TeleCondutas: prostatite crônica/síndrome da dor pélvica crônica / TeleGuides: chronic prostatitis / chronic pelvic pain syndrome

Sintomas de prostatite são muito comuns na população, ocorrendo com uma prevalência média de 8,2%. Estima-se que 35% a 50% dos homens apresentarão esses sintomas em algum momento de sua vida. Entre as formas de prostatite, a apresentação mais comum é a Prostatite Crônica/ Síndrome da Dor Pélvica Crônica (PC/SDPC). PC/SDPC é uma síndrome clínica definida essencialmente pela presença de dor pélvica crônica não causada por patologias identificáveis. Apesar do termo "prostatite", parcela significativa dos casos não tem sinal de inflamação ("-ite") da próstata. Infecções causadas por Clamídia, Micoplasma ou Ureaplasma geralmente não são responsáveis pela PC/SDPC. Tampouco se sabe em que extensão a próstata é responsável pelos sintomas. Além de prevalente, a PC/SDPC prejudica a qualidade de vida dos homens e tem importante impacto econômico. Está frequentemente associada a dor genital, dor ejaculatória, dor abdominal, sintomas do trato urinário inferior e disfunção erétil. Ansiedade e medo de doenças graves são achados comuns em pacientes com PC/SDPC e podem contribuir com os sintomas. Múltiplas consultas, investigações e procedimentos também são riscos aos quais esses pacientes estão sujeitos. Pouca atenção tem sido dada à essa condição, o que resulta em literatura relativamente escassa sobre o assunto. Considerando a diversidade e severidade dos sintomas, assim como as comorbidades sistêmicas que frequentemente estão associadas (como síndrome do intestino irritável e fibromialgia), abordagens terapêuticas uniformes e monoterápicas raramente funcionam. Não surpreende que a PC/SDPC seja uma condição associada a significativa frustração, tanto nos pacientes quanto nos médicos. É necessário, portanto, que o diagnóstico e tratamento adequado seja feito na Atenção Primária à Saúde (APS), em vistas a melhorar a qualidade de vida do paciente e evitar encaminhamentos desnecessários ao urologista. Esta guia apresenta informação que orienta a conduta para casos de prostatite crônica/síndrome da dor pélvica crônica no contexto da Atenção Primária à Saúde, incluindo: Classificação, Sinais e Sintomas, Diagnóstico, Tratamento, Encaminhamento para serviço especializado, Referências, Anexo.

Neurological status predicts response to alpha-blockers in men with voiding dysfunction and Parkinson's disease

OBJECTIVES: To evaluate predictors of the response to doxazosin, a selective alpha-adrenoceptor antagonist, when used for the treatment of lower urinary tract symptoms in men with Parkinson's disease. METHODS: In a prospective study, 33 consecutive men (mean age 59.2±7.0 years) with Parkinson's disease and lower urinary tract symptoms were evaluated. Neurological dysfunction was assessed with the Unified Parkinson's Disease Rating Scale. Urological assessment was performed at baseline and after 12 weeks of treatment with 4 mg/day of extended-release doxazosin, including symptom evaluation with the International Continence Society male short-form questionnaire, an assessment of the impact of lower urinary tract symptoms on quality of life and urodynamics. Clinical and urodynamic predictors of response were specifically evaluated. RESULTS: Compared with the score at baseline, the total International Continence Society male short-form score was reduced after doxazosin administration, from 17.4±7.5 to 11.1±6.9 (p<0.001). The impact of lower urinary tract symptoms on quality of life was also significantly reduced, from 1.8±1.1 to 1.0±1.0 (p<0.001) and the maximum urinary flow varied from 9.3±4.4 to 11.2±4.6 ml/s (p = 0.025). The severity of neurological impairment ...

Cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia in the Brazilian public health system

OBJECTIVE: To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System - "Sistema Único de Saúde (SUS)"). MATERIAL AND METHODS: A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis(Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). RESULTS: The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. CONCLUSIONS: These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.

