenoreceptor antagonists have become the primary medical treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). It was presumed that the primary mechanism by which
-blockers reduced lower urinary tract symptoms (LUTS) was by relaxation of smooth muscle in the prostate through a sympathetic response. Reduction of outlet resistance leads to changes in bladder function, thus improving both storage and voiding symptoms. However, it was observed that many patients with BPH-associated LUTS had significant improvement in storage symptoms without subjective or objective improvement in voiding. Storage symptoms associated with detrusor overactivity (frequency, urgency, and urge incontinence) are typically thought of as being parasympathetically mediated, and therefore anticholinergic medications have been the mainstay of pharmacological treatment, but recent work has suggested that several nonparasympatheticmediated mechanisms may cause detrusor overactivity. Because
receptors appear to play a role in lower urinary tract function at multiple sites and levels,
-blockers could be used to treat voiding dysfunction not related to BPH. In addition, these nonprostate effects should be gender-independent, making the use of
-blockers plausible in women with specific types of voiding dysfunction. [Rev Urol. 2005;7(suppl 4):S49–S55] © 2005 MedReviews, LLC Key words: Benign prostatic hyperplasia • Lower urinary tract symptoms • Alpha-adrenoreceptor antagonists • Neurogenic voiding dysfunction • Chronic pelvic pain/chronic prostatitis lpha-adrenoreceptor antagonists have become the primary medical treatment for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Initially it was presumed that the primary mechanism by which
-blockers reduced LUTS was by relaxation of smooth muscle in the prostate through a sympathetic response. Reduction of outlet resistance leads to changes in bladder function, thus improving both storage and voiding symptoms. A VOL. 7 SUPPL. 4 2005 REVIEWS IN UROLOGY S49 Role of
-Blockers for Non-BPH Voiding Dysfunction continued Table 1 Videourodynamic Diagnoses Found in 85 Young Males Primary vesical neck obstruction 40 (47%)* Dysfunctional voiding 12 (14%)† Sensory urgency 7 (8%) Impaired contractility 8 (9%) Detrusor overactivity alone 5 (6%) Detrusor overactivity + impaired contractility 1 (1%) DESD 1 (1%)‡ Normal urodynamics 5 (6%) No urodynamic diagnosis 6 (7%) * 13 men with primary vesical neck dysfunction also had detrusor overactivity and 1 had impaired compliance. † 3 men with dysfunctional voiding had detrusor overactivity. ‡ The patient with DESD also had impaired compliance. Data from Nitti et al.11 However, due to the observation that many patients with BPH-associated LUTS had significant improvement in storage symptoms without subjective or objective improvement in voiding symptoms, interest has subsequently focused on alternative mechanisms of actions for
-blockers. LUTS can be caused by a variety of conditions, including detrusor overactivity (detrusor overactivity or impaired compliance), sensory urgency, impaired detrusor contractility, and bladder outlet obstruction (functional or anatomic). Storage symptoms associated with detrusor overactivity (frequency, urgency, and urge incontinence) are typically thought of as being parasympathetically mediated, and therefore anticholinergic medications have been the mainstay of pharmacological treatment. However, recent work has suggested that several nonparasympathetic-mediated mechanisms may cause detrusor overactivity. These include overstimulation or upregulation of
receptors in the bladder,
1D receptors in the spinal cord, and dysfunction of the bladder neck or S50 VOL. 7 SUPPL. 4 2005 urethra.1 Each of these sympathetically mediated mechanisms could potentially be influenced by pharmacological manipulation of
receptors. It is now believed that
1 receptors influence lower urinary tract function not only through the direct effect on smooth muscle but also at the level of the spinal cord, ganglia, and nerve terminals to influence sympathetic, parasympathetic, and somatic outflows to the bladder, bladder neck, prostate, and external urethral sphincter.1 These influences may that
-blockers could be used to treat voiding dysfunction not related to BPH. In addition, these nonprostate effects should be gender-independent, making the use of
-blockers plausible in women with specific types of voiding dysfunction. Most of the limited literature on “alternative use" of
-blockers to date has been on the non–subtype-selective
-blockers. Even so, most experience with these agents for alternative use has been in clinical practice. Based on clinical experience,
-blockers appear to have an equally important role in treating various conditions, with the additional benefit of decreased side effects. This review will focus on the possible role of
receptors in several aspects of lower urinary tract function and specific applications of
-blockers, in certain conditions, including LUTS in young males (including those with prostatitis), female LUTS, and neurogenic voiding dysfunction. LUTS in Young Males Lower urinary tract symptoms in young men are fairly common and are often misdiagnosed as chronic prostatitis or prostatodynia.3-5 Patients are often treated with empiric antibiotics for prolonged periods of time with unsatisfactory results. As a con-
