Vejiga hiperactiva 2011
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Alteraciones y tratamiento de la Vejiga Hiperactiva.
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Vejiga hiperactiva 2011
- 2. VEJIGA HIPERACTIVA Dr. Manuel Ayala Tamés
- 5. Vejiga Normal Musculatura de Soporte comprimiendo Músculo vesical (detrusor) rela jado Orina Uretra c errada
- 9. BAÑO
- 11. Hiperactividad de la vejiga
- 13. Que es Vejiga Hiperactiva? I ncontinenc ia de urgencia Frecuencia urinaria Urgencia urinaria
- 16. TIPOS de INCONTIENCIA e Incidencia. z Urgenc ia Frecuencia nicturia IUE Mix ta ( IUE + IUU ) IUU Vejiga Hiperactiva Hampel C. Urology 1997;50(suppl 6A):4–14. Milsom I. et al. 2001;87:760–6. Stewart W.F. et al. World J Urol 2003;20: 327–336. Abrams P. et al. Urology 2003;62(suppl 5B):28–37 47.5% 24.0% 28.5% La Vejiga Hiperactiva afecta al 16.9% de la población americana y al 17% de la población europea (estudio realizado en 6 países europeos) - más de 22 millones de personas en 6 países europeos -. IUE: Incontiencia urinaria de Esfuerzo IUU: Incontinencia Urinaria de Urgencia VHA: Vejiga hiperactiva Vejiga Hiperactiva “SECA” Vejiga Hiperactiva “HÚMEDA”
- 17. VHA es tan común como la sinusitis 1. National Center for Health Statistics. Vital health stat 10;1994. 2. Stewart W et al. World J Urol. 2002. Available at: http://link.springer.de/link/service/journals/00345. 0 5 10 15 20 25 30 35 40 Sinusitis crónica Rinitis alérgica Colesterol Alto Bronquitis crónica Artritis Enfermedades del corazón Asma Millones de pacientes Vejiga hiperactiva 33
- 18. VHA: AFECTA LA CALIDA D DE VIDA 30 35 40 45 50 55 60 65 Finción psíquica Staus psicológico Dolor corporal Salud general Vitalidad Función social Status emocional Buena salud Salud normal Pobre salud Kobelt G et al. BJU Int. 1999;83:583-590. 2. Zorn BH et al. J Urol . 1999;162:82-84. Valoración de aspectos según pacientes con VHA 1 El 60% de los pacientes con VHA sufren depresión Salud mental
- 20. ETIOLOGIA DE LA VEJIGA HIPERACTIVA
- 24. FISIOPATOLOGIA
- 28. Incontinencia Urinaria Definición: Pérdida involuntaria de orina de magnitud suficiente para constituir un problema social y/o higiénico.
- 31. Distribución de Incontinencia Urinar ia por tipo Esfuerzo HV Mixta Otras
- 32. Incontinencia de esfuerzo Músculo vesical experi menta un aumento en la presión relacionada con el esfuerzo Pobre s oporte muscular incapaz de mantener un cierre completo
- 37. Distribución de acuerdo a grupo de edad 70 60 50 40 30 20 10 0 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+ años Esfuerzo Urge-incont. Mixta Otras % Incontinencia Urinaria Hannestad e col. J. Clin. Epidemiol., 53:1150, 2000
- 41. DIAGNOSTICO
- 48. Diagnóstico Clínico Diferencial Frecuencia con urgencia (>8 veces / 24hrs) Sí Variable Nicturia Habitualmente Rara vez Oportunidad para llegar al sanitario No Escape de orina con esfuerzo IU de Urgencia IU de Esfuerzo IU de Rebosamiento Urgencia Cantidad de orina en cada episodio de incontinencia Tiempo de micción Gotas Chorro Micción Escasa Corto varias veces Corto Prolongado intermitente Sí Sí Sí Sí Sí Sí No No No No Escasa
- 49. Urodinamia Cómo? Volumen vesical Sensibilidad Contracción Presión de micción Presión de incontinencia Volumen residual Cuándo ? Historia clínica dudosa Padecimiento neurológico Cirugía previa Por qué ? Plan terapéutico Estudio
- 54. TRATAMIENTO
- 60. TRATAMIENTOS MEDICOS FARMACOLOGICOS DE VEJIGA HIPERACTIVA
- 62. Tratamiento Farmacológico Fármacos de segunda línea - Bromuro de propantelina - Diciclomina / Dicloverina - Imipramina - Flavoxato (beneficios poco significativos relajante músculo liso inespecífico)
- 63. Receptor Caulfield e Birdsall , Pharmcol Rev, 1998 11,0 3,4 M5 2,0 5,0 M4 0,67 3,4 M3 6,7 3,8 M2 2,4 3,0 M1 Oxibutinina Tolterodina Afinidad in vitro en células ováricas de Hamster Antagonista nmol/L Antagonistas Muscarínicos Tratamiento Farmacológico
