SlideShare ist ein Scribd-Unternehmen logo
1 von 65
Downloaden Sie, um offline zu lesen
MEDICAL MANAGEMENT OF LUTS/BPH 
& 
RECENT ADVANCES 
Bikash Bk. Thapa 
MS – General Surgery
Introduction
Component of BOO 
• A dynamic (physiologic, reversible) component 
– related to the tension of prostatic smooth muscle 
in the prostate, prostate capsule, and bladder 
neck 
• A fixed (structural) component 
– related to the bulk of the enlarged prostate 
impinging upon the urethra
Association of BOO 
• Voiding Dysfunction 
– BPO- muscle hypertrophies- decompensation- reduced 
expression of connexin 43- impairs synchronise contraction-contractile 
dysfunction 
• Storage Dysfunction 
– cycle of urine storage and voiding causes repeated bladder 
distension, raised intravesical pressure, ischemia, reperfusion 
– Impaired vesical blood flow results in oxidative stress, with free 
radicals causing damage to the urothelium, nerves, and smooth 
muscle.
Pathogenesis 
• Hormonal 
• Dysregulation of stromal growth factors 
• Reawakening of embryonic process 
• Decrease cell death 
• Genetic susceptibiltiy
Role of Androgen
New Hypothesis 
• BPH is caused by malfunction of the valves in the 
internal spermatic vein manifesting as varicocele 
– Elevated venous pressure causes hypertrophy and 
exposure to high concentration of free testosterone 
causes hyperplaisa of prostate 
• Involvement of adrenergic nerves in prostatic 
hyperplasia. 
• Cytokines derived from inflammatory cells also 
induce epithelial growth factors
Summary
Diagnosis 
• History 
• Assessment of symptoms and QOL 
• Physical Examination 
• Urine Analysis 
• Uroflowmetry 
• PVR 
• PSA 
• Prostate Ultrasound 
• Case Sensitive and Elective 
– bladder diary, pressure-flow studies, serum creatinine 
measurements,and ultrasonography of the upper urinary 
tract.
Severity Index
Current treatment options 
• Conservative treatment 
• Alpha blockers 
• 5-alpha-reductase inhibitors (5ARIs) 
• Combination therapy 
• Phytotherapy 
• Minimally invasive techniques 
• Surgery
Goal of treatment 
• Relieving LUTS 
• Decreasing BOO 
• Improving bladder emptying 
• Ameliorating overactive bladder activity 
• Reversing renal insufficiency 
• Preventing disease progression
Efficacy index
Watchful waiting 
• Patient selection 
• Education, 
• Reassurance, 
• Periodic monitoring, 
• Lifestyle advice
Watchful waiting 
• Patient selection 
• Education, 
• Reassurance, 
• Periodic monitoring, 
• Lifestyle advice
Life Style Advice 
• Reduction in fluid intake 
• Avoidance of moderation of caffeine and alcohol 
• Double voiding technique 
• Urethral stripping 
• Distraction- mind out of bladder n toilet 
• Bladder retraining- Hold on 
• Optimising drugs 
• Treatment of constipation
Treatment Goals of Medical Therapy
Alpha – Blocker 
1a, 1b, 1d
Pharmacotherapy 
• Non selective alpha blockers 
– Phenoxybenzamine 
• Selective short acting (alpha 1) 
– Prazosin, Alfuzosin, Indoramin 
• Selective long acting (alpha1, all three type) 
– Terazosin, Doxazosin, Alfuzosin SR 
• Partially subtype (alpha 1a) 
– Tamsulosin, Sildosin 
• Partially subtype ( alpha 1d) 
– Naftopidil, Tamsulosin
Medical management of bph
Medical management of bph
Drug Saftey 
• Asthenia 
• Diziness 
• Nasal congestion 
• Postural hypertension 
• Co-medication 
• anejaculation 
• Intraoperative floppy iris syndrome 
– Miosis, iris billowing, iris prolapse
α-blockers should be offered to men with 
moderate to severe LUTS. 
• a1-adrenoceptor antagonists can result in a 
16–25% (2.0–2.5 mL/s) increase in maximum 
flow rate and a 30–40% (4–6 point) reduction 
in the average IPSS.
5 alpha Reductase inhibitor 
Dutasteride 
Finasteride 
Type II 5AR 
Testosterone DHT 
Dutasteride 
Prostate 
volume 
reduced 
Type I 5AR 
Bartsch G et al. Eur Urol. 2000;37:367380.
Clinical role of dual inhibition remains 
unclear 
Reduce LUTS (IPSS) by approximately 15-30%, 
Decrease prostate volume by 18-28% and 
Increase Qmax by 1.5-2.0 ml/s 
PSA dec by 50% 
Dec hematuria 
Inc apoptotic index of stromal and epithelial cell 
Dec detrusor pressure at Qmax
Proscar Long-Term Efficacy and Safety Study (PLESS)
Medical management of bph
Medical management of bph
Combination Therapy & 
Short term Efficacy 
• In the Veterans Affairs Cooperative Study, 1229 men with BPH (mean peak 
urinary flow rate of 10.5 mL/sec) were randomly assigned to placebo, 
finasteride (5 mg/day), terazosin (10 mg/day), or both for one year 
Terazosin lowered the symptom score and increased the peak 
urinary flow rate when compared with placebo. 
Finasteride alone was no better than placebo. 
The combination of finasteride and terazosin was no better than 
terazosin alone.
• PREDICT trial in which 1095 men were randomly 
assigned to doxazosin, finasteride, or both for one 
year 
– Doxazosin was more effective than finasteride or 
placebo for urinary symptoms and flow rate, but 
again, the combination was no more effective 
than doxazosin alone
Combination Therapy & 
Long Term Efficacy
Medical management of bph
Medical Therapy of Prostatic Symptoms (MTOPS) trial, in which 3047 men with 
BPH were randomly assigned to receive doxazosin, (4 to 8 mg/day), 
finasteride (5 mg/day), combination therapy, or placebo
CombAT vs MTOPS 
Clinical progression CombAT MOPTS 
Overall risk of disease 
progression % 
66 44 
Symptomatic 
progression % 
64 41 
AUR % 81 68 
Urinary incontinence % 65 26 
BPH related surgery % 67 71
Anticholinergic and OAB with BPH 
