В последние годы наметилась тенденция, в рамках которой в основе выбора оптимальной лечебной тактики лежит анализ жалоб конкретного пациента с учетом его индивидуальных ожиданий от этого лечения. Внедрение в широкую практику некоторых элементов искусственного интеллекта, в частности валидизированных опросников, экспертных систем и номограмм, значительно облегчает диагностику. Статистический анализ предъявляемых больными жалоб свидетельствует об очевидно большей распространенности проблем фазы накопления, что, вероятно, является следствием наличия у многих из пациентов гиперактивности мочевого пузыря, симптомы которого присутствуют у 8–16% взрослого населения Европы и у 60% больных с выраженной инфравезикальной обструкцией.Медикаментозная терапия симптомов нижних мочевых путей (СНМП) фазы накопления может проводиться в режиме монотерапии, ступенчато или в формате комбинированного назначения препаратов с разным механизмом действия. Основой такой терапии являются a-адреноблокаторы, М-холинолитики и появившиеся недавно агонисты b3-адренорецепторов. Столь широкое многообразие вариантов лечения позволяет подойти индивидуально к каждому больному и обеспечивает высокую вероятность избавления от СНМП.
In recent years, there has been a trend in which the basis for selection of the optimal treatment strategy is the analysis of the specific complaints of the patient, taking into account their individual expectations from this treatment. The introduction of the wide practice of some elements of artificial intelligence, such as validated questionnaires, expert systems and nomograms, greatly facilitates the diagnosis. Statistical analysis of the requirements of patient complaints indicates obviously a greater prevalence of the accumulation phase problems, which is probably a consequence of the fact that many of the patients overactive bladder symptoms is present 8–16% of the adult population in Europe and 60% of patients with severe bladder outlet obstruction. Drug therapy of lower urinary tract symptoms (LUTS) accumulation phase may be carried out as monotherapy, or in combination stepwise prescribing a format with a different mechanism of action. The basis of such therapy are a-blockers, anticholinergics M and recently appeared the b3-adrenergic receptor agonists. Such a wide variety of treatment options allows an individual approach to each patient and provides a high probability of getting rid of LUTS.
1. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol 2015; 67 (Issue 6): 1099–109.
2. Barry MJ, Jr. Fowler FJ, O'Leary MP et al. The American UrologicalAssociation symptom index for benign prostatic hyperplasia. The MeasurementCommittee ofthe American Urological Association. J Urol 1992; 148: 1549–57.
3. Van Venrooij GE, Eckhardt MD, Gisholf KW, Boon TA. Data from frequency-volume charts versus symptom scores and quality of life score in menwith lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2001; 39: 42–7.
4. Irwin DE, Milsom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50 (6): 1306–14.
5. Peters TJ, Donovan JL, Kay HE et al. The ICS-“BPH” Study: the bothersomeness of urinary symptoms. J Urol 1997; 157 (3): 885–9.
6. Van Exel NJ, Koopmanschap MA, McDonnell J et al. TRIUMPH Pan-European Expert Panel Medical consumption and costs during a one-year follow-up of patients with LUTS suggestive of BPH in six european countries: report of the TRIUMPH study. Eur Urol 2006; 49 (1): 92–102.
7. Раснер П.И., Пушкарь Д.Ю. Лечение симптомов нижних мочевых путей у пациентов с доброкачественной гиперплазией предстательной железы: современные международные стандарты. Справ. поликлин. врача. 2015; 10: 20–6. / Rasner P.I., Pushkar' D.Iu. Lechenie simptomov nizhnikh mochevykh putei u patsientov s dobrokachestvennoi giperplaziei predstatel'noi zhelezy: sovremennye mezhdunarodnye standarty. Sprav. poliklin. vracha. 2015; 10: 20–6. [in Russian]
8. Isaacs JT. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate 1990; 3 (Suppl.): 1–7.
9. Flanigan RC, Reda DJ, Wasson JH et al. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic BPH: a Department of Veterans Affairs cooperative study. J Urol 1998; 160 (1): 12–6.
10. Djavan B, Chapple C, Milani S et al. State of the art on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2004; 64 (6): 1081–8.
