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 LUTS
Voiding (obstructive) symp Weak stream Hesitancy Intermittency Straining Residual volume Storage (irritative) symp Frequency Nocturia Urge Post micturition symp Post micturition dribbling Sensation of incomplete emptying

PATHOPHYSIOLOGY

Static component

Dynamic component

LUTS

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

Type
Non selective 1 short acting 1 long acting

Generic name

1a long acting

- Phenoxybenzamine - Prazosin - IR Alfuzosin - Doxazosin - Terazosin - SR Alfuzosin - XL Alfuzosin - Tamsulosin IR : Immediate releas

SR : Sustained release

HALF LIFE
Substance
Half life (hours)
23 22 3 4 (IR) 12 10 - 13

Prazosin (1979 Hedlund) Doxazosin (1995) Alfuzosin (1998) Terazosin (1992) Tamsulosin (1998)

DOSAGE IN INDONESIA
Doxazosin Terazosin Tamsulosin Alfuzosin XL 1-2 mg once a day 1-2 mg once a day 0,2 mg once a day 10 mg once a day

SAFETY OF BLOCKING AGENT Doxazosin

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 (?)

Alfuzosin

SAFETY OF BLOCKING AGENT

Terazosin

dose dependent (1-10mg) dose titration necessary given in the evening retrograde ejaculation (<2%)

Tamsulosin fast onset

5 REDUCTASE INHIBITOR
Rationale

Testosteron

5 reductase

DHT

5 reductase inhibitor Prostate volume reduced by 20 30 % after 3 months of treatment

5 REDUCTASE INHIBITOR

5 reductase inhibitor

FINASTERIDE
DOSAGE : 5 MG/DAY reduces libido ED reduced ejaculate lowering PSA

DUTASTERIDE
Dosage 0,5 mg/day Symptom Score Q max Prostate vol Incidence of AUR

Better than finasteride

PHYTOTHERAPY
Species
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)