pharmacologic treatment for bph
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bphTRANSCRIPT
Pharmacologic Treatment For BPH
Dr. Harnold P. Sihaloho, Sp. U
SMF UROLOGY RSUD Dr. Pirngadi Kota Medan
Anatomy of BPH Bladder
Anatomy of BPH
ProstateUrethra Obstructed
Urinary flow
HypertrophiedDetrusor muscle
Kirby RS, et al, eds benign Prostatic Hyperplasia, 5th ed. 1995
Pathophysiology of BPH• Size of the prostate does not always
correlate to symptom severity
• symptom severity depends on :* Ability of prostate capsule to expand* Location of hyperplasia with respect to urethra* Ability of bladder to compensate for the obstruction* Central nervous system influences
Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the long term care setting, Princeton CME,September 14 2007 WWW. Princetoncme.com
DHT
Nocturia and Frequency Most Nocturia and Frequency Most Common ComplaintsCommon Complaints
Nocturia occurs in 87 % of men over 50+Nocturia occurs in 87 % of men over 50+Frequency occurs in 71 % of men over Frequency occurs in 71 % of men over
50+50+Disrupts lifestyleDisrupts lifestyle Impacts productivityImpacts productivity
Grayhack JT, et al Benign prostatic hyperplasia In :Grayhack JT, et al Benign prostatic hyperplasia In : Gillenwater JJ, et al, eds. Adult and Pediatric Urology. Vol 2, 4 Gillenwater JJ, et al, eds. Adult and Pediatric Urology. Vol 2, 4 thth ed 2002 : ed 2002 :
1401-14701401-1470
Symptoms of LUTS/BPHSymptoms of LUTS/BPH
Obstructive SymptomsObstructive Symptoms Irritative Irritative SymptomsSymptoms
* Hesitancy* Hesitancy * Urgency* Urgency* Weak stream* Weak stream * Frequency* Frequency* Straining to pass urine* Straining to pass urine * Nocturia* Nocturia* Prolenged micturition* Prolenged micturition * Urge incontinence* Urge incontinence* Felling of incomplete Bladder emptying* Felling of incomplete Bladder emptying* Urinary retention* Urinary retention
LUTS/BPH and QualityLUTS/BPH and Quality of Life of Life
The Impact of BPH on the The Impact of BPH on the PatientPatient
Concern Over
Need For Surgery
Symptoms
ConcernOver RiskOf AUR
Bother
Interferenceand Quality
Of lifeConcern
Over Cancer
Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the long term care setting, Princeton CME,
September 14 2007 WWW. Princetoncme.com
Diagnostic Tests for BPHDiagnostic Tests for BPH AUASI = IPSSAUASI = IPSS DREDRE PSAPSA UrinalysisUrinalysis TRUSTRUS Urinary flow rate *Urinary flow rate * Postvoid residual * Postvoid residual * * Denotes optional testing.* Denotes optional testing. AUASI = American Urological Association Symptom indexAUASI = American Urological Association Symptom index
Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the long term care setting, Princeton CME,long term care setting, Princeton CME,
September 14 2007 WWW. Princetoncme.comSeptember 14 2007 WWW. Princetoncme.com
Differential Diagnosis of LUTSDifferential Diagnosis of LUTSProstateProstate
Obstruction ( BPH, BPE, BOO )Obstruction ( BPH, BPE, BOO )BladderBladder
* Detrusor overactivity* Detrusor overactivity* Impaired detrusor contractility* Impaired detrusor contractility* Sphincteric incontinence* Sphincteric incontinence* Polyuria/nocturnal polyuria* Polyuria/nocturnal polyuria
MedicationsMedications* Anthihistamines* Anthihistamines* Antidepressants* Antidepressants
Medical Therapy AlgorithmMedical Therapy AlgorithmPatien
IPSS ≤ 7 IPSS > 7
No or Little Bother
Moderate to Severe bother
Prostate SmallPSA Low
Prostate LargePSA Hight
Prostate SmallPSA Low
α adnenergicblocker
5α reductase InhibitorCombination Pα
Prostate LargePSA High
No Treatment
Prevertive Therapy ?5α Reductase Inhibitor
FISIOLOGI FISIOLOGI αα BLOCKERBLOCKER αα11- adreno receptors predominate in the - adreno receptors predominate in the
prostateprostate Prostatic smooth muscle is sympathhetically Prostatic smooth muscle is sympathhetically
innervatedinnervated Sympathetic nerve impluse result in release of Sympathetic nerve impluse result in release of
noradrenaline ( stored within nerve terminals )noradrenaline ( stored within nerve terminals ) Into the synaptic cleft Into the synaptic cleft bind by bind by αα11--
adrenoreceptorsadrenoreceptors αα11-adrenoreceptors simulation -adrenoreceptors simulation Influx Influx