-Blockers appear to have an equally important role in treating various conditions. vary according to different pathological conditions. For example, it has been reported that detrusor tissue from patients with nonneurogenic bladder overactivity had an almost fourfold increase in
receptors when compared to normals.2 Because
receptors appear to play a role in lower urinary tract function at multiple sites and levels, it seems logical REVIEWS IN UROLOGY sequence, this approach has resulted in frustration on the part of both physician and patient.6 Several authors have reported on the occurrence of voiding dysfunction in young men and its association with LUTS and pelvic pain. For example, primary bladder neck obstruction,3–5,7,8 dysfunctional voiding (or pseudodyssynergia),9 detrusor overactivity, Role of
-Blockers for Non-BPH Voiding Dysfunction Figure 1. Videourodynamic study of primary vesical neck obstruction in a 45-year-old man with lower urinary tract symptoms. Note the incomplete opening of the bladder neck and prostatic urethra (arrow) and the high-pressure, low-flow-voiding dynamics with relaxation of the electromyogram. Prostate size was 15 g. Flow, urinary flow rate; Volume, volume voided; Pves, vesical pressure; Pabd, abdominal pressure; Pdet, detrusor pressure. and impaired detrusor contractility10 have all been described as causes of LUTS in young men. We recently prospectively evaluated a group of young males with LUTS who were less than 45 years of age to determine the prevalence of these specific types of voiding dysfunction.11 Results are summarized in Table 1. Although this study looked at a selected group of fairly symptomatic men, it is interesting that 47% had a diagnosis of primary vesical neck obstruction (Figure 1). The precise cause of primary vesical neck obstruction has not been clearly elucidated, but theories as to its etiology include hyperplasia and/or abnormal morphological arrangement of the smooth muscle,12,13 and sympathetic nervous system dysfunction.7,14 Based on their established mechanism of action,
-blockers should be beneficial in at least a subgroup of young men with this condition. In addition to relaxation of smooth muscle at the bladder outlet,
-blockers would presumably have similar effects on the bladder, as in BPH patients. Trockman and colleagues reported a rather disappointing response to
-blockers for the treatment of primary bladder neck obstruction. Seventy percent of those treated discontinued treatment because of inadequate response.15 However, relatively low doses of terazosin (5 mg once daily) or prazosin (2 mg twice daily) were used. We have had better success with higher doses of terazosin (10 mg daily) and tamsulosin (0.4–0.8 mg daily). To date there have been no randomized, placebo-controlled studies on the use of
-blockers in young men with primary vesical neck obstruction, probably because the diagnosis requires invasive urodynamic testing. However, studies using
-blockers to treat symptoms in young men diagnosed with “prostatitis and prostatodynia" have been shown to be beneficial. Presumably some of these men had functional vesical neck obstruction. In any event,
-blockers are widely used in clinical practice for this condition. We prefer tamsulosin, as we have found that there is a marked increase in tolerability over the non–subtype-selective
-blockers, especially in young men. However, patients must be warned about the 10%–25% incidence of ejaculatory dysfunction. This side effect is often bothersome enough in younger men that it results in discontinuation of treatment. When this occurs, an alternative
-blocker, such as alfuzosin, terazosin or doxazosin, can be tried. Alfuzosin also has a favorable side effect profile when compared to terazosin and doxazosin, but our experience in men with this condition is limited. Nevertheless, we continue to use tamsulosin as our first-line treatment for primary bladder neck obstruction, and recommend a trial before considering alternative medications or bladder neck incision. There is some precedent for using
-blockers to treat chronic pelvic pain/chronic prostatitis (CPPS/CP). Neal and Moon conducted an openlabel study of terazosin on men with CPPS/CP, titrating the dose to response. They noted a 76% symptomatic improvement and 58% asymptomatic rate after 3 months of treatment.16 Barbalias and colleagues evaluated
-blockers and antibiotics for the treatment of chronic prostatitis. They found the recurrence rate of bacterial prostatitis was reduced in patients receiving
-blockers (terazosin or alfuzosin) with antibiotics.17 They also found a lower rate of recurrence of abacterial prostatitis in patients who received
-blockers alone versus those who received
-blockers plus antibiotics. Maintaining
-blocker treatment for more than 6 months VOL. 7 SUPPL. 4 2005 REVIEWS IN UROLOGY S51 Role of
-Blockers for Non-BPH Voiding Dysfunction continued decreased the likelihood of relapse. What is not clear from these studies is whether patients had urodynamically proven voiding dysfunction associated with their symptoms. Female LUTS As with men, LUTS in women may be caused by a variety of conditions that are potentially treatable by
blockade. Inspired by the results of
