Up to date in LUTS treatment Dan Stanca sept 2015Up#to#date#in#LUTS# treatment! Dan!Vasile!Stanca!...
Transcript of Up to date in LUTS treatment Dan Stanca sept 2015Up#to#date#in#LUTS# treatment! Dan!Vasile!Stanca!...
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Up to date in LUTS treatment
Dan Vasile Stanca Clinica Urologică, Spitalul Clinic Municipal Cluj-‐Napoca
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RPM 200 mL Qmax 16,6 mL/s PSA 1,1 V prostaFc 35 mL
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RPM 200 mL Qmax 16,6 mL/s PSA 1,1 V prostaFc 35 mL
Dacă amână urinatul, urinează greu. Dacă merge la prima senzație, urinează foarte bine -‐ de când se șFe -‐
Tratament?
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• Serenoa repens + • alfa 1 blocant
• control după 30 zile – clinic staționar
Qmax 27,2 ml/s RPM 0
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?!
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V urinar 700 + 200 ml RPM
V urinar 382 ml RPM
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HBP sau LUTS?
• în trecut (prezent?): – orice tulburare a micțiunii = HBP („prostaFsm”)
• cuanFficarea simptomelor: chesFonarul IPSS (InternaFonal Prostate Symptom Score)
– tratamentul tulburării micționale= tratamentul HBP • fitoterapie / alfablocant / 5ARI
• TURP/open
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HBP sau LUTS?
• disurie • polakiurie • poliurie • poliurie nocturnă • urgență micțională • jet urinar slab • ...
alfablocant / 5ARI / fitoterapie TURP/open
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HBP sau LUTS?
Nu toți pacienții au LUTS din cauza prostatei
Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. Worldwide prevalence es0mates of lower urinary tract symptoms, overac0ve bladder, urinary incon0nence and bladder outlet obstruc0on. BJU Int. 2011 Oct;108(7):1132-‐8. doi: 10.1111/j.1464-‐410X.2010.09993.x. Epub 2011 Jan 13
Prevalența mondială
Cel puțin un LUTS 45,2%
OAB 10,7%
UI 8,2%
LUTS din cauza BOO 21,5%
aceșFa vin la consultație
pentru aceșFa sunt tratamentele BPH
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Revoluționare a modului de abordare a pacientului cu LUTS -‐ Tractul urinar inferior = unitate funcțională
-‐ vezica urinară, sfincterele urinare, prostata, uretra -‐ gândire ”funcțională”, nu ”anatomică” -‐ egalitatea între sexe
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Ghidurile EAU se aplică pacientului cu simptome urinare • adenomul prostaFc • vezica urinară hiperacFvă • poliuria nocturnă
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Terminologie actuală
• HBP (hiperplazie benignă de prostată) – termen histopatologic – focare de hiperplazie celulară intraprostaFcă
• BPE (benign prostaFc enlargement) – termen clinic – prostată mărită în volum (TR, ecografie)
• BOO (obstrucția colului vezical) – termen funcțional – clinic, ecografic, urodinamic
• LUTS (lower urinary tract symptoms) – simptome clinice – anamneză
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Evaluarea pacientului cu LUTS A. eFologia și mecanismul fiziopatologic al LUTS
– prostata – vezica urinară – poliuria nocturnă
B. gravitatea LUTS – anamneză, chesFonare
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A. EFologia și mecanismul fiziopatologic al LUTS
1. prostata (HBP) – acționează prin obstrucție urinară • simptome: disurie, jet urinar slab, ezitant, dribbling terminal • ecografie: RPM • uroflowmetrie: Qmax, durata micFunii, aspectul curbei, Fme to the max
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A. EFologia și mecanismul fiziopatologic al LUTS
1. prostata (HBP) – acționează prin obstrucție urinară • simptome: disurie, jet urinar slab, ezitant, dribbling terminal • ecografie: RPM • uroflowmetrie: Qmax, durata micFunii, aspectul curbei, Fme to the max
2. vezica urinară – alterarea proprietăților peretelui vezical, cu complianță -‐-‐-‐,
hiperexcitabilitate, fibroză, contracFlitate-‐-‐-‐ • simptome de stocare: micțiuni imperioase, inconFnență urinară prin urgență • jurnalul micțional • urodinamică (facultaFv)
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A. EFologia și mecanismul fiziopatologic al LUTS
1. prostata (HBP) – acționează prin obstrucție urinară • simptome: disurie, jet urinar slab, ezitant, dribbling terminal • ecografie: RPM • uroflowmetrie: Qmax, durata micFunii, aspectul curbei, Fme to the max
2. vezica urinară – alterarea proprietăților peretelui vezical, cu complianță -‐-‐-‐,
hiperexcitabilitate, fibroză, contracFlitate-‐-‐-‐ • simptome de stocare: micțiuni imperioase, inconFnență urinară prin urgență • jurnalul micțional • urodinamică (facultaFv)
3. poliuria nocturnă/diurnă – diureză excesivă. Aparat urinar inferior normal • simptome: trebuie să se trezească noaptea pentru a urina, edeme • jurnal micțional+++
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Tratamentul pacientului cu LUTS