11. Давидов М.И., Локшин К.Л., Горбунова И.С. Частота острой задержки мочи у больных аденомой предстательной железы при 8-летнем лечении тамсулозином. Урология. 2015; 2: 74–81. / Davidov M.I., Lokshin K.L., Gorbunova I.S. Chastota ostroi zaderzhki mochi u bol'nykh adenomoi predstatel'noi zhelezy pri 8-letnem lechenii tamsulozinom. Urologiia. 2015; 2: 74–81. [in Russian]
12. Kaplan SA. Medical Therapy for Benign Prostatic Hyperplasia: New Terminology, New Concepts, Better Choices. Rev Urol 2006; 8 (1): 14–22.
13. Вишневский А.Е. Роль гипоксии детрузора в патогенезе расстройств мочеиспускания у больных доброкачественной гипеплазией предстательной железы и обоснование методов их консервативного лечения. Автореф. дис. … канд. мед. наук. М., 1998. / Vishnevskii A.E. Rol' gipoksii detruzora v patogeneze rasstroistv mocheispuskaniia u bol'nykh dobrokachestvennoi gipeplaziei predstatel'noi zhelezy i obosnovanie metodov ikh konservativnogo lecheniia. Avtoref. dis. … kand. med. nauk. M., 1998. [in Russian]
14. Кривобородов Г.Г., Школьников М.Е., Ефремов Н.С. и др. Холинолитики в лечении симптомов накопления мочевого пузыря у мужчин с доброкачественной гиперплазией предстательной железы. Эффективная фармакотерапия. Урология и Нефрология. 2011; 3: 26–8. / Krivoborodov G.G., Shkol'nikov M.E., Efremov N.S.i dr. Kholinolitiki v lechenii simptomov nakopleniia mochevogo puzyria u muzhchin s dobrokachestvennoi giperplaziei predstatel'noi zhelezy. Effektivnaia farmakoterapiia. Urologiia i Nefrologiia. 2011; 3: 26–8. [in Russian]
15. Michel MC, Schneider T, Krege S et al. Does gender or age affect the efficacy and safety of tolterodine? J Urol 2002; 168 (3): 1027–31.
16. Stenzelius K, Mattiasson A, Hallberg IR, Westergren A. Symptoms of urinary and faecal incontinence among men and women 75+ in relations to health complaints and quality of life. Neurourol Urodynam 2004; 23: 211–22.
17. Борисов В.В. Гиперактивный мочевой пузырь: эффективное лечение. Consilium Medicum. 2014; 16 (7): 22–8. / Borisov V.V. Giperaktivnyi mochevoi puzyr': effektivnoe lechenie. Consilium Medicum. 2014; 16 (7): 22–8. [in Russian]
18. Gravas S, Bachmann A, Descazeaud A et al. Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). http://www.uroweb.org/gls/pdf/Non-Neurogenic%20Male%20LUTS_(2705).pdf
19. Gong М, Dong W, Huang G et al. Tamsulosin Combined Solifenacin versus Tamsulosin Monotherapy on Male Lower Urinary Tract Symptoms: A Meta-analysis. Curr Med Res Opin 2015 20; 31 (9): 1781–92.
20. Drake MJ, Chapple C, Sokol R et al. NEPTUNE Study Group. Long-term safety and efficacy of single-tablet combinations of solifenacin and tamsulosin oral controlled absorption system in men with storage and voiding lower urinary tract symptoms: results from the NEPTUNE Study and NEPTUNE II open-label extension. Eur Urol 2015; 67 (2): 262–70.
21. Witte LP, Mulder WM, De la Rosette JJ et al. Muscarinic receptor antagonists for overactive bladder treatment: does one fit all? Curr Opin Urol 2009; 19 (1): 13–9.
22. Zinner N, Noe L, Rasouliyan L et al. Impact of solifenacin on resource utilization, work productivity and health utility in overactive bladder patients switching from tolterodine ER. Curr Med Res Opin 2008.
23. Abrams P, Kaplan S, De Koning Gans HJ, Millard R. Safety and tolerability of tolterodine for treatment of overactive bladder and coexisting benign prostatic obstruction: a prospective randomized, controlled multicenter study. J Urol 2006; 169: 2253–6.
24. Athanasopoulos A, Gyftopoulos K, Giannitsas K et al. Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized, controlled study. J Urol 2003; 169: 2253–6.
