Up to date in LUTS treatment

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1 Up to date in LUTS treatment Dan Vasile Stanca Clinica Urologică, Spitalul Clinic Municipal Cluj- Napoca

2 RPM 200 ml Qmax 16,6 ml/s PSA 1,1 V prostafc 35 ml

3 Tratament? 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 -

4 Serenoa repens + alfa 1 blocant control după 30 zile clinic staționar Qmax 27,2 ml/s RPM 0

5 ?!

6 V urinar 382 ml RPM V urinar ml RPM

7 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

8 HBP sau LUTS? disurie polakiurie poliurie poliurie nocturnă urgență micțională jet urinar slab... alfablocant / 5ARI / fitoterapie TURP/open

9 HBP sau LUTS? Nu toți pacienții au LUTS din cauza prostatei Prevalența mondială Cel puțin un LUTS 45,2% aceșfa vin la consultație OAB 10,7% UI 8,2% LUTS din cauza BOO 21,5% pentru aceșfa sunt tratamentele BPH 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 Oct; 108(7): doi: /j X x. Epub 2011 Jan 13

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12 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

13

14 Ghidurile EAU se aplică pacientului cu simptome urinare adenomul prostafc vezica urinară hiperacfvă poliuria nocturnă

15 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

16 Evaluarea pacientului cu LUTS A. efologia și mecanismul fiziopatologic al LUTS prostata vezica urinară poliuria nocturnă B. gravitatea LUTS anamneză, chesfonare 16

17 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 17

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21 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) 21

22 22

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24 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+++ 24

25

26 Tratamentul pacientului cu LUTS

27 Tratamentul pacientului cu LUTS A. obiec0vele tratamentului B. mijloace disponibile C. strategii de tratament

28 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

29 B. Mijloace terapeufce disponibile modificarea sflului de viață medicamente chirurgia obstrucției subvezicale 29

30

31 VU foarte desfnsă (> ml) arhitectura detrusorului compromisă raportul spațial între fasciculele musculare forță de contracție redusă Qmax mic RPM senzație de golire incompletă

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34 Medicamente alfa 1 blocante anfmuscarinice beta 3 mimefce 5 ARI fitoterapice PDE5I combinații ale acestora 34

35 Alfa 1 blocante relaxează musculatura netedă din stroma prostatei și sfincterul neted vezical efect instalat foarte rapid

36 Alfa 1 blocante Qmax IPSS 36

37 Alfa 1 blocante relaxează musculatura netedă din stroma prostatei și sfincterul neted vezical efect instalat foarte rapid

38 Alfa 1 blocante

39 Alfa 1 blocante eficacitate similară profil diferit de efecte adverse hipotensiune ortostafcă selecfvitatea față de α 1a vs. α 1b anejaculare efect excesiv asupra sfincterului neted vezical Tamsulosin

40 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

41 AnFmuscarinice reduc spasfcitatea detrusorului prin blocarea receptorilor M3 efect instalat rapid indicate pacienților cu simptome de stocare vezicală

42 Efecte adverse uscăciunea gurii uscăciunea conjuncfvelor consfpație disfuncție cognifvă iris lacrimal glands salivary glands heart gall bladder stomach colon detrusor

43 AnFmuscarinice Efecte adverse selecfvitate M1 vs M2 vs M3 solifenacina disfuncția cognifvă vârstnici

44 mirabegron Beta 3 mimefci

45 fitoterapice 45

46 PDE5- I 46

47 desmopresin simptomafc poliuria nocturnă <65 ani risc de hiposodemie 47

48 5ARI: dutasterida, finasterida acționează patogenefc intră în combinații terapeufce cu un simptomafc 48

49 C. Strategii de tratament pacientul are simptome terapie simptomafcă: α 1 b, am, β 3 mimefc, PDE 5 I, 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 49

50 Creșterea eficienței terapiei 50

51 2 loturi de pacienți cu LUTS terapie standard terapie standard + self management: educație, sfaturi pentru sfl de viață 51

52 52

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54 Take home messages (1) funcție vs. anatomie aparatul urinar inferior = unitate funcțională există LUTS și fără HBP! 54

55 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 55

56 Take home messages (3) alfa 1 blocante selecfvitate efect excesiv asupra sfincterului neted vezical anfmuscarinice selecfvitate disfuncție cognifvă beta 3 mimefce

57 Take home messages (4) Self- management creșterea eficienței medicației

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