Alpha blockers prior to removal of a catheter for acute urinary retention in adult men

  • Review
  • Intervention

Authors


Abstract

Background

Acute urinary retention is a urological emergency in men and requires urgent catheterisation. Any intervention which aims at increasing the rate of a successful trial without a catheter following an acute urinary retention episode would be considered potentially beneficial. Alpha blockers relax prostatic smooth muscle cells thereby decreasing the resistance to urinary flow and by doing so improve urinary symptoms.

Objectives

To assess the effects of alpha blockers on successful resumption of micturition following removal of a urethral urinary catheter after an episode of acute urinary retention in men.

Search methods

We searched the Cochrane Incontinence Group Specialised Register (11 February 2009) and the reference lists of relevant articles. No language or other restrictions were imposed on the searches.

Selection criteria

Only randomised and quasi-randomised clinical trials of alpha blockers for trial without a urethral catheter following an episode of acute urinary retention in men were included.

Data collection and analysis

Both review authors independently examined all the citations and abstracts derived from the search strategy. Any disagreement about trial selection and inclusion was resolved by discussion. A third independent judgement was sought where disagreement persisted. Both review authors extracted independently, cross-checked and processed the data as described in the Cochrane Collaboration Handbook (Higgins 2008).

Main results

Five randomised clinical trials were eligible for inclusion in this review. All five trials compared alpha blockers versus placebo. In four trials alpha blockers were used between 24 to 72 hours (in one study up to a maximum of eight days) before trial without a catheter (TWOC); in one trial alpha blockers were used for eight days prior to trial without a catheter. Four trials tested alfuzosin and one trial tested tamsulosin. Four trials favoured alpha blockers and one trial favoured placebo. Overall rates of successful TWOC tended to favour alpha blockers over placebo. This was statistically significant (RR 1.39, 95% CI 1.18 to 1.64) irrespective of the alpha blocker used (alfuzosin: RR 1.31, 95% CI 1.10 to 1.56; tamsulosin: RR 1.86, 95% CI 1.17 to 2.97).

With regard to causing fewer vasodilatation-related side effects (for example hypotension, dizziness), two studies favoured placebo and one favoured alpha blockers. Overall side effects were low for both placebo and alpha blockers. Failure rates were high and mainly caused by the need for re-catheterisation rather than vasodilatation-related side effects.

Authors' conclusions

The limited available evidence suggests that alpha blockers increase success rates of TWOC. Alpha blocker side effects are low and comparable to placebo. It is uncertain whether alpha blockers reduce the risk of recurrent urinary retention and need for prostate surgery. The cost effectiveness and recommended duration of alpha blocker treatment after successful TWOC remains unknown. There are a lack of internationally agreed outcome measures for what constitutes successful TWOC. This makes meta-analysis difficult. More randomised clinical trials are needed to address these issues.

摘要

背景

急性尿滯留的成年男性移除導管前阿爾法受體阻斷劑之使用

急性尿滯留是男性泌尿系統的緊急情況需要使用緊急導管插入。任何介入手段,旨在提高急性尿滯留症狀之後無導管的成功率將被視為對病患有益處。阿爾法受體阻斷劑放鬆前列腺平滑肌細胞,從而減少尿流的阻力並改善排尿症狀。

目標

評估急性尿滯留的男性在移除導尿管之後,藉由阿爾法受體阻斷劑成功恢復排尿之效果。

搜尋策略

我們檢索了考科藍實證醫學資料庫尿失禁組專科試驗(2009年2月11號)和參考有關的文獻。搜尋沒有語言或其他限制。

選擇標準

只納入有使用阿爾法受體阻斷劑的隨機和半隨機臨床試驗,藥物使用在急性尿滯留男性發作之後且移除尿道導尿管。

資料收集與分析

兩位審查員根據搜尋準則獨立評估所有的引文和摘要。對任何在選擇與文章是否納入意見上的分歧皆通過討論解決。當意見分歧持續時,將徵求第三位獨立判斷的意見。兩名審查者根據Cochrane手冊(希金斯2008年),獨立提取資料,交叉比對和處理數據。

主要結論

5個隨機臨床試驗有資格列入評估。所有試驗皆比較阿爾法受體阻斷劑與安慰劑。有四個試驗在導管移除前(TWOC)使用阿爾法受體阻斷劑24至72小時(在某項研究中使用至多長達8天),另一試驗在導管移除前使用阿爾法受體阻斷劑8天。四項試驗測試阿夫唑?而另一項試驗測試坦索羅辛。四項試驗支持阿爾法受體阻斷劑有效而一項試驗支持安慰劑。總體而言TWOC成功率傾向於支持阿爾法受體阻斷劑比安慰劑有效。這具有統計顯著性(相對危險性:1.39,95%CI為 1.18至1.64),無論何種阿爾法受體阻斷劑被使用(阿夫唑?,相對危險性:1.31,95%CI為 1.10至1.56;蘇洛辛:相對危險性:1.86,95%CI為 1.17至2.97)。關於造成輕微血管舒張有關的副作用(如低血壓,頭暈),兩項研究支持安慰劑,另一項支持阿爾法受體阻斷劑。總體說來,安慰劑與阿爾法受體阻斷劑副作用都低。失敗率高主要是由於需要重新插入導管,並非血管舒張功能相關的副作用。