25. Kaplan SA, Walmsley K, Te AE. Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2005; 174: 2273–6.
26. Lee JY, Kim HW, Lee SJ et al. Comparison of doxazosin with or without tolterodine in men with symptomatic bladder outlet obstruction and an overactive bladder. BJU Int 2004; 94: 817–20.
27. Robinson D, Thiagamoorthy G, Cardozo L. A drug safety evaluation of mirabegron in the management of overactive bladder. Exp Opin Drug Saf 2016; 15 (5): 689–96. Doi: 10.1517/14740338.2016.1165663. Epub 2016 Apr 21.
28. Nitti VW, Auerbach S, Martin N et al: Results of a randomized phase III trial of mirabegron in patients with overactive bladder. J Urol 2013; 189: 1388.
29. Khullar V, Amarenco G, Angulo JC et al: Efficacy and tolerability of mirabegron, a b(3)-adrenoceptor agonist, in patients with overactive bladder: results from a randomised European-Australian phase 3 trial. Eur Urol 2013; 63: 283.
30. Chapple CR, Kaplan SA, Mitcheson D et al: Randomized Double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron,
a b(3)-adrenoceptor agonist, in overactive bladder. Eur Urol 2013; 63: 296.
________________________________________________
1. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol 2015; 67 (Issue 6): 1099–109.
2. Barry MJ, Jr. Fowler FJ, O'Leary MP et al. The American UrologicalAssociation symptom index for benign prostatic hyperplasia. The MeasurementCommittee ofthe American Urological Association. J Urol 1992; 148: 1549–57.
3. Van Venrooij GE, Eckhardt MD, Gisholf KW, Boon TA. Data from frequency-volume charts versus symptom scores and quality of life score in menwith lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol 2001; 39: 42–7.
4. Irwin DE, Milsom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50 (6): 1306–14.
5. Peters TJ, Donovan JL, Kay HE et al. The ICS-“BPH” Study: the bothersomeness of urinary symptoms. J Urol 1997; 157 (3): 885–9.
6. Van Exel NJ, Koopmanschap MA, McDonnell J et al. TRIUMPH Pan-European Expert Panel Medical consumption and costs during a one-year follow-up of patients with LUTS suggestive of BPH in six european countries: report of the TRIUMPH study. Eur Urol 2006; 49 (1): 92–102.
7. Rasner P.I., Pushkar' D.Iu. Lechenie simptomov nizhnikh mochevykh putei u patsientov s dobrokachestvennoi giperplaziei predstatel'noi zhelezy: sovremennye mezhdunarodnye standarty. Sprav. poliklin. vracha. 2015; 10: 20–6. [in Russian]
8. Isaacs JT. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Prostate 1990; 3 (Suppl.): 1–7.
9. Flanigan RC, Reda DJ, Wasson JH et al. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic BPH: a Department of Veterans Affairs cooperative study. J Urol 1998; 160 (1): 12–6.
10. Djavan B, Chapple C, Milani S et al. State of the art on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology 2004; 64 (6): 1081–8.
11. Davidov M.I., Lokshin K.L., Gorbunova I.S. Chastota ostroi zaderzhki mochi u bol'nykh adenomoi predstatel'noi zhelezy pri 8-letnem lechenii tamsulozinom. Urologiia. 2015; 2: 74–81. [in Russian]
12. Kaplan SA. Medical Therapy for Benign Prostatic Hyperplasia: New Terminology, New Concepts, Better Choices. Rev Urol 2006; 8 (1): 14–22.
13. Vishnevskii A.E. Rol' gipoksii detruzora v patogeneze rasstroistv mocheispuskaniia u bol'nykh dobrokachestvennoi gipeplaziei predstatel'noi zhelezy i obosnovanie metodov ikh konservativnogo lecheniia. Avtoref. dis. … kand. med. nauk. M., 1998. [in Russian]
14. Krivoborodov G.G., Shkol'nikov M.E., Efremov N.S.i dr. Kholinolitiki v lechenii simptomov nakopleniia mochevogo puzyria u muzhchin s dobrokachestvennoi giperplaziei predstatel'noi zhelezy. Effektivnaia farmakoterapiia. Urologiia i Nefrologiia. 2011; 3: 26–8. [in Russian]
15. Michel MC, Schneider T, Krege S et al. Does gender or age affect the efficacy and safety of tolterodine? J Urol 2002; 168 (3): 1027–31.