-blockers in men with LUTS, Lepor and Theune enrolled 29 women into a randomized study comparing terazosin and placebo.18 Selection criteria were similar to studies on men with BPH and were based primarily on symptoms. These authors found no significant differences in change in symptoms in the two groups, leading them to conclude that terazosin is not effective for “prostatism-like" symptoms in aging women. Although this was a small sample size, it suggests that if
blockade is to be effective in women, it will likely be so in a subgroup of women with specific abnormalities. Serels and Stein evaluated 34 women with LUTS in an open label, prospective study comparing the
1blocker doxazosin to hyoscyamine, an anticholinergic.19 Patients received pves pabd pdet Figure 2. Videourodynamic study of primary vesical neck obstruction in a 35-year-old woman with lower urinary tract symptoms and intermittent urinary retention. Note the closed bladder neck (circle) during voiding with relatively high detrusor pressure (> 50 cm H2O). pves, vesical pressure; pabd, abdominal pressure; pdet, detrusor pressure. was also mentioned that a “higher percentage of women with elevated voiding pressures on urodynamics responded to doxazosin than hyoscyamine." No specifics were given with respect to urodynamic data; however, these results suggest that women with voiding phase dys- It is important to investigate the prevalence of voiding phase dysfunction in women with LUTS. one or the other drug and were then crossed over to the other or a combination of both after a minimum of 1 month of treatment. They found that an equal number of women had symptom improvement on the monotherapies (68%), and 77% had improvement on combination therapy. They also noted that 50% of women who failed to respond to hyoscyamine responded to addition of or replacement with doxazosin. It S52 VOL. 7 SUPPL. 4 2005 function may find a significant benefit from
-blockers. We believe that it is important to investigate the prevalence of voiding phase dysfunction in women with LUTS because this may be the very population likely to respond. Two large studies have shown a 33%–62% prevalence of voiding symptoms and a 15%–21% incidence of objective emptying abnormalities in women with LUTS.20,21 With that in REVIEWS IN UROLOGY mind, we set out to determine the value of routine evaluation of the voiding phase in women with LUTS.22 We discovered a 33% incidence of voiding phase abnormalities. As in men, dysfunctional voiding (12%) and primary vesical neck obstruction (4%) were the two most common etiologies.
-Blockers have been reported to be effective in women with primary vesical neck obstruction (Figure 2). Kumar and colleagues showed a 50% response of symptoms and objective parameters (uroflow and postvoid residual) to phenoxybenzamine or prazosin in highly symptomatic women, many of whom were in retention.23 Unfortunately, no validated symptom score was used to assess symptoms. Most of the women we treat with videourodynamically proven primary vesical neck obstruction have a less dramatic presentation and are mostly treated for symptoms and not retention or renal insufficiency. Our experience with
1-blockers Role of
-Blockers for Non-BPH Voiding Dysfunction is similar, with about half of the women having symptomatic improvement. Thus
-blockade is our initial recommended treatment for these women, and most will opt for medical therapy because of the fear of incontinence (though actual rates are low) with bladder neck incision. It has been our experience that
-blockers are well tolerated in women, with minimal orthostatic symptoms. Dysfunctional voiding (Figure 3) is another condition that may be potentially treated with
-blockers. Although it is an abnormality of voiding, most women with dysfunctional voiding complain primarily of storage symptoms.24 Urodynamically, urinary flow rates tend to be reduced or interrupted and voiding pressures tend to be elevated, though there is a large variation in these parameters.24 Dysfunctional voiding is typically treated with biofeedback, though it has been suggested that
-blockers may be beneficial. Austin and colleagues showed evidence of benefit using doxazosin in a small group of children with the condition.25 The presumed mechanism of action here is decreased somatic efferent activity to the external sphincter via the pudendal nerve. Such a decrease has been demonstrated by Danuser and Thor after administration of the
1 receptor antagonist prazosin.26 It is possible that such an effect may also occur in adult women and men with dysfunctional voiding, but this has not been studied in a placebo-controlled manner. As with primary vesical neck obstruction in women, dysfunctional voiding is difficult to study rigorously on a large scale because of its relatively low prevalence and the fact that urodynamic testing is required to make the diagnosis. Currently there is an ongoing randomized, placebo-controlled study comparing tamsulosin to placebo in women with LUTS who have a significant component of voiding symptoms and abnormal uroflow (decreased flow rate or grossly abnormal pattern). Many of these women will likely have voiding phase dysfunction and may have dysfunctional voiding or primary vesical neck obstruction. Such a study will determine if a select group of women with LUTS can be effectively treated with
-blockers. Neurogenic Voiding Dysfunction The goals of treatment for neurogenic voiding dysfunction are to facilitate storage of urine (inhibit detrusor overactivity, improve compliance) and to facilitate emptying (inhibit sphincter dyssynergia, improve contractility).