• 75% of clinical BPH have concomitant urodynamic detrusor 
overactivity 
• In concomitant BPH and DO, 65% have inadequate 
symptoms control 
• 19% have persistent OAB symptoms after TURP 
• Recurrence of OAB symptoms after TURP in long term mean 
follow up of 12.6 years .
Anitcholinergic agents
Anticholinergic - M1 , M3 receptor 
• Adverse effect 
– Dry mouth (up to 16%), 
– Constipation(up to 4%), 
– Micturition difficulties (up to 2%) 
– Nasopharyngitis (up to 3%), 
– And dizziness (up to 5%). 
– Disorientiation, hallucination, convulsion 
– hyperthermia 
• Contraindications 
– Myasthenia gravis 
– Glaucoma 
– Significant bladder outflow obstruction 
– Urinary retention 
– Severe ulcerative colitis 
– Gastrointestinal obstruction 
– Hypethyroidism 
– CAD 
– CCF
Alpha blocker n Anticholinergic 
• Reducing voiding frequency, nocturia, or IPSS 
compared to α-blockers or placebo alone. 
• Reduce urgency urinary incontinence episodes 
as well as urgency and significantly increased 
QoL
Plant Extract- Phytotherapy 
• Have anti-inflammatory, antiandrogenic, or oestrogenic 
effects 
• Decrease sexual hormone binding globulin (SHBG) 
• Inhibit aromatase, lipoxygenase, growth-factor stimulated 
proliferation of prostatic cells 
• Α-adrenoceptors, 5α-reductase, muscarinic cholinoceptors, 
dihydropyridine receptors, or vanilloid receptors 
• Improve detrusor function 
• Neutralize free radicals .
Phytotherapeutic agents
Conclusion from systemic reviews 
• The plant extract beta-sitosterol improved symptoms 
• Cernilton, which is prepared from the rye grass pollen, 
Secale cereale, has been evaluated in four clinical trials 
– It improved symptoms, but did not affect urinary flow rates or 
residual urine or prostate volume. 
• Pygeum africanum is an extract of bark from an African 
plum tree. 
– In a meta-analysis of 18 randomized controlled trials, active 
treatment improved symptoms two times more frequently than 
placebo and increased peak urinary flow rates 23 percent
Medical management of bph
Desmopression (v1, v2 receptor) 
• Desmopressin significantly reduced nocturnal 
diuresis by approximately 0.6-0.8 ml/min (-40%) 
• Decreased the number of nocturnal voids by 
approximately 0.8-1.3 (-40%) 
• Extended the time until the first nocturnal void by 
approximately 1.6 hours 
• Reduced night-time urine volume as well as the 
percentage of urine volume excreted at night
• headache, nausea, diarrhoea, abdominal pain, 
dizziness, dry mouth, and hyponatraemia. 
• Peripheral oedema (2%) and hypertension (5%)
Practical Consideration 
• Desmopressin should be taken once daily before sleeping. 
• desmopressin treatment should be initiated at a low dose (0.1 
mg/day) 
• The maximal daily dose recommended is 0.4 mg/day. 
• Patients should avoid drinking fluids at least 1 hour before using 
desmopressin until 8 hours thereafter. 
• In men aged 65 years or older, desmopressin should not be used if 
the serum sodium concentration is below the normal value. 
• In all other men aged 65 years or older, serum sodium 
concentration should be measured at day 3 and 7 as well as after 1 
month and, if serum sodium concentration has remained normal, 
every 3-6 months subsequently.
Nitric Oxide 
cGMP 
activate protein kinases, ion 
channels, and cGMP-binding 
phosphodiesterases 
Calcium depletion 
Smooth muscle relaxation 
guanylyl-cyclase 
PDE5 hydrolyses 
PDE- INHIBITORS
Newer Agents 
Phosphodiesterase inhibitors 
mean Qmax increase 3.7-4.3 mLs or 24-38% 
reduced IPSS by approximately 17-35%
Side Effects of PDE5 inhibitors 
• Headache, flushing, dizziness, dyspepsia, nasal 
congestion, myalgia, 
• Hypotension, syncope, tinnitus, conjunctivitis, 
or altered vision (blurred, discoloration). 
• Priapism or acute urinary retention is 
considered minimal.
New Trials 
• Several new drugs are currently under clinical investigation 
(phase II-III trials) of which none has been licensed for male 
LUTS so far. These new drugs target: 
– the prostate, e.g. gonodotrophin-releasing hormone 
antagonists, oestrogen receptor antagonists, 
• Chlormadinone/allylesternol 
• Zanoterone/Flutamide 
– apoptosis-inducing agents, vaccines, vitamin D agonists, or 
androgen replacement therapies; 
– the bladder, e.g. β3-adrenoceptor agonists; 
– the nervous system, e.g. neuromuscular blocking agents, 
tachykinin receptor antagonists.
Medical management of bph
Medical management of bph
Is bladder diary recommended?
USG is recommended for the 
anatomical evaluation of Prostate
Evaluation of upper urinary tract
Is long-term therapy with a1-adrenoceptor 
antagonists recommended? 
Approximately 18, 64, and 36–80% of patients 
withdrew from the studies after2, 3, and >4 years, 
respectively.
What urodynamic test is recommended for men 
undergoing surgical treatment for BPH?
What foods and dietary habits are 
recommended for patients with BPH?
Is a reduced alcohol intake recommended 
in patients with BPH
What treatments are recommended for 
urinary retention by BPH?
What therapeutic strategies are 
recommended to avoid sexual dysfunction 
as an adverse event?
Medical management of bph
Referal for Surgical therapy 
• Symptom assessment 
• Duration of therapy 
• Disease progression 
• Complication 
• Follow up 
• Cost effectiveness
AUA GUIDELINES
References 
• JUA clinical guidelines for benign prostatic 
hyperplasia 
• EUA guidelines for LUTS 
• AUA Guidelines 
• Campbell Urology- 9th edn
Medical management of bph

