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Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH). 26 Juli 2012. Kaplan, S.A. Identification of the patient with enlarged prostate: diagnosis and guidelines for management. Osteopathic Medicine and Primary Care 2007, 1:11.

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Benign Prostatic Hyperplasia (BPH)

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  1. Benign Prostatic Hyperplasia(BPH) 26 Juli 2012

  2. Kaplan, S.A. Identification of the patient with enlarged prostate: diagnosis and guidelines for management. Osteopathic Medicine and Primary Care 2007, 1:11. • U Chong Lai, Yuk TsanWun, Tze Chao Luo & SaiMengPang. In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)? Asia Pacific Family Medicine 2011, 10:7. • Edwards, J.E., & Moore, R.A. Finasteride in the treatment of clinical benign prostatic hyperplasia: A systematic review of randomisedtrials. BMC Urology 2002, 2:14

  3. Kaplan, S.A. Identification of the patient with enlarged prostate: diagnosis and guidelines for management. EP (Enlarged Prostate): • Gejala?  terapisimptomatik BAK dgnα-blocker. • PerjalananpenyakitygmemburukmenjadiAUR (Acute Urinary Retention)?  terapiygmenyusutkanselepitelprostatdgn5α-reductase inhibitor(5ARI)

  4. Indikatorperjalananpenyakitygmemburuk: LUTS meningkat, ukuranprostatmeningkat, kecepatanaliranurinmenurun, komplikasikandungkemih, hematuriadanresiko AUR meningkat. • Pencegahan AUR lebihbaikkarenaprostatektomiatauinsersikatetermenurunkanQoL, meningkatkanmorbiditas & mortalitas.

  5. Gejala2 ygmengganggu • Rubahperjalanpenyakit(5ARIs, terapikombinasi) • Obatigejala • Obatigejala (α-blocker/ anti-cholinergik) • Pemantauanketat Tanpa EP EP • Berinasihatttggayahidup, periksapengobatan, tenteramkanhati • Rubahperjalanpenyakit(5ARIs) pd orangResTitertentu • Pemantauanketat • Berinasihatttggayahidup, periksapengobatan, besarkanhati. Tanpa gejala2 ygmengganggu

  6. DxBPH: • LUTS (Lower Urinary Tract Symptoms): freq, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying & urgency  Ringan (skor= 1-7), Sedang (skor = 8-19); Berat (skor = 20-35) • DRE (Digital Rectal Examination): diameter > 2 lebarjari  prostate volume > 30 mL • PSA (Prostate-specific antigen)  > 1.5ng/mL

  7. 1 ng = 0.000001 mg = 0.000000001 gr

  8. PeranDokterKeluarga • EP > 50% padapriaantara 50-60 th. • DK memulaidiskusitentang LUTS*. • DK melakukan DRE untukmenentukan EP. • DK meresepkan α-blockers kalauadagejala yang mengganggudan/atau5α-reductase inhibitors (5ARIs) kalauada EP. *)U Chong Lai, Yuk TsanWun, Tze Chao Luo & SaiMeng Pang. In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)? Asia Pacific Family Medicine 2011, 10:7.

  9. Menundakonsultasi LUTS • Dianggapgejalapenuaanbiasa • Malu, takut • Tidakspesifik EP  DDx

  10. DDx LUTS: • Urologic and nonurologic: Prostate cancer, Prostatitis, Bladder cancer, Bladder stones, Overactive bladder, Interstitial cystitis, DM, Parkinson's disease, Congestive heart failure, Lumbosacraldisc disease, Multiple sclerosis, Spinal cord injury, Stroke • Obat: Tricylic antidepressants, Anticholinergic agents, Diuretics, Narcotics, First-generation antihistamines, Decongestants • Obesitas, merokok, miras, hipertensi.

  11. Peripheral zone (PZ) Up to 70% in young men The sub-capsular portion of the posterior aspect of the prostate gland that surrounds the distal urethra. It is from this portion of the gland that ~70–80% of prostatic cancers originate.[16][17] Central zone (CZ) Approximately 25% normally This zone surrounds the ejaculatory ducts. The central zone accounts for roughly 2.5% of prostate cancers although these cancers tend to be more aggressive and more likely to invade the seminal vesicles.[18 Transition zone (TZ) 5% at puberty ~10–20% of prostate cancers originate in this zone. The transition zone surrounds the proximal urethra and is the region of the prostate gland that grows throughout life and is responsible for the disease of benign prostatic enlargement. (2)[16][17] Anterior fibro-muscular zone (or stroma) Approximately 5% This zone is usually devoid of glandular components, and composed only, as its name suggests, of muscle and fibrous tissue.