作者結論

有限的現有證據顯示,阿爾法受體阻斷劑提高TWOC成功率。阿爾法受體阻斷劑副作用低,與服用安慰劑的患者相比。目前還不清楚是否阿爾法受體阻斷劑降低急性尿滯留復發的風險以及前列腺手術的需要。在成本效益以及成功TWOC之後,建議持續已阿爾法受體阻斷劑治療的時間,仍然不得而知。目前仍缺乏國際間在結果判定的認可,什麼是成功的TWOC。這使得統合分析變得困難。需要更多的隨機臨床試驗來處理這些問題。

翻譯人

本摘要由中國醫藥大學附設醫院陳祖裕翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

阿爾法受體阻斷劑,為男性增加了移除導尿管的機會。男性急性尿滯留是一種醫療上的緊急狀況,特點是突然和痛苦往往無法排尿。有許多已知的造成原因,包括前列腺梗阻(因為肥大的前列腺或癌症),尿道狹窄,尿液感染,便秘及神經系統疾病。一條窄的引流管(導尿管)暫時插入,經由陰莖進入膀胱,使尿液引流。一旦導管被移除,有些人便不能排尿,需要重新再插入導管。針對這些人,繼續使用導管或前列腺手術是標準的治療方案。導尿管會帶來風險,如感染,也會影響生活品質。提高成功移除導尿管,同時幫助患者再次正常排尿的手段,對患者是有益的。阿爾法受體阻斷劑(如坦索羅辛,阿夫唑?)是一組藥物被認定對改善泌尿系統症狀,如排尿困難,有正面效果。據認為,該藥物對前列腺的放鬆效果也增加了移除等尿管後的再次排尿機會。這次審查評估證據支持這個作法。五項臨床試驗的男性在導管移除前被給予糖片(安慰劑,無效藥)或阿爾法受體阻斷劑 1至3天(在一項研究中最多可8天)。無論病人或醫生均不知病患被給予何種類型的藥劑,以防止研究結果的誤差。結果顯示,阿爾法受體阻斷劑治療的機會增加了成功的導管移除和恢復正常排尿,雖然整體的科學證據仍舊相當有限的。針對兩種不同的阿爾法受體阻滯劑也進行了測試(坦索羅辛和阿夫唑?)。他們的研究結果相似。與安慰劑相比,阿爾法受體阻斷劑治療造成的副作用很少。其中包括無法射精,頭暈,低血壓,頭昏,嗜睡,感覺不適及頭痛。沒有足夠的證據說明是否阿爾法受體阻斷劑也能減少復發的風險或是否需要未來的前列腺手術。因此,目前不清楚阿爾法受體阻斷劑在導尿管成功移除後需持續治療多久,以及在這種情形下治療的費用是否合理。未來還需要進一步研究來回答這些問題。

Plain language summary

Alpha blocker treatment for men to increase chances to have urinary catheter successfully removed

Acute urinary retention in men is a medical emergency characterised by the sudden and often painful inability to pass urine. There are many known causes including prostate obstruction (because of enlargement of the prostate or cancer), urethral strictures, urine infection, constipation and neurological conditions. A narrow drainage tube (urinary catheter) is temporarily inserted into the bladder through the penis to allow drainage of urine. Once the catheter is removed, some men fail to pass urine and need to be re-catheterised. In these men, continued use of catheters or prostate surgery are the standard treatment options. Catheters are associated with risks such as infection and can affect quality of life. Measures for increasing the rate of successful catheter removal, that is enabling patients to urinate spontaneously again, are therefore potentially beneficial. Alpha blockers (for example tamsulosin, alfuzosin) are a group of drugs known to have positive effects on urinary symptoms such as poor urinary flow. It is believed that their relaxing effect on the prostate may also increase the chance to void again after catheter removal. This review evaluated the evidence available to support this practice.

In five clinical trials men were either given a sugar tablet (placebo, inactive drug) or alpha blockers for one to three days (and in one study up to a maximum of eight days) before the catheter was removed. Neither patients nor doctors knew which type of tablet was given, to prevent the bias in reporting the results. The results suggested that alpha blocker treatment increased the chances of successful catheter removal and resumption of normal voiding although the overall scientific evidence available to support this was limited. Two different alpha blockers were tested (tamsulosin and alfuzosin). Their results were similar. Side effects caused by alpha blockers were few and comparable to placebo treatment. They included lack of ejaculation, dizziness, low blood pressure, fainting, sleepiness, feeling unwell and headache.

There was not enough evidence to say whether alpha blockers also reduce the risk of suffering another (recurrent) episode of urinary retention after successful catheter removal or whether they reduce the need for future surgery on the prostate. It is therefore unclear whether or for how long alpha blocker treatment should be continued after successful catheter removal and whether the costs of alpha blocker treatment in such situations are justified. Further research is needed to answer these questions.

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