Más contenido relacionado

Was ist angesagt?

Bladder outlet obstruction
Bladder outlet obstructionBladder outlet obstruction
Bladder outlet obstructionjavaria mehtab
 
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...Gagan Adhikari
 
Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH)Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH)Abhay Rajpoot
 
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]Edmond Wong
 
benign prostatic hyperplasia (BPH)
benign prostatic hyperplasia (BPH)benign prostatic hyperplasia (BPH)
benign prostatic hyperplasia (BPH)Omer Muayed Al-Naqib
 
Bladder outlet obstruction in children
Bladder outlet obstruction in childrenBladder outlet obstruction in children
Bladder outlet obstruction in childrenVernon Pashi
 
BPH BENGIN PROSTATE HYPERPLASIA
BPH BENGIN PROSTATE HYPERPLASIA BPH BENGIN PROSTATE HYPERPLASIA
BPH BENGIN PROSTATE HYPERPLASIA ANILKUMAR BR
 
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract SymptomsFamily Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract SymptomsSiewhong Ho
 
Obstructive uropathy
Obstructive uropathyObstructive uropathy
Obstructive uropathyPius Musau
 
Etiology and pathophysiology of bph
Etiology and pathophysiology of bphEtiology and pathophysiology of bph
Etiology and pathophysiology of bphAhmed Eliwa
 
Bladder OVERACTIVE BLADDER (OAB)- overview
Bladder  OVERACTIVE BLADDER (OAB)- overviewBladder  OVERACTIVE BLADDER (OAB)- overview
Bladder OVERACTIVE BLADDER (OAB)- overviewGovtRoyapettahHospit
 
