Critérios de escolha das abordagens terapêuticas da hiperplasia prostática benigna

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Critérios de escolha das abordagens terapêuticas da hiperplasia prostática benigna

Mensagem  Joyce Carvalho Martins em Ter Out 28, 2014 8:45 pm

watchful waiting
   o recommended for (AUA Standard)
           • mild symptoms of lower urinary tract symptoms (LUTS) secondary to BPH (American Urological Association Symptom Index [AUASI] score <8 )
           • moderate or severe symptoms (AUASI score ≥ 8 ) who are not bothered by their LUTS symptoms
  o behavioral strategies (diet and activity)
           • limit fluid intake in evening
           • avoid excess alcohol and highly seasoned or irritative foods
           • increase physical activity (avoid sedentary lifestyle)
     • medical management options for patients with moderate-to-severe symptoms of BPH
  o alpha-1 blockers
           • allow 2-4 weeks from initiation of therapy to treatment assessment
           • alfuzosin, doxazosin, tamsulosin and terazosin are appropriate and effective treatment alternatives for patients with bothersome, moderate-to-severe LUTS secondary to BPH (AUASI score ≥ 8 ) (AUA Option)
           • older, less expensive, generic alpha blockers remain reasonable choices (require dose titration and blood pressure monitoring) (AUA Option)
           • use caution when prescribing alpha blocker in patients using phosphodiesterase inhibitors (sildenafil, vardenafil, tadalafil) which may cause symptomatic hypotension
           • if cataract surgery planned, avoid starting alpha blockers until after cataract surgery completed due to risk of intraoperative floppy iris syndrome (IFIS) (AUA Recommendation)
           • alpha-1 blockers appear effective for symptom improvement (level 2 [mid-level] evidence, level 1 [likely reliable] evidence for terazosin); clinical efficacy similar for alpha-1 blockers evaluated (level 2 [mid-level] evidence)
           • alpha-1 blockers may increase risk for dizziness, hypotension or syncope (level 2 [mid-level] evidence)
  o 5-alpha reductase inhibitors (5-ARIs)
           • allow ≥ 3 months from initiation of therapy to treatment assessment
           • appropriate and effective treatment alternative for men with LUTS secondary to BPH who have prostate enlargement (AUA Option)
           • should not be used in men with LUTS secondary to BPH who do not have prostate enlargement (AUA Recommendation)
           • finasteride for > 1 year improves symptoms and reduces risk of acute urinary retention and surgery for BPH, but increases sexual adverse effects (level 1 [likely reliable] evidence)
           • dutasteride may improve symptoms and reduce incidence of acute urinary retention and BPH-related surgery (level 2 [mid-level] evidence)
           • finasteride and dutasteride appear to have similar efficacy for reducing prostate volume and urinary symptoms in men with BPH (level 2 [mid-level] evidence)
           • finasteride is less effective than doxazosin or terazosin for improving BPH symptoms and nocturia (level 1 [likely reliable] evidence)
    o combination of alpha blocker plus 5-ARI
           • combination of alpha blocker and 5-alpha reductase inhibitor is an appropriate and effective treatment for patients with LUTS associated with prostate enlargement (AUA Option)
           • combination of alpha blocker (doxazosin or tamsulosin) plus 5-alpha reductase inhibitors (finasteride or dutasteride) appears more effective than either monotherapy in men with prostate size > 25-30 mL (level 2 [mid-level] evidence)
   o other medications
          • phosphodiesterase 5 inhibitors may improve prostate symptom scores for LUTS due to BPH (level 2 [mid-level] evidence, level 1 [likely reliable] evidence for vardenafil)
          • anticholinergic agents may be appropriate and effective treatment alternatives for management of LUTS secondary to BPH in men without an elevated postvoid residual (> 250-300 mL) and when LUTS are predominantly irritative (AUA Option)
          • tamsulosin plus tolterodine extended release reduces symptoms in men with LUTS and overactive bladder (level 1 [likely reliable] evidence)
          • intramuscular cetrorelix (60 mg, then 30 mg at 2 weeks) improves International Prostate Symptom Score in men with symptomatic BPH (level 1 [likely reliable] evidence)
          • nonsteroidal anti-inflammatory drugs may improve International Prostate Symptom Score in men with BPH (level 2 [mid-level] evidence)
   o no dietary supplement, combination phytotherapeutic agent or other nonconventional therapy is recommended for management of LUTS secondary to BPH (AUA Recommendation)
         • some specific saw palmetto extracts shown not to improve LUTS in men with BPH (level 1 [likely reliable] evidence); saw palmetto likely has no clinically meaningful effect on LUTS secondary to BPH (AUA Recommendation)
         • beta-sitosterols (nonglucosidic B-sitosterols) may improve short-term urinary symptoms and flow measures (level 2 [mid-level] evidence)
         • other herbs which may be associated with improved symptoms include Pygeum africanum (African plum), rye grass extract (Cernilton), and stinging nettle root (level 2 [mid-level] evidence)
        • surgery
   o indicated if (AUA Recommendation)
         • renal insufficiency clearly due to BPH
         • recurrent urinary tract infections, bladder stones or gross hematuria due to BPH
         • LUTS refractory to other therapies
         • bladder diverticulum associated with recurrent urinary tract infections or progressive bladder dysfunction
  o surgical options include
         • transurethral resection of the prostate (TURP) (AUA Option)
         • transurethral vaporization of the prostate (AUA Option)
         • transurethral incision of the prostate (AUA Option)
         • laser therapies (AUA Option)
         • prostatectomy (AUA Option)
  o TURP is effective and cost-effective, other surgical treatments appear to have similar outcomes and not clearly more cost-effective than TURP (level 2 [mid-level] evidence)
  o bipolar TURP may be associated with similar symptom improvement at 12 months and decreased hospital stay and less bleeding compared to conventional TURP (level 2 [mid-level] evidence)
  o electrosurgical enucleation of prostate associated with shorter duration of catheterization and hospital stay and similar symptom improvement compared to TURP or prostatectomy (level 2 [mid-level] evidence)
• minimally invasive therapies
   o treatment options for bothersome moderate or severe LUTS due to BPH
         • transurethral needle ablation (AUA Option)
         • transurethral microwave thermotherapy (AUA Option)
    o National Institute for Health and Clinical Excellence recommends AGAINST offering minimally invasive treatments limited evidence to determine which minimally invasive intervention is most effective, but all appear less effective than TURP (level 2 [mid-level] evidence)

• 1. American Urological Association (AUA), McVary KT, Roehrborn CG, et al. Management of Benign Prostatic Hyperplasia (BPH) (Revised, 2010). AUANet PDF
• 2. National Institute for Health and Clinical Excellence (NICE). The management of lower urinary tract symptoms in men. NICE 2010 May:CG97 PDF

Joyce Carvalho Martins

Mensagens : 6
Data de inscrição : 27/10/2014

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