medical treatment in bph

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)

Thank you