Obstructive Uropathy "online"
Obstructive Uropathy "online"Obstructive Uropathy "online"
Obstructive Uropathy "online"Ayman Rashed, MD
 
Benign enlargement of prostate . medical therapy
Benign enlargement of prostate . medical therapy Benign enlargement of prostate . medical therapy
Benign enlargement of prostate . medical therapy Dr Pralhad Patki
 

Was ist angesagt? (20)

Bladder outlet obstruction
Bladder outlet obstructionBladder outlet obstruction
Bladder outlet obstruction
 
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...
BENIGN PROSTATIC HYPERPLASIA: Epidemiology, Etiology, Pathophysiology, and ev...
 
Treatment of BPH
Treatment of BPHTreatment of BPH
Treatment of BPH
 
Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH)Benign prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH)
 
Posterior urethral valve
Posterior urethral valvePosterior urethral valve
Posterior urethral valve
 
Overactive bladder
Overactive bladderOveractive bladder
Overactive bladder
 
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]
Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]
 
benign prostatic hyperplasia (BPH)
benign prostatic hyperplasia (BPH)benign prostatic hyperplasia (BPH)
benign prostatic hyperplasia (BPH)
 
overactive bladder
 overactive bladder overactive bladder
overactive bladder
 
Priapism ppt
Priapism ppt Priapism ppt
Priapism ppt
 
Bladder outlet obstruction in children
Bladder outlet obstruction in childrenBladder outlet obstruction in children
Bladder outlet obstruction in children
 
BPH BENGIN PROSTATE HYPERPLASIA
BPH BENGIN PROSTATE HYPERPLASIA BPH BENGIN PROSTATE HYPERPLASIA
BPH BENGIN PROSTATE HYPERPLASIA
 
Family Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract SymptomsFamily Physician's Approach to Lower Urinary Tract Symptoms
Family Physician's Approach to Lower Urinary Tract Symptoms
 
Obstructive uropathy
Obstructive uropathyObstructive uropathy
Obstructive uropathy
 
Overactive bladder
Overactive bladderOveractive bladder
Overactive bladder
 
Etiology and pathophysiology of bph
Etiology and pathophysiology of bphEtiology and pathophysiology of bph
Etiology and pathophysiology of bph
 
Penile fracture
Penile fracturePenile fracture
Penile fracture
 
Bladder OVERACTIVE BLADDER (OAB)- overview
Bladder  OVERACTIVE BLADDER (OAB)- overviewBladder  OVERACTIVE BLADDER (OAB)- overview
Bladder OVERACTIVE BLADDER (OAB)- overview
 
Obstructive Uropathy "online"
Obstructive Uropathy "online"Obstructive Uropathy "online"
Obstructive Uropathy "online"
 
Benign enlargement of prostate . medical therapy
Benign enlargement of prostate . medical therapy Benign enlargement of prostate . medical therapy
Benign enlargement of prostate . medical therapy
 

Ähnlich wie Medical management of bph

Ähnlich wie Medical management of bph (20)

14. Benign prostatic hyperplasia.pptx
14. Benign prostatic hyperplasia.pptx14. Benign prostatic hyperplasia.pptx
14. Benign prostatic hyperplasia.pptx
 
Sexual tx
Sexual txSexual tx
Sexual tx
 
Bph..ibrahim hakami
Bph..ibrahim hakamiBph..ibrahim hakami
Bph..ibrahim hakami
 
Prostate carcinoma- hormonal therapy 1
Prostate  carcinoma- hormonal therapy 1Prostate  carcinoma- hormonal therapy 1
Prostate carcinoma- hormonal therapy 1
 
Benign prostatic hyperplasia
Benign prostatic hyperplasiaBenign prostatic hyperplasia
Benign prostatic hyperplasia
 
BPH
BPHBPH
BPH
 
BPH-medical management
BPH-medical managementBPH-medical management
BPH-medical management
 
Drug presentation
Drug presentationDrug presentation
Drug presentation
 
Nephrotic syndrome
Nephrotic syndromeNephrotic syndrome
Nephrotic syndrome
 
Principles of management,bph
Principles of management,bphPrinciples of management,bph
Principles of management,bph
 
Management of pulmonary artery hypertension
Management of pulmonary artery hypertensionManagement of pulmonary artery hypertension
Management of pulmonary artery hypertension
 
Benign Prostatic Hyperplasia.ppt
Benign Prostatic Hyperplasia.pptBenign Prostatic Hyperplasia.ppt
Benign Prostatic Hyperplasia.ppt
 
