BPH合并OAB症状的诊治

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,BPH,合并,OAB,症状的诊治,下尿路,症,症状(LUTS)的分类,下尿路症状,(LUTS),储尿期症状,排尿期症状,排尿后期症状,尿流变,细,细,尿流分,叉,叉,尿流间,断,断,尿踌躇,排尿费,力,力,尿滴沥,排尿后,滴,滴沥,尿不尽,尿急症,尿频,夜尿,尿失禁,BPH合并OAB发生率,高,高,LeeJYetal,.,.BJUInt2004;94:817,-,-20,J.Starkmanetal,JUrol,2008,179(3),1018-1023,47%,的膀胱,出,出口梗,阻,阻患者,同,同时合,并,并有OAB；,高达约,50%,的膀胱,出,出口梗,阻,阻合并OAB的患者,在,在BOO解除后OAB症状仍,然,然存在,。,。,患者比,例,例%,BOO越严重,，,，OAB发生率,越,越高,TomasKnutson,etal.BPH withCoexistingOveractive BladderDysfunction,-,-AnEveryday,Urological Dilemma,.,.NeurourologyandUrodynamics,2001,20,:,:237247.,OAB发生率,（,（%）,随着梗,阻,阻的加,重,重，OAB的发生,率,率增高,PetersTJ,et al.J Urol1997;157,:,:885-9,储尿期,症,症状更,困,困扰BPH患者,在男性OAB,/,/储尿期LUTS患者中,，,，抗胆碱,能,能药物,没,没有合,理,理应用,在过去12个月中,，,，诊断,为,为OAB的男性,，,，只有25%接受抗,胆,胆碱能,药,药物治,疗,疗,储尿期LUTS的男性,，,，只有6%-7%处方过,抗,抗胆碱,能,能药物,Adapted fromMorant SV et al.IntJClin Pract 2008,;,;62,:,:688694,2000,2006,(n,=,=2547,),),(n,=,=13,486),(n,=,=4089,),),(n,=,=30,933),a1-AR阻滞剂,和,和抗胆,碱,碱能药,物,物联合,治,治疗能更全,面,面地缓,解,解症状,逼尿肌,过,过度活,动,动症状,：,：尿急,、,、尿频,、,、夜尿,膀胱出,口,口梗阻,症,症状：,排,排尿踌,躇,躇、尿,流,流中断,、,、尿流,变,变细,一半以,上,上BPH患者合,并,并OAB,如何缓,解,解OAB症状？,如何缓,解,解BOO症状？,1-AR阻滞剂,抗胆碱,能,能药物,BPH,OAB,1-AR阻滞剂,能,能缓解79%的BOO症状但仅能,缓,缓解35%的BOO,+,+OAB症状,79%,35%,没有改,善,善,得到改,善,善,患者比,例,例%,LeeJYetal,.,.BJUInt2004;94:817,-,-20,1-AR阻滞剂,对,对BOO症状和BOO,+,+OAB症状的,治,治疗效,果,果观察,单用1-AR阻滞剂3个月症,状,状无改,善,善者加,用,用M受体拮,抗,抗剂能,进,进一步,缓,缓解症,状,状,37.5%,73%,79%,35%,没有改,善,善,得到改,善,善,LeeJYetal,.,.BJUInt2004;94:817,-,-20,患者比,例,例%,患者主,观,观感受,显,显示联,合,合治疗(1,-,-AR阻滞剂+M受体拮,抗,抗剂)更有益,KaplanSAetal,.,.JAMA2006;296,:,:2319-28,N=215,N=210,N=209,N=217,12周RCT研究：,男,男性，40岁,IPSS,12,排尿日,记,记提示OAB,Qmax 5ml,/,/s;PVR 200 ml,安慰剂,1-AR阻滞剂,联合治,疗,疗,M受体拮,抗,抗剂,*P 0,.,.03,(与其他,各,各组相,比,比),*,加用抗,胆,胆碱能,药,药物是,否,否会增,加,加尿潴,留,留的风,险,险？,联合用药是否有根据？,急性尿潴留,(AUR),？,抗胆碱能药物有抑制逼尿肌收缩的效应,KaplanSAetal,.,.Int JClinPract.2011Jan7.doi:10.1111/j,.,.1742-1241.2010,.,.02611,.,.x.,在患者PVR较小时,，,，抗胆碱,能,能药物,并,并不增,加,加残余尿,量,量,残余尿,（,（ml）,Yang Yongetal,.,.ChinMedJ2007;120,(,(5),:,:372:370,-,-374,朝阳医,院,院门诊,中,中纳入,的,的191例BPH伴发LUTS的患者,，,，经过1周a受体阻,滞,滞剂治,疗,疗后，,仍,仍有69例患者,存,存在尿,急,急，尿,频,频等OAB症状，,加,加用抗,胆,胆碱能,药,药物后,，,，IPSS评分显,著,著改善,，,，且残,余,余尿没,有,有显著,改,改变,（n=36）,（n=33）,P=0,.,.584,P=0,.,.016,在患者PVR较小时,，,，联合抗胆碱,能,能药物,并,并不增,加,加AUR的发生,联合治疗组,基线,PVR(mL,）,AUR,发生例数,(,发生率,(%),1,-AR,阻滞剂,+,安慰剂,1,-AR,阻滞剂,+,抗胆碱能药物,MacDiarmid SA et al.,50.7,0,0,Kaplan SA et al.,51.5,0,3(1.5),Chapple C et al.,45.1,1.8(0.6)*,1.8(0.3)*,Yang