-Blockers potentially have a role in both of these areas. With respect to facilitation of storage, evidence from in vivo studies suggests that there may be a shift in receptor function, resulting in an upregulation of
receptors in the detrusor body.27 There has been a plethora of reports on the use of
-blockers in the treatment of neurogenic voiding dysfunction; however, most are small, uncontrolled series with limited follow-up. Some of these showed benefits of phenoxybenzamine and prazosin in reducing detrusor overactivity and increasing capacity. Unfortunately, side effects of these medications were high. Swierzewski and colleagues showed an improvement in compliance in all patients who were treated for 4 weeks with terazosin 5 mg daily.28 Bladder pressures at maximum volume decreased by 36 cm H2O, and maximum safe volume stored increased by 157 mL. The average improvement in compliance was 73%. These effects were reversed when medication was discontinued, indicating that improvement in Figure 3. Videourodynamic study of dysfunctional voiding in young women with lower urinary tract symptoms and incomplete bladder emptying. Note the increased electromyogram activity during voiding and the high-pressure, low-flow-voiding dynamics. The proximal urethra is dilated to the contracting external sphincter like a “spinning-top" (arrow). Flow, urinary flow rate; volume, volume voided; Pves, vesical pressure; Pabd, abdominal pressure; Pdet, detrusor pressure. VOL. 7 SUPPL. 4 2005 REVIEWS IN UROLOGY S53 Role of
-Blockers for Non-BPH Voiding Dysfunction continued compliance was truly an effect of the medication. However, it is not clear if this effect is directly on the detrusor or a consequence of decreased outlet resistance. Unfortunately, only 54% of patients completed 4 weeks of therapy, and 27% discontinued terazosin because of side effects. Tamsulosin may prove to be a better option for such patients, because side effects may be reduced. Yasuda and colleagues reported an improvement in neurogenic detrusor overactivity using the
-blocker urapidil versus placebo in one of the only placebo-controlled studies.29 With respect to bladder outlet resistance, neurological disease can cause dyssynergia of either the internal or external sphincter. Lesions in the spinal cord above the lower thoracic level where the sympathetic nerves exit the cord may result in detrusor–internal sphincter dyssynergia. Urodynamically, this behaves similarly to primary vesical neck obstruction.