Bph dr mnr
Bph dr mnrBph dr mnr
Bph dr mnr
 
Nocturia
NocturiaNocturia
Nocturia
 
Pcos
PcosPcos
Pcos
 
common urologica lproblems.pptx
common urologica lproblems.pptxcommon urologica lproblems.pptx
common urologica lproblems.pptx
 
Management of the Enlarged Prostate Gland
Management of the Enlarged Prostate GlandManagement of the Enlarged Prostate Gland
Management of the Enlarged Prostate Gland
 
Tamsulosin hydrochloride
Tamsulosin hydrochlorideTamsulosin hydrochloride
Tamsulosin hydrochloride
 
Organophosphorous poisoning
Organophosphorous poisoningOrganophosphorous poisoning
Organophosphorous poisoning
 
Benign Prostate Hypertrophy
Benign Prostate HypertrophyBenign Prostate Hypertrophy
Benign Prostate Hypertrophy
 

Mehr von bbthapa

Management of enterocutaneous fistula
Management of enterocutaneous fistulaManagement of enterocutaneous fistula
Management of enterocutaneous fistulabbthapa
 
Urinary Diversion
Urinary DiversionUrinary Diversion
Urinary Diversionbbthapa
 
Neuroblastoma
NeuroblastomaNeuroblastoma
Neuroblastomabbthapa
 
Deep Vein Thrombosis
Deep Vein ThrombosisDeep Vein Thrombosis
Deep Vein Thrombosisbbthapa
 
Leg ulcer
Leg ulcerLeg ulcer
Leg ulcerbbthapa
 
Blunt trauma abdomen
Blunt trauma abdomenBlunt trauma abdomen
Blunt trauma abdomenbbthapa
 

Mehr von bbthapa (6)

Management of enterocutaneous fistula
Management of enterocutaneous fistulaManagement of enterocutaneous fistula
Management of enterocutaneous fistula
 
Urinary Diversion
Urinary DiversionUrinary Diversion
Urinary Diversion
 
Neuroblastoma
NeuroblastomaNeuroblastoma
Neuroblastoma
 
Deep Vein Thrombosis
Deep Vein ThrombosisDeep Vein Thrombosis
Deep Vein Thrombosis
 
Leg ulcer
Leg ulcerLeg ulcer
Leg ulcer
 
Blunt trauma abdomen
Blunt trauma abdomenBlunt trauma abdomen
Blunt trauma abdomen
 

Último

airway management recorded for S2.pptx
airway management  recorded  for S2.pptxairway management  recorded  for S2.pptx
airway management recorded for S2.pptxnakera38
 
HERPES SIMPLEX VIRUS 12032019 TUESDAY pptx
HERPES SIMPLEX VIRUS 12032019 TUESDAY  pptxHERPES SIMPLEX VIRUS 12032019 TUESDAY  pptx
HERPES SIMPLEX VIRUS 12032019 TUESDAY pptxPulkitMittal54
 
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Dr. Dheeraj Kumar
 
Explaining "pathology" in digital pathology
Explaining "pathology" in digital pathologyExplaining "pathology" in digital pathology
Explaining "pathology" in digital pathologyYves Sucaet
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...JakeMatthews12
 
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeTracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeQuick MedTalk
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedSBL DIGITAL
 
Ovarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxOvarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxSizan Thapa
 
Histology of lymph node(lymph node histology)
Histology of lymph node(lymph node histology)Histology of lymph node(lymph node histology)
Histology of lymph node(lymph node histology)pranavguleria2
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisAshishMaletha2
 
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...DUY NGUYEN PHUC
 
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...Genesis Institute of Pharmacy, Radhanagari.
 
SMA Implementation science seminar (Day 1).pptx
SMA Implementation science seminar (Day 1).pptxSMA Implementation science seminar (Day 1).pptx
SMA Implementation science seminar (Day 1).pptxAbdirahmanWaseem
 
CELL BLOCK PREPARATION AND ITS IMPORTANCE
CELL BLOCK PREPARATION AND ITS IMPORTANCECELL BLOCK PREPARATION AND ITS IMPORTANCE
CELL BLOCK PREPARATION AND ITS IMPORTANCEShubhadip Ghosh
 
Spinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxSpinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxsiddharthroy26587
 
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKLaryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKQuick MedTalk
 
Ayurveda research in Hypothyroidism, P
Ayurveda  research  in Hypothyroidism, PAyurveda  research  in Hypothyroidism, P
Ayurveda research in Hypothyroidism, PDr.Shalu Jain
 