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Tratamentul pacientului cu LUTS
A. obiec0vele tratamentului
B. mijloace disponibile
C. strategii de tratament
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A. ObiecFvele tratamentului
• pacientul are LUTS – tratamentul este în principal simptoma0c
• nu avem terapii eFologice • LUTS pot fi interpretate ca semn al îmbătrânirii/uzării tractului urinar
• Fpul de tratament este dictat de – simptomele pacientului – mecanismul fiziopatogeneFc – riscul de evoluție a afecțiunii de bază
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B. Mijloace terapeuFce disponibile
• modificarea sFlului de viață
• medicamente
• chirurgia obstrucției subvezicale
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VU foarte desFnsă (>400-‐500 ml) – arhitectura detrusorului compromisă
• raportul spațial între fasciculele musculare
– forță de contracție redusă • Qmax mic • RPM • senzație de golire incompletă
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Medicamente
• alfa 1 blocante • anFmuscarinice • beta 3 mimeFce • 5 ARI • fitoterapice • PDE5I
• combinații ale acestora
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Alfa 1 blocante • relaxează musculatura netedă din
stroma prostatei și sfincterul neted vezical
• efect instalat foarte rapid
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Alfa 1 blocante
36 Qmax IPSS
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Alfa 1 blocante • relaxează musculatura netedă din stroma prostatei și sfincterul neted
vezical • efect instalat foarte rapid
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Alfa 1 blocante
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Alfa 1 blocante • eficacitate similară • profil diferit de efecte adverse
– hipotensiune ortostaFcă • selecFvitatea față de α1a vs. α1b
– anejaculare • efect excesiv asupra sfincterului neted vezical
Tamsulosin
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• Alpha1-‐blockers can be offered to men with moderate-‐to-‐severe LUTS/ – (LE)1a (GR)A
• Alpha1-‐blockers are oven considered the first-‐line drug treatment of male LUTS because of their rapid onset of acFon, good efficacy, and low rate and severity of adverse events
• Alpha1-‐blockers are able to reduce both storage and voiding LUTS. Prostate size does not affect α1-‐blocker efficacy in studies with follow-‐up periods of less than one year
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AnFmuscarinice • reduc spasFcitatea
detrusorului prin blocarea receptorilor M3 – efect instalat rapid – indicate pacienților cu
simptome de stocare vezicală
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Efecte adverse
• uscăciunea gurii • uscăciunea conjuncFvelor • consFpație • disfuncție cogniFvă
iris lacrimal glands
salivary glands
heart
gall bladder
stomach
colon
detrusor
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AnFmuscarinice
• Efecte adverse – selecFvitate M1 vs M2 vs M3
– solifenacina
– disfuncția cogniFvă • vârstnici
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Beta 3 mimeFci
• mirabegron
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fitoterapice
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PDE5-‐I
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desmopresin
• simptomaFc • poliuria nocturnă • <65 ani – risc de hiposodemie
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5ARI: dutasterida, finasterida
• acționează patogeneFc • intră în combinații terapeuFce cu un simptomaFc
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C. Strategii de tratament
• pacientul are simptome – terapie simptomaFcă: α1b, aM, β3 mimeFc, PDE5I, desmopresin... – mai multe Fpuri de simptome – mai multe Fpuri de simptomaFce
• escaladarea terapiei
• unii dintre pacienții cu LUTS sunt la risc de progresie – la terapie simptomaFcă se asociază terapie patogeneFcă
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Creșterea eficienței terapiei
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• 2 loturi de pacienți cu LUTS
– terapie standard
– terapie standard + self management: • educație, sfaturi pentru sFl de viață
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Take home messages (1)
• funcție vs. anatomie – aparatul urinar inferior = unitate funcțională
• există LUTS și fără HBP!
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Take home messages (2)
• controlul consumului de lichide – de evitat supraîncărcarea aparatului urinar
• tratament simptomaFc – uneori este necesară asocierea simptomaFcelor
• terapie de lungă durată – efectele adverse sunt relevante
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Take home messages (3) • alfa 1 blocante
– selecFvitate – efect excesiv asupra sfincterului neted vezical
• anFmuscarinice – selecFvitate – disfuncție cogniFvă
• beta 3 mimeFce
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Take home messages (4)
• Self-‐management – creșterea eficienței medicației