-Blockers should be beneficial in these cases; however, it is difficult to assess their effect on the isolated internal sphincter, because many patients also have detrusor–external sphincter dyssynergia. Effects of
-blockers on the external sphincter are not as clear, as controversy surrounds the topic of external sphincter innervation. According to some studies,
adrenoreceptors may be responsible for some external sphincter function and theoretically could be of some benefit to patients with external sphincter dyssynergia. Several uncontrolled studies have been done on the effects of
-blockers on bladder emptying in patients with neurogenic voiding dysfunction, with mixed results.27,30-33 Most of these were performed using nonselective shorter-acting agents with high side effects. The randomized, placebo-controlled study on urapidil demonstrated improvement in detrusor–external sphincter dyssynergia in 29% of patients who received the drug.29 In summary, there appears to be a potential role for
-blockers in the treatment of neurogenic voiding dysfunction. It appears that the best potential use, based on available literature, is in the patient with persistent overactivity and impaired compliance while on anticholinergics. The addi- tion of
-blockade may circumvent surgery. Also,
-blockers may be useful in the treatment of isolated detrusor–internal sphincter dyssynergia. Effects in patients with detrusor–external sphincter dyssynergia are less clear. Controlled studies on
-blockers for the different manifestations of neurological disease are important. However, such placebocontrolled studies are difficult to do, because the patients typically have problems that are potentially dangerous, and delaying treatment may be detrimental. Tamsulosin, with its favorable side effect profile, appears promising for patients with neurogenic voiding dysfunction who would benefit from
blockade. References 1. 2. 3. 4. Andersson KE, Lepor H, Wyllie MG. Prostatic
1-adenoreceptors and uroselectivity. Prostate. 1997;30:205–215. Restorick JM, Mundy AR. The density of cholinergic and alpha and beta adrenergic receptors in normal and hyper-reflexic human detrusor. Br J Urol. 1989;63:32–35. Kaplan SA, Te AE, Jacobs BZ. Urodynamic evidence of vesical neck obstruction in men with misdiagnosed chronic nonbacterial prostatitis and the therapeutic role of endoscopic incision of the bladder neck. J Urol. 1994;152:2063–2065. Mishra VK. Kumar A, Kapoor R, et al. Functional bladder neck obstruction in males: a progressive disorder? Eur Urol. 1992;22:123–129. Main Points • Recent work suggests that several nonparasympathetic-mediated mechanisms may cause detrusor overactivity symptoms of frequency, urgency, and urge incontinence. •
1 Receptors may influence lower urinary tract function not only through the direct effect on smooth muscle but also at the level of the spinal cord, ganglia, and nerve terminals to influence sympathetic, parasympathetic, and somatic outflows to the bladder, bladder neck, prostate, and external urethral sphincter. • We recommend a trial of tamsulosin as a first-line treatment for primary bladder neck obstruction before considering alternative medications or bladder neck incision. • An open-label study of terazosin to treat chronic pelvic pain/chronic prostatitis found a 76% symptomatic improvement and 58% asymptomatic rate after 3 months of treatment. • A trial of
-blockers and antibiotics to treat chronic prostatitis found the recurrence rate of bacterial prostatitis was reduced in patients receiving
-blockers with antibiotics. •
-Blockers have been reported to be effective in women with primary vesical neck obstruction and are well tolerated in women, with minimal orthostatic symptoms. •
-Blockers have been shown to improve compliance and to reduce detrusor overactivity in patients with neurogenic voiding dysfunction. S54 VOL. 7 SUPPL. 4 2005 REVIEWS IN UROLOGY Role of
-Blockers for Non-BPH Voiding Dysfunction 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Webster GD, Lockhart JL, Older RA. The evaluation of bladder neck dysfunction. J Urol. 1980;123:196–198. Nickel JC. Prostatitis: myths and realities. Urology. 1998;51:362–366. Woodside JR. Urodynamic evaluation in dysfunctional bladder neck obstruction in men. J Urol. 1980;124:673–677. Blaivas JG, Norlen LJ. Primary bladder neck obstruction. World J Urol. 1984;2:191–195. Kaplan SA, Santarosa RP, D’Alisera PM, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol. 1997;157:2234–2237. Kaplan SA, Ikeguchi EF, Santarosa RP, et al. Etiology of voiding dysfunction in men less than 50 years of age. Urology. 1996;47:836–839. Nitti VW, Lefkowitz G, Ficazzola M, Dixon CM. Lower urinary tract symptoms in young men: videourodynamic findings and correlation with non-invasive measures. J Urol. In press. Marion G. Surgery of the neck of the bladder. Br J Urol. 1933;5:351. Turner-Warwick R, Whiteside CG, Worth PHL, et al. A urodynamic view of the clinical problems associated with bladder neck dysfunction and its treatment by endoscopic incision and transtrigonal posterior prostatectomy. Br J Urol. 1973;45:44–59. Awad SA, Downie JW, Lywood DW, et al. Sympathetic activity in the proximal urethra in patients with urinary obstruction. J Urol. 1976;115:545–547. Trockman BA, Gerspach J, Dmochowski R, et al. Editor’s Summary of Meeting Presentation Dr. Nitti delivered a presentation focusing on alternative indications for
