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BPO/LUTS – Aktuelles zur medikamentösen Therapie

BPO/LUTS—latest news on drug treatment

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Journal für Urologie und Urogynäkologie/Österreich Aims and scope

Zusammenfassung

„Lower urinary tract symptoms“ (LUTS) gehören zu den häufigsten Beschwerden der Patienten in der täglichen urologischen Praxis, wobei eine benigne Prostatavergrößerung die häufigste Ursache für LUTS bei Männern darstellt. Für die Therapie, die nur bei subjektiv störender Symptomatik eingeleitet werden sollte, stehen neben einer operativen Sanierung zunächst konservative und medikamentöse Therapiestrategien zur Verfügung. Diverse Phytotherapeutika führen zwar zur Verbesserung der Symptomatik (IPSS [„international prostate symptome score“]) und des Harnstrahls (Qmax), die Krankheitsprogression wird jedoch nicht beeinflusst. Ähnliches, wenn auch deutlich besser untersucht, gilt für die Gruppe der schnell wirksamen α1-Blocker. Bei Patienten mit einem Prostatavolumen <40 ml gelten sie als Mittel der ersten Wahl. Mit einer Reduktion des Prostatavolumens und damit einhergehend einer Verhinderung der Krankheitsprogression bilden 5α-Reduktase-Hemmer eine wichtige Säule in der medikamentösen Therapie der männlichen LUTS. Ein Wirkungseintritt ist jedoch frühestens nach 3‑monatiger Therapiedauer zu erwarten. Mit Tadalafil, 5 mg/Tag, steht auch ein PDE5-Hemmer („Phosphodiesterase-5“) für die Pharmakotherapie der LUTS zur Verfügung. Neben der Verbesserung einer ED („Erektile Dysfunktion“) vermindert die Behandlung auch die LUTS-Symptomatik (IPSS). Patienten, bei denen die Harnspeichersymptomatik vordergründig ist, profitieren von einer Therapie mit verschiedenen Muskarinrezeptorantagonisten. Dabei sollte im Vorfeld eine ausgeprägte subvesikale Obstruktion mit Restharnbildung ausgeschlossen werden. Bei schlechter Verträglichkeit dieser Substanzgruppe (Mundtrockenheit, Obstipation) kann alternativ der Beta-3-Agonist Mirabegron eingesetzt werden, der bei ähnlicher Wirksamkeit besser verträglich ist, sofern keine ausgeprägte Hypertonie bekannt ist. Die angeführten Substanzgruppen wurden in verschiedenen Kombinationen getestet, wobei neben der erwünschten additiven Wirkung auch eine Verstärkung der Nebenwirkungen berücksichtigt werden muss.

Abstract

“Lower urinary tract symptoms” (LUTS) are among the most common complaints of urological patients. Benign prostate enlargement represents the most common cause of LUTS in men and treatment should only be initiated in patients with bothering symptoms. There are various different therapeutic strategies to choose from: phytotherapeutic drugs significantly improve obstructive symptoms (IPSS [“international prostate symptome score”]) and maximum urinary flow (Qmax), yet disease progression is not inhibited. The same applies to the group of the rapid-acting α1-blockers, which are considered as first-line therapy in patients with a prostate volume <40 ml. The 5α-reductase inhibitors are another important therapeutic option for men with symptoms of LUTS and a prostate volume >40 ml, accompanying the effect of prostate volume reduction and concomitant prevention of disease progression—onset of these favorable effects are expected after a therapy period of 3 months. Tadalafil, a phosphodiesterase type 5 (PDE 5) inhibitor, has its main indication in the treatment of erectile dysfunction, yet a daily oral dose of 5 mg was also shown to significantly improve LUTS. Patients predominantly suffering from storage symptoms can benefit from oral therapy with a muscarinic receptor antagonist. Here, infravesical obstruction should be ruled out in advance and the absence of increased post-void residual urine volume is necessary. Mirabregone, a beta-3 agonist, can be used as a safe alternative in individuals with persistent side effects like xerostomia or constipation, yet is not recommended for patients with severe hypertension. Combination therapies have been subject to many studies in the past and have been shown to achieve more symptom relief when the higher rate of side effects is well tolerated by the patient.

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  1. Universitätsklinik für Urologie, Anichstraße 35, 6020, Innsbruck, Österreich

    Thomas Burtscher FEBU &  Jasmin Bektic FEBU

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Correspondence to Jasmin Bektic FEBU.

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Burtscher, T., Bektic, J. BPO/LUTS – Aktuelles zur medikamentösen Therapie. J. Urol. Urogynäkol. AT 26, 114–120 (2019). https://doi.org/10.1007/s41972-019-0076-0

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