Efficacy of three different alpha 1-adrenergic blockers and hyoscine N-butylbromide for distal ureteral stones

PURPOSE: To evaluate hyoscine N-butyl bromide (HBB) and three different alpha-1 blockers in the treatment of distal ureteral stones. MATERIALS AND METHODS: A total of 140 patients with stones located in the distal tract of the ureter with stone diameters of 5 to 10mm were enrolled in the present study and were randomized into 4 equal groups. Group 1 received HBB, Group 2 received alfuzosin, Group 3 received doxazosin and Group 4 received terazosin. The subjects were prescribed diclofenac injection (75 mg) intramuscularly on demand for pain relief and were followed-up after two weeks with x-rays of the kidneys, ureters, bladder and urinary ultrasonography every week. The number of pain episodes, analgesic dosage and the number of days of spontaneous passage of the calculi through the ureter were also recorded. RESULTS: The average stone size for groups 1, 2, 3 and 4 was comparable (6.13, 5.83, 5.59 and 5.48 mm respectively). Stone expulsion was observed in 11 percent, 52.9 percent, 62 percent, and 46 percent in groups 1, 2, 3 and 4 respectively. The average time to expulsion was 10.55 ± 6.21 days in group 1, 7.38 ± 5.55 days in group 2, 7.85 ± 5.11 days in group 3 and 7.45 ± 5.32 days in group 4. Alpha blockers were found to be superior to HBB (p < 0.05). CONCLUSIONS: Medical treatment of distal ureteral calculi with alfuzosin, doxazosin and terazosin resulted in a signi?cantly increased stone-expulsion rate and decreased expulsion time when compared with HBB. HBB seems to have a negative effect on stone-expulsion rate.

Pheochromocytoma in children and adolescents.

Eleven subjects aged <20 yr with histologically proven pheochromocytoma between 1987 and 2006 were analyzed. Family history was present in 18%. In 2 patients, pheochromocytoma was part of VHL and in one it was associated with MEN 2. Twenty four hour urine VMA level was elevated in 100% and metanephrine level in 73%. CT/ MRI were showing the tumor in all. Prazosin extended release tablets (maximum 30 mg/day) were used in 73% and doxazosin (maximum 12 mg/ day) in 27%. Intraoperative BP fluctuations were seen in 27%. All were biochemically cured after surgery. Preoperative á blockade with extended release prazosin and doxazosin were effective in controlling perioperative BP fluctuations. Hence these drugs can be used in children and adolescents without fear of postoperative hypotension.

Feocromocitoma bilateral: cirugía laparoscópica en dos casos / Bilateral pheochromocytoma: laparoscopic adrenalectomy in 2 cases

Laparoscopic adrenalectomy, if done by skilled surgeons, is now the first choice for treating most adrenal tumors, including bilateral pheochromocytoma. We report two women, aged 35 and 34 years old, with bilateral adrenal pheochromocytoma successfully excised by laparoscopic surgery. Both had severe hypertension, high urinary catecholamine values (epinephrine + norepinephrine: 528 and 1083 ug/24h) and bilateral adrenal tumors at CT scan. After 4 weeks of doxazosin treatment, a laparoscopic transperitoneal adrenalectomy was done (Gugner's technique), with surgical times of 7 and 5 hours respectively. Both patients received hydrocortisone and only the second one required one unit of packed cells. Postoperative evolution was uneventful and both patients were discharged at the fifth postoperative day. At two months of follow up, both patients are asymptomatic and normotensive

Proposta para o uso de doxozosina e dexametasona para facilitar a micçäo espontânea após cirurgia ginecológica e/ou uroginecológica / Proposal for the use of doxozosine and dexametasone to facilitate the spontaneous miction after gynecologic and/or urogynecologic surgery

Estamos mostrando nossa experiência com o uso de doxazosina e dexametasona no tratamento e na prevençäo da retençäo urinária após colpossuspensäo abdominal. Estamos propondo o uso destas drogas com a finalidade de facilitar a micçäo espontânea após cirurgia ginecológica e/ou uroginecológica

