lower urinary tract symptoms in men & women · lower urinary tract symptoms in men & women...
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![Page 1: Lower Urinary Tract Symptoms in Men & Women · Lower Urinary Tract Symptoms in Men & Women Daniel J lewinshtein Chief, Urologic Surgery CISSS Pierre Boucher](https://reader031.vdocuments.mx/reader031/viewer/2022020206/5cc68eaa88c9931e4b8ce978/html5/thumbnails/1.jpg)
Lower Urinary Tract Symptoms in Men & Women
Daniel J lewinshteinChief, Urologic Surgery CISSS Pierre Boucher
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Divulgation: Astellas, Sanofi, Jansen
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Canadian Bladder Urinary Survey:
Incontinence
Males Females
Age group (y) N any leakage once/day N any leakage once/day
All 476 15% 5% 524 29% 8%
18-40 205 9% 3% 213 16% 3%
41-64 200 16% 5% 239 33% 8%
65+ 70 30% 11% 61 55% 20%
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Quality of Life
-60
-50
-40
-30
-20
-10
0VHA1 IC2 INC3
% d
e r
éd
ucti
on
0 = témoins
1. O'Conor RM et al. Pharmacoeconomics. 1998;14:531-539.2. Rothrock NE et al. J Urol. 2002;167:1763-1767.3. Ellis AK, Verma S. J Am Board Fam Pract. 2000;13:392-397.
Rôle physique
État général de santé
Vitalité
Fonctionnement
social
Fonction mentale
Rôle émotionnel
Fonction physique
p < 0,01
p < 0,001
*p < 0,012 †p < 0,001
†
†
†
†
*
†
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Cost
* Dont la VH1, le SDPC (F2), le SDPC (M3) et les IVU4.† Le calcul des coûts est surtout fondé sur les fractures de la hanche.
SDPC = syndrome douloureux pelvien chronique
1. Wagner TH, Hu T-W. Urology. 1998;51:355-361.2. Mathias SD et al. Obstet Gynecol. 1996;87:321-327.3. Calhoun EA et al. J Urol. 2001;165(suppl):25.
4. Foxman B. Am J Med. 2002;113(suppl 1A):5S-13S.5. CDC. MMWR Morb Mortal Wkly Rep. 2001;50(32):682-686.6. Lindsay R. Am J Med. 1995;98(suppl 2A):9S-11S.
0
10
20
30
Co
ûts
(m
illiard
s $
US
)
12,7
20
32,9
Ostéoporose†6Bladder Sx* Asthme5
40
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OAB: Definition
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Urge vs. Stress Incontinence
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OAB vs SUI
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Case 1
Female 55 YO
Incontinent
Questionnaire?
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Evaluation
Frequency?
Urgency?
Inc Effort?
Urge inc?
hematuria?
Sx neuro?
ATCD: HAT? kids?
A + C urine/ journal
Dx?
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Evaluation: Cysto
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Pelvic diaphragm: Post- delivery
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POST HAT: no uterosacrals!
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SUI: video fluoroscopy
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RX?
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Kegel
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Biofeedback?
Vaginal probe
Cochrane review july 2011
N=1583, 17 trials
HR 0.75 (0.66-0.86, 95% CI)
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Chirurgie: TVT-O
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Case 2
Woman 45 YO
Frequency
Suprapubic pain important
Worse with certain foods
Pas d’incontinence
Dx?
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OAB vs. interstitial cystitis
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OAB vs. interstitial cystitis
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IC: Treatment as per CUA
guidelines 2016 Re-assurance
• Timed voiding
• Stress management
• Massage
Oral:
• amitryptiline 25-50 die (drowsy vomiting)
• hydroxyzine
• Elmiron 100 TID
Intravesical
• Dmso
• Heparin
• lidocaine
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Case 3
Femme 65 ans
smoker
Frequency/nycturia
Question cle?
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Evaluation
Frequence?
Urgence?
Inc Effort?
Inc d’urge?
Sang?
Sx neuro?
ATCD: HAT? Enfants?
A + C urine
Dx?
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Symptomes de VHA mais…CIS
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Case 4
femme 65 ans
Frequency/nycturia/inc
Atcd stroke
Dx?
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neurogenic
bladder
Rx?
Anti cholinergic
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Inhibition de miction: Enfant vs Adulte
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Case
Femme 35 ans
Frequency/nycturia
Questionnaire?
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Evaluation
Frequence?
Urgence?
Inc Effort?
Inc d’urge?
Sang?
Sx neuro-gait, visual?
ATCD: HAT? Enfants?
A + C urine
Dx?
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MS
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Case
Woman 55 YO
Frequency/nycturiA
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Evaluation
Frequence?
Urgence?
Inc Effort?
Inc d’urge?
Sang?
Sx neuro?
ATCD: HAT? Enfants?
A + C urine/ journal
Dx?
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Etiology: myogenic?
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Emptying:
parasympathic
Inhibition:
sympathetic
Etiology: neurogenic?
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OAB: Urodynamics
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Conservative Therapy
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Antimuscarinics: fonction
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Réduction des épisodes de miction par période de
24 h (n=32 020)
Buser et al. Eur Urol. 2012;62:1040-1060
Solifenacin
10 mg
Oxybutynin
IR 15 mg
Oxybutynin
IR 10 mg
Fesoterodine
8 mg
Trospium
chloride 40 mg
Solifenacin
5 mg
Tolterodine
ER 4 mg
Oxybutynin
gel
Fesoterodine
4 mg
Oxybutynin
ER 15 mg
Frequence ~20% (placebo 10%)
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Buser et al. Eur Urol. 2012;62:1040-1060
Solifenacin
10 mg
Oxybutynin
IR 15 mg
Oxybutynin
IR 10 mg
Fesoterodine
8 mg
Trospium
chloride 40 mg
Solifenacin
5 mg
Tolterodine
ER 4 mg
Oxybutynin
gel
Fesoterodine
4 mg
Oxybutynin
ER 15 mg
n/a
épisodes d’incontinence par période de 24 heures N=14 807 patients.
