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LUTS ~ BPH

(Benign Prostate Hyperplasia)

Dr. dr. Nur Rasyid SpU (K)

Departemen Urologi FKUI - RSCM


LUTS
BPH

n Normal Size of the young adult is 15-20 cc.

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
BPH Prevalence
BPH

Benign prostatic hyperplasia (BPH) is a histologic diagnosis


that refers to the proliferation of smooth muscle and
epithelial cells within the prostatic transition zone
McVary KT. Update on AUA guideline on the management of benign
prostatic hyperplasia. J Urol. 2011;185(5):1793-803.
Patophysiology

Voiding problems Voiding symptoms

Bladder aging
Neuropathic Storage problems Storage symptoms
BPH Symptoms
Voiding (obstructive)
Symptoms Storage (irritative or filling
symptoms
Hesitancy
Urgency
Weak stream
Frequency
Straining to pass urine
Nocturia
Prolonged micturition
Urge incontinence
Feeling of incomplete
bladder emptying
Urinary retention

DR
BPH Symptoms
DIAGNOSTIC EVALUATION
Medical History
Symptom score questionnaires
The International Prostate Symptom Score (IPSS)
Frequency volume charts and bladder diaries
Physical examination and digital-rectal examination
Digital-rectal examination and prostate size evaluation
Urinalysis, Prostate-specific antigen (PSA),
PVR, uroflowmetry.
etc
International Prostate Symptom Score
(IPSS)

Score / Severity
0-7 Mild
8 - 19 Moderate
Barry MJ et al. J Urol 1992;148:1549-57. 20 - 35 Severe
DRE & TRUS prostat

TRUS prostat
Digital-rectal examination (transrectal ultrasonography)
Method of Digital Rectal
Examination (DRE)
COLOK DUBUR ~ Rectal Touche (RT)
Yang terpenting
Prostat keras,
nodul, atau asimetri
staging T
(tumor)

Curiga (+) pada RT


dg PSA < 2ng/ml
(+) Ca P = 5-30%
Uroflometry
Uroflowmetri
LE GR
Uroflowmetry disarankan untuk penegakan diagnosis awal 1b A
dan harus dilakukan sebelum terapi

Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak IAUI. 2015


Pemeriksaan PSA

Bisa Meningkat pada :


1.BPH : Pembesaran Prostat Jinak
2.Prostatitis : Akut & Koronis
3. Kanker Prostat

Total PSA : < 4ng/ml (Nilai Normal )


Untuk screening awal Kanker Prostat
Prediktor yang lebih baik daripada Colok Dubur &
USG TransRectal (TRUS)
Pemeriksaan PSA
Total PSA< 4 ng/ml

Free PSA ( bila PSA 4-10)


Rasio Free/Total PSA ~ (+)CaP pada Biopsi
< 0,10 56%
> 0.25 8%

PSA velocity / percepatan peningkatan PSA _


Kurang bermanfaat untuk diagnosis CaP
monitoring pengobatan CaP
Diagnosis kanker prostat
Indikasi biopsi:

Kecurigaan pada pemeriksaan colok dubur


PSA > 4 ng/ml
PSA-D ( kadar PSA/volume prostat) > 0.15 bila
kadar PSA antara 2 4 ng/ml.
Peningkatan PSA : (>0.75-1.0 ng/dL/yr)
Who is at risk of BPH disease
progression?
Older age (> 60 years)
Moderate-to-severe symptoms (IPSS > 8)
Low urinary flow rate (Qmax <10.6mL / s)
Enlarged prostate (PV > 30mL)
Increased PSA level ( 1.5 ng/mL)

1. McConnell J et al. N Engl J Med. 2003;349:23872398; 2. Emberton M et al. IJCP. 2008;62:10761086; 3. Emberton M et al. BJU Int.
2011;107:876880.
BPH Management: treatment

Conservati Medical MIST (Minimally Surgical


ve treatment invasive Surgical treatment
Therapy)
Watchful 1 adrenergic TUNA Open
waiting blocker prostatectomy
Dietary 5-ARI Thermotherapy TUIP/TURP
Modification
Antimuscarinic Urolift TUVP
PDE-5 inhibitor Laser
Prostatectomy
Combination
Phytotherapy
Medical Treatment
IPSS > 7

Gratzke C. Eur Urol. 2015;67(6):1099-109.


Medical Treatment

- Alpha blocker
- Androgen suppression (5 ARIs)
- PDE 5 Inhibitor
- Combination Therapy
- Phytotherapy

DR
BPH Medical Treatment Options
- blockers
Mechanism of action: 1-blockers aim to inhibit
the effect of endogenously released noradrenaline
on smooth muscle cells in the prostate and
thereby reduce prostate tone and BOO
Molecular studies have further identified three
subtypes of the 1-AR(1A, 1B, and 1D).
Their relative distribution and concentration in the
prostate, bladder, neck, brain, and vascular
smooth muscle have been exploited to develop
uroselective 1-adrenergic antagonists and reduce
side effects.
Gratzke C. Eur Urol. 2015;67(6):1099-109.
Dhingra. Indian J Pharmacol. 2011;43(1):6-12.
Type of Alpha Adrenergic Receptor