intracellularintracellular CaCa++ ++ smooth muscle contraction smooth muscle contraction
Alpha BlockerAlpha Blocker Kontraksi otot polos prostat : alpha – receptor Kontraksi otot polos prostat : alpha – receptor
mediated sympathetic stimulationmediated sympathetic stimulation Kontraksi otot polos ( kapsul, adenoma, leher Kontraksi otot polos ( kapsul, adenoma, leher
buli-buli) : kontribusi 40 % obstruksibuli-buli) : kontribusi 40 % obstruksi Alpha blocker :Alpha blocker :
Relaksasi otot polos prostatRelaksasi otot polos prostat Mengurangi keluhanMengurangi keluhan Memperbaiki pancaran kencingMemperbaiki pancaran kencing
Distribution of Distribution of αα- Adrenoreceptors- Adrenoreceptorsin the Lower Urinary Tractin the Lower Urinary Tract
Steven A Kaplan, MD Department of Urology, College of Physicians & Surgeons, Columbia University, New York, NY
αα-Blockers-Blockers NonselectiveNonselective
- Phenoxybenzamine- Phenoxybenzamine Short-acting selective Short-acting selective αα1-blocker1-blocker
- Prazosin- Prazosin Long-acting selective Long-acting selective αα1-blocker1-blocker
- Alfuzosin- Alfuzosin- Doxazosin- Doxazosin- terazosin- terazosin
Long-acting selective Long-acting selective αα1-subtype1-subtype- Tamsulosin- Tamsulosin
Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the long term care Mc Vary K, Medication Management of Benign Prostatic Hyperplasia in the long term care setting, Princeton CME,setting, Princeton CME,
September 14 2007 WWW. Princetoncme.comSeptember 14 2007 WWW. Princetoncme.com
5- reduktase inhibitor - finasteride
- episteride- dutastride
mekanisme kerja menghambat perubahan hormon testosteron DHT
T DHT
Decrease in volume
IndicationIndication BPH No complicationBPH No complication IPSS : 8 – 18IPSS : 8 – 18 Q max : 10 – 15Q max : 10 – 15Contra Indication :Contra Indication :
HypotensionHypotensionHypersensitive reactionHypersensitive reactionAcute or chronic urinary retentionAcute or chronic urinary retention
- Renal insufisiensiRenal insufisiensi- Recurren hematuriaRecurren hematuria- Recurren urinary tract infectionRecurren urinary tract infection- Vesicolithiasis or Baladder diverrticulaVesicolithiasis or Baladder diverrticula
Adverse EventsAdverse Events
AdverseAdverseEffectEffect
TerazosinTerazosin(n = 636)(n = 636)
PlaceboPlacebo(n = 360)(n = 360)
Asthenia/fatigueAsthenia/fatigue 7.4%7.4% 3.3%3.3%PosturalPostural 3.9%3.9% 0.8%0.8%hypotensionhypotensionDizzinessDizziness 9.1%9.1% 4.2%4.2%
SomnolenceSomnolence 3.6%3.6% 1.9%1.9%Nasal congestion/Nasal congestion/ 1.9%1.9%** 00
Rhinitis ImpotenceRhinitis Impotence 1.6%1.6%** 0.6%0.6%
Terazosin Adverse Effects
Doxazosin Adverse EffectsDoxazosin Adverse Effects
AdverseAdverseEffectEffect
DoxazosinDoxazosin(n = 665)(n = 665)
PlaceboPlacebo(n = 300)(n = 300)
DizzinessDizziness(includes (includes
vertigo)vertigo)15.6%15.6%** 9.0%9.0%
FatigueFatigue 8.0%8.0%** 1.7%1.7%HypotensionHypotension 1.7%1.7%** 00EdemaEdema 2.7%2.7%** 0.7%0.7%DyspneaDyspnea 2.6%2.6%** 0.3%0.3%
Tamsulosin Adverse EffectsTamsulosin Adverse Effects
Adverse Adverse EffectEffect
Tamsulosin Tamsulosin 0.4 mg0.4 mg
(n = 502)(n = 502)
Tamsulosin Tamsulosin 0.8 mg0.8 mg
(n = 492)(n = 492)
PlacePlacebobo
(n = (n = 49493)3)
DizzinessDizziness 14.9%14.9% 17.1%17.1% 10.110.1%%
Abnormal Abnormal ejaculatioejaculationn
8.4%8.4% 18.1%18.1% 0.2%0.2%
AstheniaAsthenia 7.8%7.8% 8.5%8.5% 5.5%5.5%Libido Libido
decreaseddecreased 1.0%1.0% 2.0%2.0% 1.2%1.2%
AmblyopiaAmblyopia 0.2%0.2% 2.0%2.0% 0.4%0.4%
Alfuzosin Adverse EffectsAlfuzosin Adverse Effects
Adverse EffectAdverse Effect AlfuzosinAlfuzosin(n = 473)(n = 473)
PlaceboPlacebo(n = 678)(n = 678)
Upper Upper respiratoryrespiratory
tract infectiontract infection3.0%3.0% 0.6%0.6%
DizzinessDizziness 5.7%5.7% 2.8%2.8%HeadacheHeadache 3.0%3.0% 1.8%1.8%FatigueFatigue 2.7%2.7% 1.8%1.8%
5α Reductase inhibitor adverse effect
Common adverse drugs reactions include :Common adverse drugs reactions include : ImpotenceImpotenceDecreased libidoDecreased libidoDecreased ejaculate volumeDecreased ejaculate volume
Rare : breast tendernes and enlargment.Rare : breast tendernes and enlargment.
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