INC~ 60% (placebo 30%)
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Anti-muscarinics: Interdit?
glaucome angle fermé!
Chez l’homme: si residu >150cc
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Side effects: A function of receptor type
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Posologies et Effets secondaires
courants des antimuscariniques
Monographies respectives des produits.
Sécheresse
buccaleConstipation
Sécheresse
oculaire
Dyspep-
sie
Étourdis-
sements
Oxybutynine (5-30 mg ) 60,8 % 13,1% 6,1 % 6,8 % 6,3 %
Oxybutynine XL (5-30 mg ) 64,0 % 5,1 % 2,5 % 5,1 % 6,4 %
Oxybutynine en timbre 4,1 % 3,3 % s.o. s.o. s.o.
Toltérodine LP (4 mg .) 23,4 % 5,9 % < 5 % < 5 % < 5 %
Solifénacine (5 mg ) 10,9 % 5,4 % 0,3 % 1,4 % 1,9 %
Solifénacine (10 mg) 18.0% 9.2% 0.5% 2.0% 4.0%
trospium (20 mg BID) 20,1 % 9,6 % 1,2 % 1,2 % s.o.
Darifénacine (7,5 mg) 20,2 % 14,8 % 2,1 % 2,7 % 0,9 %
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Compliance
Wagg A et al. BJU Int
2012;110(11):1767-1774.
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B3 receptor agonists
Mirabegron (Myrbetriq)
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Mécanisme d’action sur la vessie
NE
relaxation
Récepteurβ3-adrénergique
Agoniste B3
(contraction)
Antimuscariniques
Récepteur muscarinique M3
Ach
Yamaguchi O and Chapple CR. Neurourol and Uro 2007;6:752-756. Gras J. Drugs of Today 2012;48(1):25-32. Sacco E and
Bientinesi R. Ther Adv Urol 2012;4(6):315-324. Tyagi P, Tyagi V, et Chancellor M. Expert Opin Drug Saf. 2011;10(2):287-294.
Hicks A, McCafferty GP, Riedel E et al. J Pharmacol Exp Ther 2007;323(1):202-209.
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Efficacité: mirabegron vs. Tolterodine
incontinence/24 heures mictions/24 heures d’épisodes d’urgence
/24 heures
Khullar V et al. Eur Urol 2013;63:283-295.
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Mirabegron : Effets secondaires
Placebo
(%)
Mirabegron 50 mg
(%)
Toltérodine LP
4 mg (%)
EICT courants
Hypertension 7,7% 5,9% 8,1%
Sécheresse buccale 2,6% 2,8% 10,1%
Céphalées 2,8% 3,7% 3,6%
Constipation 1,4% 1,6% 2,0%
EICT cardiovasculaires
Allongement de
l’intervalle QTc ou ses
séquelles
0 0 0,4%
Arythmie 1,0% 2,2% 3,2%
EICT = Effets indésirables apparus en cours de traitement; Khullar V et al. Eur Urol 2013;63:283-295.
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Pulse, pressure
and QT same as
monotherapy
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HBP: Définition
Clinique: symptômesobstructive/irritative qui sontattribuées à l’HBP
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Cas clinique
Homme 55 ans
Frequence/nycturie
Question cle?
Jet urinaire?
Si normal: Dx
Si lent: Dx?
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Evaluation initiale
HMA• hématurie, UTI, pelvic CHX, Db, neuro, stènose, α-
cholinergique,
TR
A+C urine: • r/o UTI, hématurie
PSA si 50-69
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Cause des symptômes
obtructive
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La vessie est comme le coeur!
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Cause des symptômes
irritatives
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HBP: complications
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Progression de l’HBP/Annee:
MTOPS
Clinical progression overall 4.5%
retention 0.6%
incontinence 0.3%
UTIs 0.1%
TURP 1.3%
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cystoscopie
Stènose uretre?
Planification chirurgicale
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Rx: Plan
Rx Médical• Alpha bloqueurs• Inhibiteurs de la 5 alpha réductase• Anti-cholinérgiques• PDE5-I
Rx Chirurgical• RTUP
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Alpha bloqueurs
Logic• Obstruction 2° smooth muscle tone medié par
α1 AR
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Alpha bloqueurs : Classification
α1Long action• Terazosin ( Hytrin)• Doxazosin ( cardura)• Alfuzosin SR 10 (xatral)
α1a• Tamsulosin 0.4( flomax)• Silodosin 8 (rapaflow)
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Alpha bloqueurs:
Effets secondaires?
HypoTA orthostatique/syncope (1b)
Éjaculation rétrograde (1a)
Congestion nasale (1d)
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FLOMAX
sur les Sx LUTS (IPSS)
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Inhibiteurs de 5a reductase
Finasteride (proscar)
Dutasteride (Avodart)
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Finasteride: Retention
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Finastéride : Effets secondaires
Libido 6%
ED 8%
Hypoejaculate 4%
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Toltérodine
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RTUP
-Standard
-Green light
-Holep
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RTUP