Último (20)

airway management recorded for S2.pptx
airway management  recorded  for S2.pptxairway management  recorded  for S2.pptx
airway management recorded for S2.pptx
 
Oral disorders .pptx
Oral disorders .pptxOral disorders .pptx
Oral disorders .pptx
 
HERPES SIMPLEX VIRUS 12032019 TUESDAY pptx
HERPES SIMPLEX VIRUS 12032019 TUESDAY  pptxHERPES SIMPLEX VIRUS 12032019 TUESDAY  pptx
HERPES SIMPLEX VIRUS 12032019 TUESDAY pptx
 
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
 
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
 
Explaining "pathology" in digital pathology
Explaining "pathology" in digital pathologyExplaining "pathology" in digital pathology
Explaining "pathology" in digital pathology
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...
 
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on timeTracheostomy .pdf ENT by QuickMedTALK. getting things done on time
Tracheostomy .pdf ENT by QuickMedTALK. getting things done on time
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limited
 
Ovarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxOvarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptx
 
Histology of lymph node(lymph node histology)
Histology of lymph node(lymph node histology)Histology of lymph node(lymph node histology)
Histology of lymph node(lymph node histology)
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth Analysis
 
Catalysts for Change in SCLC: Optimizing the Use of Standard Therapies and Ac...
Catalysts for Change in SCLC: Optimizing the Use of Standard Therapies and Ac...Catalysts for Change in SCLC: Optimizing the Use of Standard Therapies and Ac...
Catalysts for Change in SCLC: Optimizing the Use of Standard Therapies and Ac...
 
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...Routine Medicine Laboratory Testing  _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
Routine Medicine Laboratory Testing _ CÁC XÉT NGHIỆM THƯỜNG QUY ÁP DỤNG TRON...
 
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
HDT Unit 2: Nutraceuticals Global Market Overview And Growth Of Nutraceutical...
 
SMA Implementation science seminar (Day 1).pptx
SMA Implementation science seminar (Day 1).pptxSMA Implementation science seminar (Day 1).pptx
SMA Implementation science seminar (Day 1).pptx
 
CELL BLOCK PREPARATION AND ITS IMPORTANCE
CELL BLOCK PREPARATION AND ITS IMPORTANCECELL BLOCK PREPARATION AND ITS IMPORTANCE
CELL BLOCK PREPARATION AND ITS IMPORTANCE
 
Spinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptxSpinal cord Gross anatomy with Clinical Anatomy.pptx
Spinal cord Gross anatomy with Clinical Anatomy.pptx
 
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKLaryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
 
Ayurveda research in Hypothyroidism, P
Ayurveda  research  in Hypothyroidism, PAyurveda  research  in Hypothyroidism, P
Ayurveda research in Hypothyroidism, P
 