yong et al.,17.1,0,0,MacDiarmid SA et al.Mayo ClinProc2008;83(9,),):1002,-,-10,;,;,KaplanSAetal,.,.JUrol2009;182:2825-30;,Chapple Cetal,.,.EurUrol 2009,;,;56,:,:534-43,*AUR发生率(%),(,(需导尿,率,率(%),),),Yang Yongetal,.,.ChinMedJ2007;120,(,(5),:,:372:370,-,-374,N=220,N=216,N=215,N=225,KaplanSAetal,.,.JAMA2006;296,:,:2319-28,与安慰,剂,剂相比,，,，联合治,疗,疗并没,有,有显著,增,增加AUR的发生,联合治,疗,疗前应,进,进行残,余,余尿评,估,估,残余尿PVR,50ml时患者BPH并发症,（,（如急,性,性尿潴,留,留）发,生,生的风,险,险小,PVR,40,%,%功能性,膀,膀胱容,积,积时可以,应,应用联,合,合治疗,William I,.,.Jaffe,MD*and AlexisE.Te,MD,.,.CurrentUrology Reports2005,6:410,418,BPH/OAB,储尿期症状明显,PVR 40%,功能性膀胱容积,2010 EAUGuideline,有越来,越,越多的,证,证据表,明,明:对于有梗阻,存,存在的,男,男性患,者,者的OAB症状，1-AR阻滞剂,与,与抗胆碱,能,能药物联合使,用,用治疗是安全,的,的（B级推荐,）,）。,Treatmentofnon-neurogenicmaleLUTS.,EuropeanAssociationofUrology,2010,评估加,用,用索利那,新,新对于单,用,用坦索罗,辛,辛治疗后仍有OAB症状的BPH患者的,疗,疗效及,耐,耐受性,ASSIST研究设,计,计,入选标,准,准,24小时内,尿,尿急次,数,数2次,24小时内,排,排尿次,数,数8次,Qmax5ml/秒，PVR,8Weeks,多中心,，,，随机,、,、双盲,、,、安慰,剂,剂对照,研,研究,TAM：坦索,罗,罗辛PBO：安慰,剂,剂SOL：索利,那,那新,TAM,+,+PBO,(n,=,=209),TAM,+,+SOL2.5mg,(n,=,=210),TAM,+,+SOL5mg,(n,=,=208),*:p0.05(vs安慰剂,ANCOVA),-3,-2,-1,0,-1.93,-2.18,-2.36,*,尿急次,数,数/24h(主要终,点,点),平均次,数,数改变/24 h,ASSIST研究结,果,果,加用索,利,利那新5mg联合治,疗,疗可显,著,著减少,尿,尿急、,尿,尿频次,数,数,*,:p0.001(vs,安慰剂,ANCOVA),-2,-1.5,-1,-0.5,0,-1.27,-1.06,*,*,*,排尿,/24 h,平均次数改变,/24 h,TAM+PBO,(n=209),TAM+SOL 2.5mg,(n=210),TAM+SOL 5mg,(n=208),SolifenacinSuccinateSeventhPeriodical ReportontheSafety,September,2010,.,.,TAM：坦索,罗,罗辛PBO：安慰,剂,剂SOL：索利,那,那新,-0.22,*:p,0.05,*,*,:,:p0.01,*,*,:,:p0.001(vs安慰剂,ANCOVA),总评分,尿频,夜尿评,分,分,尿急评,分,分,尿失禁,评,评分,8.1,8.2,8.3,1.0,1.0,1.0,2.0,2.0,1.9,4.1,4.1,4.1,1.0,1.0,1.2,-5,-4,-3,-2,-1,0,-2.3,-3.1,-3.2,-0.1,-0.2,-0.3,-0.2,-0.3,-0.4,-1.5,-1.9,-1.9,-0.5,-0.7,-0.7,TAM,+,+SOL5mg(n=213),TAM,+,+PBO,(,(n=212,),),TAM,+,+SOL2.5mg,(,(n=210,),),*,*,*,*,*,*,*,*,*,治疗前(平均),评分改,变,变,SolifenacinSuccinateSeventhPeriodical ReportontheSafety,September,2010,.,.,TAM：坦索,罗,罗辛PBO：安慰,剂,剂SOL：索利,那,那新,ASSIST研究结,果,果,加用索,利,利那新,治,治疗可,显,显著改,善,善患者OABSS评分,SolifenacinSuccinateSeventhPeriodical ReportontheSafety,September,2010,.,.,加用索,利,利那新,治,治疗不,会,会影响Qmax,TAM：坦索,罗,罗辛PBO：安慰,剂,剂SOL：索利,那,那新EOT：试验,结,结束,0,10,20,(mL/s),Qmax,TAM,+,+PBO,(n=212,),),基线,*,EOT,基线,基线,TAM,+,+SOL2.5mg,(n=210,),),TAM,+,+SOL5mg,(n=213,),),EOT,EOT,平均值,*:n,=,=214,12.9,13.1,13.5,12.8,14.5,13.5,(mL,),),TAM,+,+PBO,(n=212,),),EOT,基线,基线,TAM,+,+SOL2.5mg,(n=210,),),TAM,+,+SOL5mg,(n=213,),),0,10,20,30,4