Displasia fibromuscular sistémica: compromiso de ramas supraaórticas y renales / Systemic fibromuscular dysplasia with supra aortic and renal artery involvement: report of 1 case

We report a 39 years old male presenting with an intense hemicrania pain in the tract of the carotid artery and Claude Bernard Horner syndrome. The patient had also a high blood pressure. Magnetic resonance imaging demonstrated a left carotid artery fibrodysplastic disease. Conventional angiography of 4 cerebral vessels showed a dissection of the left carotid artery and fibromuscular dysplasia of the left vertebral artery. Renal angiography showed a stenosis and occlusion of renal artery with radiological exclusion of right kidney. On the left side there was a stenosis and occlusion of segmental branches. The diagnostic importance of Claude Bernard Horner syndrome and the need to study renal artery involvement when carotid dissection is accompanied with high blood pressure, is highlighted

Uso de doxazosin en la hiperplasia prostática benigna obstructiva: experiencia clínica / Use of doxazosin in the obstructive benign prostate hyperplasia: clinical experience

Mucho se ha publicado sobre farmacoterapia para el manejo de la hiperplasia prostática benigna, pero no está bien definido la existencia de influencia ambientales, genéticas o alimenticias sobre su desarrollo y la respuesta a los distintos medicamentos comercialmente disponibles. Un total de 24 pacientes son evaluados con un parámetro urodinámico (uroflujometría) a la administración de dosis creciente de doxazosin y se confirma su beneficio en mejoría de flujo, buena tolerancia y efectos positivos en bajas dosis, con efecto residual prolongada

Prostatismo feminino: tratamento clínico versus tratamento cirúrgico / Female prostatism: clinical treatment versus surgical treatment

Estudamos mulheres com prostatismo objetivando comparar a eficiência dos tratamentos clínico e cirúrgico. O tratamento clínico foi efetuado em 24 mulheres, com provável causa funcional, com droga bloqueadora dos receptores alfa-adrenérgicos; enquanto que o tratamento cirúrgico foi efetuado em 26 mulheres com retirada da provável causa mecânica. Os resultados dos tratamentos clínico e cirúrgico foram equivalentes, sugerindo que o prostatismo feminino tem etiologia, fisopatologia e conduta terapêutica similar ao masculino.

Doxazosin en el tratamiento de la hiperplasia prostática benigna: estudio multicentrico venezolano: reporte preliminar / Doxazosin in the treatment of the bening prostatic hyperplasia venezuelan multicentral study: preliminary report

Objetivos: evaluar la eficacia y tolerancia del doxazosin en el tratamiento de la hiperplasia prostática benigna (HPB) en pacientes venezolanos. Pacientes y Métodos: Es un estudio abierto controlado con placebo basal, se incluyeron 39 pacientes con HPB diagnosticada por score de síntomas (I-PSS) y medición de flujo urinario. Se administró placebo por dos semanas y doxazosin con titulación de dosis a un máximo de 8 mg una vez al día por 14 semanas. Se monitorizó presión arterial, eventos adversos y calidad de vida. Resultados: Se incluyeron 39 pacientes de cinco centros, con un promedio de edad de 61,8 años (rango 45-78 años) y con una duración de los síntomas de 19,8 meses desde su diagnóstico (rango 3-60 meses). Doxazosin produjo mejoría significativa del 62 por ciento en el total de score de síntomas (I-PSS) de 18,7 basal a 7,08 al final del tratamiento (p<0,01) y un aumento del flujo urinario máximo (Qmax) en 1,34ml/seg, de 11,98ml/seg basal a 12,32ml/seg, al final del tratamiento. La medición de calidad de vida por síntomas urinarios, mejoró significativamente en 50,1 por ciento en promedio, desde muy insatisfecho (4) a muy satisfecho (2) (p<0,01). No se observaron efectos adversos ni cambios en la presión arterial. Conclusión: en este reporte preliminar doxazosin fue bien tolerado y produjo mejoría significativa en los síntomas y en la calidad de vida de pacientes con HPB. El estudio continúa.