Repeated intensification of lower urinary tract symptoms in the

CLINICAL NOTES – DONIESIENIA KLINICZNE
Jacek SEIN ANAND
Zygmunt CHODOROWSKI
Adam HAJDUK
Repeated intensification of lower urinary tract
symptoms in the patient with benign prostatic
hyperplasia during bisoprolol treatment
Nasilenie dolegliwoœci ze strony dolnych dróg
moczowych u chorego z ³agodnym przerostem gruczo³u
krokowego podczas terapii bisoprololem
1st Clinic of Internal Diseases
and Acute Poisonings
Medical University of Gdañsk, Poland
Head: Prof. Zygmunt Chodorowski MD PhD
Additional key words:
benign prostatic hyperplasia
lower urinary tract symptoms
bisoprolol
Dodatkowe s³owa kluczowe:
³agodny przerost gruczo³u krokowego
dolegliwoœci ze strony dolnych
dróg moczowych
bisoprolol
A case of a 60-year-old male patient, suffering from benign prostatic
hyperplasia (BPH), with deterioration
of lower urinary tract symptoms
(LUTS) during antihypertensive treatment with bisoprolol was presented.
Discontinuation of beta-blocker resulted in giving a relief whereas the
resumption of its use caused repeated
deterioration. Conclusion: Bisoprolol
deteriorated lower urinary tract symptoms in patient with benign prostatic
hyperplasia. Increase of lower urinary
tract symptoms caused by betablockers can be more significant in
elderly men.
Case report
Address for correspondence:
Jacek Sein Anand MD, PhD
1st Clinic of Internal Diseases
and Acute Poisonings
Medical University of Gdañsk
ul. Dêbinki 7, 80-211 Gdañsk, Poland
phone/fax: (+48) 58 349-29-32;
phone: (+48) 58 349-28-31
e-mail: [email protected]
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In April 2004 a 60-year-old male patient was admitted to the Clinic of Acute Poisonings Medical University
of Gdañsk with lower urinary tract symptoms (LUTS)
suggesting benign prostatic hyperplasia (BPH). The patient complained of urinary frequency, urgency, nocturia,
incomplete bladder emptying and a weak stream of urine
lasting for about six months. Moreover the patient suffered from hypertension for more than three years but
was taken antihypertensive drugs (amlodypine, enalapril,
hydrochlorothiazide) irregularly.
On admission the patient was in a good general
condition. The arterial blood pressure varied from 145/
95 mmHg to 150/100 mmHg and the heart rate was regular from 68 to 72 beats/min. There were no significant
changes in basic biochemical tests, urinanalysis, urine
bacterial culture, echocardiography, chest X-ray and
ophtalmological examination. Abdomen ultrasound revealed insignificant increase of prostate gland (40 ml
volume, 51x34x43 millimeters dimensions) and lack of
complete urinary bladder emptying.
Prostate specific antigen (PSA) level was 0.48 ng/
ml and the patient had 20 points according to American
Urological Association's Symptom Index (AUASI) [1].
Five weeks before admission to the Clinic bisoprolol in a dosage of 10 mg per day (Bisocard á 10mg, ICN
Polfa Rzeszów) was included as a single drug to antihypertensive therapy. The symptoms of LUTS were closely connected with the initial treatment with bisoprolol. After
discontinuation of beta blocker in the clinic the patient
had less symptoms of LUTS. The follow up after 4 weeks
with AUASI score showed significant clinical improvement (5 points in AUASI). Resumption of the use of bisoprolol caused repeated deterioration of the symptoms
(the patient had 21 points in AUASI score after one
month).
Przegl¹d Lekarski 2005 / 62 / 6
W pracy przedstawiono przypadek
60-letniego chorego, z ³agodnym przerostem gruczo³u krokowego (BPH), u
którego dosz³o do nasilenia dolegliwoœci ze strony dolnych dróg moczowych
(LUTS) podczas terapii bisoprololem.
Odstawienie beta-blokera spowodowa³o zmniejszenie dolegliwoœci, zaœ
jego ponowne w³¹czenie doprowadzi³o do ich nasilenia. Wnioski: Wydaje
siê, ¿e u niektórych chorych bisoprolol mo¿e pogorszyæ objawy ze strony
dolnych dróg moczowych w razie
wspó³istnienia ³agodnego przerostu
gruczo³u krokowego. Dolegliwoœci ze
strony dolnych dróg moczowych, wynikaj¹ce ze stosowania leków blokuj¹cych receptory beta-adrenergiczne,
mog¹ byæ szczególnie nasilone u mê¿czyzn w wieku podesz³ym.
During the test of discontinuation and after discharged from the clinic blood pressure was controlled
with enalapril in a dose of 2 x 5 mg per day and the
arterial blood pressure varied from 125/80 mmHg to 135/
85 mmHg. After two months of further observation the
arterial blood pressure did not exceed 140/90 mmHg and
the patient had 3 points in AUASI scale.
Discussion
Generally there is a three-component
model responsible for BPH-induced lower
urinary tract symptoms. This model involves
the static (increased prostatic tissue mass),
dynamic (increased prostatic smooth muscle tone) and detrusor-related component
[10]. Almost 50% of patients with BPH also
experience involuntary detrusor contractions
that lead to histological alterations in bladder musculature, decreased bladder compliance, and compromised detrusor contractile strength. These foregoing changes can
also be the reason for incomplete emptying, urgency, and frequency [3].