Medical management of bph

  • 1. MEDICAL MANAGEMENT OF LUTS/BPH & RECENT ADVANCES Bikash Bk. Thapa MS – General Surgery
  • 3. Component of BOO • A dynamic (physiologic, reversible) component – related to the tension of prostatic smooth muscle in the prostate, prostate capsule, and bladder neck • A fixed (structural) component – related to the bulk of the enlarged prostate impinging upon the urethra
  • 4. Association of BOO • Voiding Dysfunction – BPO- muscle hypertrophies- decompensation- reduced expression of connexin 43- impairs synchronise contraction-contractile dysfunction • Storage Dysfunction – cycle of urine storage and voiding causes repeated bladder distension, raised intravesical pressure, ischemia, reperfusion – Impaired vesical blood flow results in oxidative stress, with free radicals causing damage to the urothelium, nerves, and smooth muscle.
  • 5. Pathogenesis • Hormonal • Dysregulation of stromal growth factors • Reawakening of embryonic process • Decrease cell death • Genetic susceptibiltiy
  • 7. New Hypothesis • BPH is caused by malfunction of the valves in the internal spermatic vein manifesting as varicocele – Elevated venous pressure causes hypertrophy and exposure to high concentration of free testosterone causes hyperplaisa of prostate • Involvement of adrenergic nerves in prostatic hyperplasia. • Cytokines derived from inflammatory cells also induce epithelial growth factors
  • 9. Diagnosis • History • Assessment of symptoms and QOL • Physical Examination • Urine Analysis • Uroflowmetry • PVR • PSA • Prostate Ultrasound • Case Sensitive and Elective – bladder diary, pressure-flow studies, serum creatinine measurements,and ultrasonography of the upper urinary tract.
  • 11. Current treatment options • Conservative treatment • Alpha blockers • 5-alpha-reductase inhibitors (5ARIs) • Combination therapy • Phytotherapy • Minimally invasive techniques • Surgery
  • 12. Goal of treatment • Relieving LUTS • Decreasing BOO • Improving bladder emptying • Ameliorating overactive bladder activity • Reversing renal insufficiency • Preventing disease progression
  • 14. Watchful waiting • Patient selection • Education, • Reassurance, • Periodic monitoring, • Lifestyle advice
  • 15. Watchful waiting • Patient selection • Education, • Reassurance, • Periodic monitoring, • Lifestyle advice
  • 16. Life Style Advice • Reduction in fluid intake • Avoidance of moderation of caffeine and alcohol • Double voiding technique • Urethral stripping • Distraction- mind out of bladder n toilet • Bladder retraining- Hold on • Optimising drugs • Treatment of constipation
  • 17. Treatment Goals of Medical Therapy
  • 18. Alpha – Blocker 1a, 1b, 1d
  • 19. Pharmacotherapy • Non selective alpha blockers – Phenoxybenzamine • Selective short acting (alpha 1) – Prazosin, Alfuzosin, Indoramin • Selective long acting (alpha1, all three type) – Terazosin, Doxazosin, Alfuzosin SR • Partially subtype (alpha 1a) – Tamsulosin, Sildosin • Partially subtype ( alpha 1d) – Naftopidil, Tamsulosin
  • 22. Drug Saftey • Asthenia • Diziness • Nasal congestion • Postural hypertension • Co-medication • anejaculation • Intraoperative floppy iris syndrome – Miosis, iris billowing, iris prolapse
  • 23. α-blockers should be offered to men with moderate to severe LUTS. • a1-adrenoceptor antagonists can result in a 16–25% (2.0–2.5 mL/s) increase in maximum flow rate and a 30–40% (4–6 point) reduction in the average IPSS.
  • 24. 5 alpha Reductase inhibitor Dutasteride Finasteride Type II 5AR Testosterone DHT Dutasteride Prostate volume reduced Type I 5AR Bartsch G et al. Eur Urol. 2000;37:367380.
  • 25. Clinical role of dual inhibition remains unclear Reduce LUTS (IPSS) by approximately 15-30%, Decrease prostate volume by 18-28% and Increase Qmax by 1.5-2.0 ml/s PSA dec by 50% Dec hematuria Inc apoptotic index of stromal and epithelial cell Dec detrusor pressure at Qmax
  • 26. Proscar Long-Term Efficacy and Safety Study (PLESS)
  • 29. Combination Therapy & Short term Efficacy • In the Veterans Affairs Cooperative Study, 1229 men with BPH (mean peak urinary flow rate of 10.5 mL/sec) were randomly assigned to placebo, finasteride (5 mg/day), terazosin (10 mg/day), or both for one year Terazosin lowered the symptom score and increased the peak urinary flow rate when compared with placebo. Finasteride alone was no better than placebo. The combination of finasteride and terazosin was no better than terazosin alone.
  • 30. • PREDICT trial in which 1095 men were randomly assigned to doxazosin, finasteride, or both for one year – Doxazosin was more effective than finasteride or placebo for urinary symptoms and flow rate, but again, the combination was no more effective than doxazosin alone
  • 31. Combination Therapy & Long Term Efficacy
  • 33. Medical Therapy of Prostatic Symptoms (MTOPS) trial, in which 3047 men with BPH were randomly assigned to receive doxazosin, (4 to 8 mg/day), finasteride (5 mg/day), combination therapy, or placebo
  • 34. CombAT vs MTOPS Clinical progression CombAT MOPTS Overall risk of disease progression % 66 44 Symptomatic progression % 64 41 AUR % 81 68 Urinary incontinence % 65 26 BPH related surgery % 67 71