16. Stenzelius K, Mattiasson A, Hallberg IR, Westergren A. Symptoms of urinary and faecal incontinence among men and women 75+ in relations to health complaints and quality of life. Neurourol Urodynam 2004; 23: 211–22.
17. Borisov V.V. Giperaktivnyi mochevoi puzyr': effektivnoe lechenie. Consilium Medicum. 2014; 16 (7): 22–8. [in Russian]
18. Gravas S, Bachmann A, Descazeaud A et al. Guidelines on the Management of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO). http://www.uroweb.org/gls/pdf/Non-Neurogenic%20Male%20LUTS_(2705).pdf
19. Gong М, Dong W, Huang G et al. Tamsulosin Combined Solifenacin versus Tamsulosin Monotherapy on Male Lower Urinary Tract Symptoms: A Meta-analysis. Curr Med Res Opin 2015 20; 31 (9): 1781–92.
20. Drake MJ, Chapple C, Sokol R et al. NEPTUNE Study Group. Long-term safety and efficacy of single-tablet combinations of solifenacin and tamsulosin oral controlled absorption system in men with storage and voiding lower urinary tract symptoms: results from the NEPTUNE Study and NEPTUNE II open-label extension. Eur Urol 2015; 67 (2): 262–70.
21. Witte LP, Mulder WM, De la Rosette JJ et al. Muscarinic receptor antagonists for overactive bladder treatment: does one fit all? Curr Opin Urol 2009; 19 (1): 13–9.
22. Zinner N, Noe L, Rasouliyan L et al. Impact of solifenacin on resource utilization, work productivity and health utility in overactive bladder patients switching from tolterodine ER. Curr Med Res Opin 2008.
23. Abrams P, Kaplan S, De Koning Gans HJ, Millard R. Safety and tolerability of tolterodine for treatment of overactive bladder and coexisting benign prostatic obstruction: a prospective randomized, controlled multicenter study. J Urol 2006; 169: 2253–6.
24. Athanasopoulos A, Gyftopoulos K, Giannitsas K et al. Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized, controlled study. J Urol 2003; 169: 2253–6.
25. Kaplan SA, Walmsley K, Te AE. Tolterodine extended release attenuates lower urinary tract symptoms in men with benign prostatic hyperplasia. J Urol 2005; 174: 2273–6.
26. Lee JY, Kim HW, Lee SJ et al. Comparison of doxazosin with or without tolterodine in men with symptomatic bladder outlet obstruction and an overactive bladder. BJU Int 2004; 94: 817–20.
27. Robinson D, Thiagamoorthy G, Cardozo L. A drug safety evaluation of mirabegron in the management of overactive bladder. Exp Opin Drug Saf 2016; 15 (5): 689–96. Doi: 10.1517/14740338.2016.1165663. Epub 2016 Apr 21.
28. Nitti VW, Auerbach S, Martin N et al: Results of a randomized phase III trial of mirabegron in patients with overactive bladder. J Urol 2013; 189: 1388.
29. Khullar V, Amarenco G, Angulo JC et al: Efficacy and tolerability of mirabegron, a b(3)-adrenoceptor agonist, in patients with overactive bladder: results from a randomised European-Australian phase 3 trial. Eur Urol 2013; 63: 283.
30. Chapple CR, Kaplan SA, Mitcheson D et al: Randomized Double-blind, active-controlled phase 3 study to assess 12-month safety and efficacy of mirabegron,
a b(3)-adrenoceptor agonist, in overactive bladder. Eur Urol 2013; 63: 296.
Авторы
П.И.Раснер*, Д.Ю.Пушкарь
ГБОУ ВПО Московский государственный медико-стоматологический университет им. А.И.Евдокимова Минздрава России. 127473, Россия, Москва, ул. Делегатская, д. 20, стр. 1
*dr.rasner@gmail.com
________________________________________________
P.I.Rasner*, D.Yu.Pushkar
A.I.Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of the Russian Federation. 127473, Russian Federation, Moscow, ul. Delegatskaia, d. 20, str. 1
*dr.rasner@gmail.com