1A 1B 1D
Primary subtype expressed in the Primary subtype expressed in the Primary subtype expressed in the
prostate. Regulates contraction blood vessels. Regulates bladder, spinal cord, and nasal
of the smooth muscle in the contraction of arterial blood passages. Thought to play a role
prostate, bladder base and neck, vessels in response to postural in bladder symptoms and nasal
urethra, seminal vesicles, and redistribution of blood volume.4-7 secretions.1,6
vas deferens.8-12

1. Schwinn DA, . Int J Urol. 2008;15:193-199.


2. Kaplan SA. Urology. 2004;63:428-434. 5. Carbone DJ, . Int J Impotence Res. 2003;15:299-306.
3. Nasu K, . Br J Pharmacol. 1996;119:797-803. 6. Stafford-Smith M, . Can J Anesth. 2007;54:549-555.
4. Murata S, . J Urol. 2000;164:578-583. 7. Townsend SA, . Hypertension. 2004;44:776-782.
- blockers
Practical considerations:
Alpha1-blockers are often considered the first-line drug
treatment of male LUTS because of their rapid onset of
action, good efficacy, and low rate and severity of
adverse events.
Doxazosin Non Selective Alpha Blocker
Terazosin
Alfuzosin

Tamsulosin Selective Alpha Blocker


Silodosin

Silodosin is the newest selective alpha 1 Blocker


Gratzke C. Eur Urol. 2015;67(6):1099-109.
Pharmacologic Selectivity Profiles of 1-Blockers

1-Blocker 1-Receptor Selectivity


Doxazosin1 1A = 1D = 1B

Terazosin1 1A = 1D = 1B

Alfuzosin1 1A = 1D = 1B

Tamsulosin1,2 1A = 1D >1B

Silodosin3 1A >1D >1B


Results based on in vitro data

1. Schwinn DA, et al. Mayo Clin Proc. 2004;79:1423-1434.


2. Kenny BA, et al. Br J Pharmacol. 1996;118:871-878.
3. Akiyama K, et al. J Pharm Exp Ther. 1999;291:81-91.
Silodosin: High uroselectivity in Alpha 1A

Silodosin has extremely higher selectivity for a1A-AR compared


with other a1AR blockers (162 times)
Tatemichi S et al., Yakugaku Zasshi 126: 209-216 (2006)
% of patients with a simultaneous improvement
in 3 of the most bothersome symptoms

Statistically significant superiority vs


tamsulosin on simultaneous
improvement of frequency, nocturia
and incomplete emptying
(EU study - post hoc analysis)

Montorsi F., Eur. Urol. Suppl. 2010; 9: 491-495.


5 ARI (5-alpha reductase inhibitors)
Prostate growth is stimulated by androgenic hormones,
especially dihydrotestoster-one.
Finasteride and dutasteride inhibit the conversion of
testosterone to dihydrotestosterone, suppressing
prostate growth.
These agents appear to be most beneficial when the
prostate volume is 40 mL or greater.
The 5-alpha reductase inhibitors do not provide
immediate symptom relief, and approximately six months
of therapy is required to achieve clinical benefit

Edwards J. Am Fam
5 ARI
Practical considerations:
Treatment with 5-ARIs should be considered
in men with moderate-to-severe LUTS and an
enlarged prostate (> 40 mL) and/or elevated
PSA concentration (> 1.4-1.6 ng/mL). Due to
the slow onset of action, they are suitable
only for long-term treatment (years).
Their effect on the serum PSA concentration
needs to be considered for prostate cancer
screening.
Gratzke C. Eur Urol. 2015;67(6):1099-
- blocker vs 5 ARI

Lepor H. Rev Urol 2007; 9: 181-190;


Tanguay S et al. Can Urol Assoc J 2009; 3: S92-S100
Algoritma Tata Laksana Pilihan Terapi Medikamentosa
IAUI Guideline 2017
Pria diduga BPH dengan indikasi
tatalaksana medikamentosa

Tidak Gejala yang Ya


mengganggu?

Tidak Gejala
storage yang Poliuria nokturnal
Tidak yang dominan?
paling
Volume prostat dominan?
> 30 ml?

Tidak Ya
Ya
Ya
Edukasi & modifikasi
gaya hidup dengan/tanpa Tata laksana
-blocker Tidak jangka panjang?

Ya
Gejala storage
residual

Konservatif Edukasi & modifikasi Edukasi & Edukasi dan


dengan/tanpa Tambahkan gaya hidup modifikasi gaya modifikasi gaya
edukasi & modifikasi Antagonis Reseptor dengan/tanpa 5 ARI hidup dengan/tanpa hidup
gaya hidup Muskarinik 1-blocker /PDE5I* Antagonis Reseptor
Muskarinik
33
Ref: IAUI guideline 2017. Panduan Penatalaksanaan Klinis Pembesaran Prostat Jinak (BPH). Januari 2015.
Surgery
Surgery is recommended for patients who have
Renal insufficiency secondary to BPH,
Recurrent urinary tract infections (UTIs),
Gross hematuria due to BPH, or
Bladder stones,
LUTS refractory to other therapies.

The presence of a bladder diverticulum is not an


absolute indication surgery unless associated with
recurrent UTI or progressive bladder dysfunction.
Take home message
The successful management of patients with
LUTS associated with BPH should include
assessments of QoL and monitoring of
medication-related side effects
Alpha blocker gives fast and effective relief of
bothersome symptoms
5ARI should give by indications
Individualized your patients treatment >
Selective Alfa 1 Blocker
Thank you

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