  • 35. Anticholinergic and OAB with BPH • 75% of clinical BPH have concomitant urodynamic detrusor overactivity • In concomitant BPH and DO, 65% have inadequate symptoms control • 19% have persistent OAB symptoms after TURP • Recurrence of OAB symptoms after TURP in long term mean follow up of 12.6 years .
  • 37. Anticholinergic - M1 , M3 receptor • Adverse effect – Dry mouth (up to 16%), – Constipation(up to 4%), – Micturition difficulties (up to 2%) – Nasopharyngitis (up to 3%), – And dizziness (up to 5%). – Disorientiation, hallucination, convulsion – hyperthermia • Contraindications – Myasthenia gravis – Glaucoma – Significant bladder outflow obstruction – Urinary retention – Severe ulcerative colitis – Gastrointestinal obstruction – Hypethyroidism – CAD – CCF
  • 38. Alpha blocker n Anticholinergic • Reducing voiding frequency, nocturia, or IPSS compared to α-blockers or placebo alone. • Reduce urgency urinary incontinence episodes as well as urgency and significantly increased QoL
  • 39. Plant Extract- Phytotherapy • Have anti-inflammatory, antiandrogenic, or oestrogenic effects • Decrease sexual hormone binding globulin (SHBG) • Inhibit aromatase, lipoxygenase, growth-factor stimulated proliferation of prostatic cells • Α-adrenoceptors, 5α-reductase, muscarinic cholinoceptors, dihydropyridine receptors, or vanilloid receptors • Improve detrusor function • Neutralize free radicals .
  • 41. Conclusion from systemic reviews • The plant extract beta-sitosterol improved symptoms • Cernilton, which is prepared from the rye grass pollen, Secale cereale, has been evaluated in four clinical trials – It improved symptoms, but did not affect urinary flow rates or residual urine or prostate volume. • Pygeum africanum is an extract of bark from an African plum tree. – In a meta-analysis of 18 randomized controlled trials, active treatment improved symptoms two times more frequently than placebo and increased peak urinary flow rates 23 percent
  • 43. Desmopression (v1, v2 receptor) • Desmopressin significantly reduced nocturnal diuresis by approximately 0.6-0.8 ml/min (-40%) • Decreased the number of nocturnal voids by approximately 0.8-1.3 (-40%) • Extended the time until the first nocturnal void by approximately 1.6 hours • Reduced night-time urine volume as well as the percentage of urine volume excreted at night
  • 44. • headache, nausea, diarrhoea, abdominal pain, dizziness, dry mouth, and hyponatraemia. • Peripheral oedema (2%) and hypertension (5%)
  • 45. Practical Consideration • Desmopressin should be taken once daily before sleeping. • desmopressin treatment should be initiated at a low dose (0.1 mg/day) • The maximal daily dose recommended is 0.4 mg/day. • Patients should avoid drinking fluids at least 1 hour before using desmopressin until 8 hours thereafter. • In men aged 65 years or older, desmopressin should not be used if the serum sodium concentration is below the normal value. • In all other men aged 65 years or older, serum sodium concentration should be measured at day 3 and 7 as well as after 1 month and, if serum sodium concentration has remained normal, every 3-6 months subsequently.
  • 46. Nitric Oxide cGMP activate protein kinases, ion channels, and cGMP-binding phosphodiesterases Calcium depletion Smooth muscle relaxation guanylyl-cyclase PDE5 hydrolyses PDE- INHIBITORS
  • 47. Newer Agents Phosphodiesterase inhibitors mean Qmax increase 3.7-4.3 mLs or 24-38% reduced IPSS by approximately 17-35%
  • 48. Side Effects of PDE5 inhibitors • Headache, flushing, dizziness, dyspepsia, nasal congestion, myalgia, • Hypotension, syncope, tinnitus, conjunctivitis, or altered vision (blurred, discoloration). • Priapism or acute urinary retention is considered minimal.
  • 49. New Trials • Several new drugs are currently under clinical investigation (phase II-III trials) of which none has been licensed for male LUTS so far. These new drugs target: – the prostate, e.g. gonodotrophin-releasing hormone antagonists, oestrogen receptor antagonists, • Chlormadinone/allylesternol • Zanoterone/Flutamide – apoptosis-inducing agents, vaccines, vitamin D agonists, or androgen replacement therapies; – the bladder, e.g. β3-adrenoceptor agonists; – the nervous system, e.g. neuromuscular blocking agents, tachykinin receptor antagonists.
  • 52. Is bladder diary recommended?
  • 53. USG is recommended for the anatomical evaluation of Prostate
  • 54. Evaluation of upper urinary tract
  • 55. Is long-term therapy with a1-adrenoceptor antagonists recommended? Approximately 18, 64, and 36–80% of patients withdrew from the studies after2, 3, and >4 years, respectively.
  • 56. What urodynamic test is recommended for men undergoing surgical treatment for BPH?
  • 57. What foods and dietary habits are recommended for patients with BPH?
  • 58. Is a reduced alcohol intake recommended in patients with BPH
  • 59. What treatments are recommended for urinary retention by BPH?
  • 60. What therapeutic strategies are recommended to avoid sexual dysfunction as an adverse event?
  • 62. Referal for Surgical therapy • Symptom assessment • Duration of therapy • Disease progression • Complication • Follow up • Cost effectiveness
  • 64. References • JUA clinical guidelines for benign prostatic hyperplasia • EUA guidelines for LUTS • AUA Guidelines • Campbell Urology- 9th edn