The human and animal studies revealed
that the relaxation of bladder muscle is mediated by beta-adrenoreceptors [2,4,5,7,8,
11,12]. In the described case there was observed a close relation between the therapy of beta-blocker agent and LUTS escalation. It seems that bisoprolol influenced not
only the relaxing function of bladder but also
in beta-adrenoceptor-mediated relaxation of
hyperplastic prostatic tissues. The foregoing mechanism written by Tsujii et al. was
J. Sein Anand et al.
responsible for appearance of lower urinary tract symptoms in addition to mechanical
compression of the urethra by the enlarged
prostate [9].
The age of the patient could be the additional factor which intensified adverse effect of bisoprolol. Li et al. affirmed that there is an age-related decline in beta-adrenergic responsiveness of bladder muscle
and additional administration of beta-blocker agents may increase the symptoms of
LUTS [6].
Further studies are necessary to evaluate the influence of beta-adrenoreceptors
antagonists on symptoms of LUTS and BPH.
Conclusion
Bisoprolol deteriorated lower urinary
tract symptoms in patient with benign prostatic hyperplasia.
Increase of lower urinary tract symptoms
caused by beta-blockers can be more significant in elderly men.
References
1. Barry M.J., Fowler F.J., Leary M.P. et al.: The American Urological Association Symptom Index for benign prostatic hyperplasia. J. Urol. 1992, 148, 1549.
2. Ganguly D.K., Vedasiromoni J.R.: Betadrenoreceptors in urinary bladder. Arch. Int. Pharmacodyn.
Ther. 1976, 222, 193.
3. Hald T.: Urodynamics in benign prostatic hyperplasia: a survey. Prostate Suppl. 1989, 2, 69.
4. Igawa Y., Yamazaki Y., Takeda H. et al.: Relaxant
effects of isoproterenol and selective beta3adrenoceptors agonists on normal, low compliant and
hyperreflexic human bladders. J. Urol. 2001, 165,
240.
5. Kobayashi H., Adachi-Akahane S., Nagao T.: Involvement of BK(Ca) channels in the relaxation of
detrusor muscle via beta-adrenoceptors. Eur. J.
Pharmacol. 2000, 404, 231.
6. Li G., Li K., Li Z., Wang P.: Age-dependent changes
in beta-adrenoceptor function in human detrusors
and possible mechanisms. Chin. Med. J. 2003, 116,
1511.
7. Li J.H., Yasay G.D., Kau S.T.: Beta-adrenoceptor
subtypes in the detrusor of guinea-pig urinary bladder. Pharmacol. 1992, 44, 13.
8. Longhurst P.A., Levendusky M.: Pharmacological
characterization of beta-adrenoreceptors mediating
relaxation of the rat urinary bladder in vitro. Br. J.
Pharmacol. 1999, 127, 1744.
9. Tsujii T., Azuma H., Yamaguchi T., Oshima H.: A
possible role of decreased relaxation mediated by
beta-adrenoceptors in bladder outlet obstruction by
benign prostatic hyperplasia. Br. J. Pharmacol. 1992,
107, 803.
10. Wehle M.J., Lisson S.W.: Benign prostatic hypertrophy. Physician Sportmed. 2002, 30, 4.
11. Yamamoto Y., Mori A., Koike K.: Beta-adrenoceptors in the detrusor of guinea pig bladder. J.
Smooth Muscle Res. 1998, 34, 233.
12. Yamanishi T., Chapple C.R., Yasuda K. et al.: The
functional role of beta-adrenoceptor subtypes in
mediating relaxation of pig urethral smooth muscle.
J. Urol. 2003, 170, 2508.
Przegl¹d Lekarski 2005 / 62 / 6
Enclosure number 1
Za³¹cznik numer 1
The American Urological Association’s Symptom Score
for Benign Prostatic Hyperplasia
1. During the past month or so, how often did you have the feeling of not
having completely emptied your bladder after urinating?
2. During the past month or so, how often did you have to urinate again less
than 2 hours after you finished urinating?
3. During the past month or so, how often did you have to stop and start the
urinary stream several times while urinating?
4. During the past month or so, how often did you find it difficult to delay
urination?
5. During the past month or so, how often did you find that your urinary
stream was weak?
6. During the past month or so, how often did you have to push or strain to
begin urinating?
7. During the past month or so, how often did you typically get up to urinate
between going to bed in the evening and waking up in the morning?
0 Not at all
1 Less than 1Time in 5 Times
2 Less than half of the time
3 About half of the time
4 More than half of the time
5 Almost always
012345
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1 (one time)
2 (two times)
3 (three times)
4 (four times)
5 (five times or more)
Score Key:
Mild = 0 to 7 points; Moderate = 8 to 9 points; Severe = 20 to 35 points
Adapted from Barry M.J., Fowler F.J., O'Leary M.P. et al.: The American Urological Association Symptom Index for
benign prostatic hyperplasia. J. Urol. 1992, 148, 1549.
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