MEDICAL TREATMENT IN BPH
BPH PREVALENCE Pathological process start at age 40
years 50% in men > 60 years* 90% in men > 85 years* 90% in men 50-80 years** Second most frequent in urology in
Indonesia
*AUA practice guidelines committee. J.Urol.2003,170** MSAM-7 Eur Urol. in press 2004
SYMPTOMS OF LUTSStorage (irritative)
symp• Frequency• Nocturia• Urge
Voiding (obstructive) symp
• Weak stream• Hesitancy• Intermittency• Straining• Residual volume Post micturition symp
• Post micturition dribbling
• Sensation of incomplete emptying
Staticcomponent
Dynamiccomponent
LUTS
PATHOPHYSIOLOGY
STATIC COMPONENT
• Prostate mass (volume)• Urethral closure pressure
DYNAMIC COMPONENT
• Bladder pressure• Prostate smooth muscle tone:
• in stroma• capsule• bladder neck
DYNAMIC COMPONENT Depends on smooth muscle tone Associated with adrenergic stimuli* adrenergic receptors located in
smooth muscle cells of prostate, capsule, bladder neck, Trigone**
Blockade of adrenergic receptors resulting in lowering of the smooth muscle tone
* Eri LM Treter KJ. J.Urol,1955; 184** Caine et al. Br J Urol, 1976;48
-ADRENERGIC BLOCKING AGENT SELECTIVITY
• Non selective adrenergic blocking agent : blocks 1 and 2 receptors
• Selective adrenergic blocking agent : bloks only 1 receptor
TYPES OF ADRENERGIC BLOCKING AGENT
Non selective1 short acting
1 long acting
1a long acting
- Phenoxybenzamine- Prazosin- IR Alfuzosin- Doxazosin- Terazosin- SR Alfuzosin- XL Alfuzosin- Tamsulosin
Type Generic name
IR : Immediate releaseSR : Sustained releaseXL : Prolonged release
HALF LIFE
Prazosin (1979 Hedlund)Doxazosin (1995)Alfuzosin (1998)Terazosin (1992)Tamsulosin (1998)
2 – 3223 – 4 (IR)1210 - 13
Substance Half life (hours)
DOSAGE IN INDONESIA
• Doxazosin• Terazosin• Tamsulosin• Alfuzosin XL
1-2 mg once a day1-2 mg once a day0,2 mg once a day10 mg once a day
SAFETY OF BLOCKING AGENT
Doxazosin
Alfuzosin
• Metabolized in liver• no effect to lipid profile and glucose tolerance• dose titration
• No penetration to liquor• minimal effect to blood pressure• cardiovascular effect (?)• sexual function (?)
SAFETY OF BLOCKING AGENT
Terazosin
Tamsulosin
• dose dependent (1-10mg)• dose titration necessary• given in the evening
• fast onset• retrograde ejaculation (<2%)
5 REDUCTASE INHIBITOR
Rationale
Testosteron 5 reductase
5 reductase inhibitor
DHT
Prostate volume reduced by 20 – 30 % after 3 months of treatment
5 REDUCTASE INHIBITOR
5 reductase inhibitor
FINASTERIDEDOSAGE : 5 MG/DAY
• reduces libido• ED• reduced ejaculate• lowering PSA
DUTASTERIDEDosage 0,5 mg/day
Symptom ScoreQ maxProstate volIncidence of AURBetter than finasteride
PHYTOTHERAPYSpecies
Serenoa repens Hypoxis rooperi Pygeum africanum Urtica dioica Secale cereale Cucurbita pepo Countia Pinus Picea
Generic name Saw palmetto berry South African star grass African plum tree Stinging nettle Rye pollen Pumpkin seed Cactus flower Pine flower Spruce
MECHANISM OF ACTION OF PHYTHOTHERAPY
Anti inflammation through prostaglandin metabolism
Similar to 5 reductase inhibitor Inhibition of growth factors production
(FGF, EGF)
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