1-blockers in the treatment of lower urinary tract symptoms. Specifically, he presented data for bladder neck primary obstruction, the management of LUTS in women, and prostatitis. All of the experts agreed that there were important clinical indications for
1-blockers beyond BPH. There was consensus that the role of
1-blockers was well supported for bladder neck obstruction. There was a general feeling that
1blockers would not be effective in the 16. 17. 18. 19. 20. 21. 22. 23. 24. Primary bladder neck obstruction: urodynamic findings and treatment results in 36 men. J Urol. 1996;156:1418–1420. Neal DE Jr, Moon TD. Use of terazosin in prostatodynia and validation of a symptom score questionnaire. Urology. 1994;43:460–465. Barbalias GA, Nikiforidis G, Liatsikos EN. Alphablockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. 1998;158:883–887. Lepor H, Theune C. Randomized double-blind study comparing the efficacy of terazosin versus placebo in women with prostatism-like symptoms. J Urol. 1995;154:116–118. 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. Groutz A, Gordon D, Lessing JB, et al. Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data? Urology. 1999;54:268–272. Stanton SL, Ozsoy C, Hilton P. Voiding difficulties in the female: prevalence, clinical an urodynamic review. Obstet Gynecol. 1983;61:144–147. Carlson KV, Fiske J, Nitti VW. Value of routine evaluation of the voiding phase when performing urodynamics on women with lower urinary tract symptoms. J Urol. 2000;164:1614–1618. Kumar A, Mandhani A, Gogoi S, Srivastava A. Management of functional bladder neck obstruction in women: use of
-blockers and pediatric resectoscope for bladder neck incision. J Urol. 1999;162:2061–2165. Carlson KV, Rome S, Nitti VW. Dysfunctional void- majority of women with LUTS and that stress incontinence would be a significant side effect of
1-blockers in women. It was agreed that there is likely a subset of women with LUTS who will respond to
1-blockers. Several of the experts discussed other possible indications for
1blockers in the management of voiding dysfunction. The indication that received the greatest attention was the management of voiding symptoms arising following brachytherapy or external beam radiation therapy for the treatment of localized prostate cancer. Although it was agreed that there were no randomized double- 25. 26. 27. 28. 29. 30. 31. 32. 33. ing in adult females. J Urol. 2001;165:143–148. Austin PF, Homsy YL, Masel JM, et al.
-adrenergic blockade in children with neuropathic and nonneuropathic voiding dysfunction. J Urol. 1999;162:1064–1067. Danuser H, Thor KB. Inhibition of central sympathetic and somatic outflow to the lower urinary tract of the cat by alpha 1 receptor antagonist prazosin. J Urol. 1995;153:1308–1312. Sundin T, Daklstrom A, Norlen L, et al. The sympathetic innervation and adrenoreceptor function of the human lower urinary tract in the normal state and after parasympathetic denervation. Invest Urol (Berl). 1997;14:322–328. Swierzewski SJ III, Gormlet EA, Belleville WD, et al. The effect of terazosin on bladder function in the spinal cord injured patient. J Urol. 1994:151:951–954 Yasuda K, Yamanishi, T, Kawabe K, et al. The effect of urapidil on neurogenic bladder: a placebo-controlled, double-blind study. J Urol. 1996;156:1125–1130. Vereecken RL, Van Poppel H, Boeckx G, et al. Long-term alpha-adrenergic clocking therapy in detrusor-urethra dyssynergia. Eur Urol. 1983;9:167–169. Petersen T, Husted SE. Prazosin treatment of neurological patients with lower urinary tract dysfunction. Int Urogynecol J. 1993;4:106–110. Andersson KE, Ek A, Hedlund H, Mattiasson A. Effects of prazosin on isolated human urethra and in patients with lower motor neuron lesions. Invest Urol (Berl). 1981;19:34–42. Jensen D. Uninhibited neurogenic bladder treated with prazosin. Scand J Urol Nephrol. 1981;15:229–233. blind placebo controlled studies examining the role of
-blockers for post-radiotherapy voiding dysfunction, the majority of the panel felt it was worthwhile investigating this indication. Dr. Lepor indicated that he is now removing the urinary catheter on postoperative day 7 following a radical prostatectomy. Approximately 15% of men develop acute urinary retention requiring reinsertion of the catheter. Dr. Lepor has been using tamsulosin routinely after removing the catheter on postoperative day 7, and it is his clinical impression that this intervention reduces the risk of acute urinary retention. VOL. 7 SUPPL. 4 2005 REVIEWS IN UROLOGY S55