  12. Penatalaksanaan BPH • Obat: α-blocker atau/dan 5ARI • Prosedurinvasif minimal (RawatJalan): TUNA: Transurethral Needle Ablation TUMT: Transurethral Microwave Thermotherapy + Stent prostatsementara • TURP/TUR (RawatInap): Transurethral resection of the prostate.

  13. DaftarObat PT Askes • 5α-reductaseinhibitor: Dutasteride (Avodart): 1 dd Caps mg 0.5 • α-blocker: TerazosinHCl (Hytrin, Hytroz) - 1 dd Tab mg 1-2 DoxasozinMesylate (Cardura) - 1 dd Tab mg 1-2 Tamsulosine (Harnal) - 1 dd Tab mg 0.2/04

  14. Edwards, J.E., & Moore, R.A. Finasteride in the treatment of clinical benign prostatic hyperplasia: A systematic review of randomised trials. BMC Urology 2002, 2:14 ContohFinasteride:1 dd 1 Tab mg 5 • Finaxal (Sandoz): • Finpro (Interbat) • Proscar (Merck Sharp & Dohme) • Prostacom (Combiphar) • Reprostom (Fahrenheit)

  15. Finasteride & Dutasteride = 5α-reductase inhibitor (5ARI) sintetis 5ARI = suatu inhibitor dari enzyme ygmengkonversi testosterone ke DHT. Dihydrotestosterone (DHT), atau 5α-dihydrotestosterone (5α-DHT) = hormon androgen/sex steroid. Enzyme 5α-reductasemensintesis DHT diprostat, testis, folikelrambutdankelenjaradrenalis

  16. Indikasi: pengobatan BPH dan MPB (Male Pattern Baldness)

  17. TujuanPenelitian: menentukaneficacy & efeksampingFinasteridemelaluitelaahpustaka & meta-analisis. Pustakaygdicari: uji-cobafinasteride yang randomiseddandouble-blindutk BPH hyperplasia. • KataKunciygdigunakan: 'finasteride', 'proscar', 'clinical trial', &'benign prostatic hyperplasia' Dicaridi/melalui: PubMed, the Cochrane Library, dandaftarrujukanlaporandan review.

  18. Randomized & Double Blind Trial: X = Finasteride O = symptom score, urinary flow rate, volume prostat, putusberobat & efeksamping Analisis: • RR • NNTatau NNH • Sensitivity analyses utkmenilaipengaruhkegawatansimptomawal, volume prostatawal, uji-cobautamadanintervensisebelumnya.

  19. Hasil: (3 uji-cobadngkontrolaktifdan 19 dgnkontrol placebo). Uji-cobadgn placebo: 8820 pasienfinasteride5 mg & 5909 pasien placebo selama3–48 bln. • Finasteride: a. Setelah48 bln - peningkatanlebihbesardlmhal total symptom score, maximum urinary flow rate, & vol prostate. b. Pd 12 bln – lebihbanyakdisfungsi sexual, impotensi, ggeyakulasi & penurunan libido. NNH disfungsi sexual pd 12 bln = 14. c. Pd 24 atau 48 bln: lebihsedikit AUR atauoperasi; NNT pd 12 bln = 49 (31-112) utkmencegah 1 AUR dan = 31 (21- 61) ukmencegah 1 operasi. d. Analisissensitivitasmenunjukkanmanfaatfinasteride mg 5 konstan, tidakdipengaruhi volume awalprostat.

  20. Kesimpulan: • penelitianbermutudengan N besar menunjukkanmanfaatFinasteridedalamhal symptoms, flow rate & volume prostate. • Diperlukanlebihbanyakpenelitiandengan O dikotomi. Kesimpulan Valid?

  21. Penilaianmutuuji-coba: • Setiaplaporanpenelitianygdapatdianggapsbgrandomised controlled trialdibacamasing2 penelitidandiberiJadad Score. • Ketidak-sepakatandidiskusikansampaiadakesepakatan. • Penelitianygdiikutsertakanjikaskor max 5 danskor min 2

  22. Outcome (O): Divalidasidengan 2 urologist & 3 GP dgnminaturologiuntukmenentukan O berdasarkanpendapatpenelitiataupasien. Informasiygdigali: • N finasteride & N placebo • symptom score (total, obstructive, mengganggu) • volume prostat • urinary flow rate (maximum, mean) • berhenti(total berhenti, berhentikrntidakefikasius/efeksamping) • efeksamping: AUR danoperasiprostat. • PSA) • Volume sisa • Volume total ygdikeluarkan.

  23. Yang dicatatnilaiabsolutdan/atau mean/median (SD) pada titik2 waktu: baseline dan 3, 6, 12, 18, 24, 36 & 48 blnpengobatan

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