- 64. Antagonista Gillberg et all, Eur J Pharmacol, 1998 Nilvebrant et all, Eur J Pharmacol, 1997 104 200 Oxibutinina 257 101 Tolterodina Salivación Contracción vesical nmol / kg Concentración necesaria para inhibir la contracción vesical y salivación Tratamiento Farmacológico Antagonistas Muscarínicos
- 65. Efecto de Tolterodina (2mg/2xdia) vs Oxibutinina (5mg/3xdia) a las 12 semanas de tratamiento Van Kerrebroeck y cols, Neurourol Urodyn, 1997 Abrams y cols, BJU, 1998 Drutz y cols, Int Urogynecol J, 2001 -2,5 -2 -1,5 -1 -0,5 0 n = 176 n = 145 n = 473 n = 392 n = 348 n = 286 Pro medio desde la Line de Base Placebo Tolterodina Oxibutinina Micciones/24 h. Episodios de Urgencia Incontinencia/24 h. Tratamiento Farmacológico
- 66. Reducción significativa de síntomas con TOLTERODINA , a largo plazo 1 Clemett D, Jarvis B. Tolterodine. Areview of its use in the tratment of overactive bladder. Drugs & Aging 2001; 18 (4): 227-304. Tratamiento Farmacológico Cambio promedio desde la Linea Base 76 % 30 % 22 % INCONTINENCIA DE URGENCIA Tolterodina (n=854, t=9 meses) NICTURIA Tolterodina (n=854, t=9 meses) FRECUENCIA Tolterodina (n=389, t=16 semanas)
- 67. % pacientes que abandonaron el Tratamiento por EVENTOS ADVERSOS Clemett D, Jarvis B . Tolterodine. Areview of its use in the tratment of overactive bladder. Drugs & Aging 2001; 18 (4): 227-304. Tratamiento Farmacológico % de Pacientes 20 % 8 % OXIBUTININA TOLTERODINA placebo 5 %
- 68. % pacientes que abandonaron el Tratamiento por RESEQUEDAD SEVERA DE BOCA Clemett D, Jarvis B. Tolterodine. Areview of its use in the tratment of overactive bladder. Drugs & Aging 2001; 18 (4): 227-304. Tratamiento Farmacológico % de Pacientes 29 % 4% OXIBUTININA TOLTERODINA placebo 3%
- 69. Estudios de Terapéutica Medica en Vejiga Hiperactiva
- 77. Ampliación Vesical con Segmento Intestinal
- 78. Tratamiento electrónico: Medtronic InterStim®
Notas del editor
- The normal bladder acts as a storage organ for urine. The bladder muscle, or detrusor, remains relaxed to allow urine to fill the bladder; the urethra is closed, with the surrounding support muscles contracted, to prevent urine from flowing out.
- Note the term overactive bladder (OAB) actually describes the pathology of the syndrome, which is manifested by one or more of the above symptoms in the absence of other obvious pathology. All these symptoms are bothersome to the patient. Urinary incontinence is defined as the involuntary leakage of urine to such an extent as to pose a social or hygienic problem to the patient. This means that the same (presumably small) amount of urine leakage may be considered incontinence for one patient, but not for another.
- The results of the NOBLE Program suggest that as many as 33 million people in the US have OAB. This is higher than the number of people with other chronic conditions such as heart disease, high cholesterol, or diabetes and is comparable to the number of people with chronic sinusitis and arthritis. Despite the high number of people with OAB, this disease has received less attention among the medical community than other chronic conditions. This graph may be used to demonstrate and emphasize the high prevalence of OAB as well as to provide a comparison with other chronic diseases that are considered serious medical conditions.
- People with OAB have substantially lower quality of life compared with healthy people. OAB affects all aspects of quality of life. *Graph adapted from article; data points not available.*
- La etiologia de la hiperactividad vesical cae dentro de estas 6 grandes categorias
- La etiologia de la hiperactividad vesical cae dentro de estas 6 grandes categorias
- La etiologia de la hiperactividad vesical cae dentro de estas 6 grandes categorias
- This slide shows the parasympathetic arm of the micturition reflex Neurons located in the sacral spinal cord send signals to the bladder via the pelvic nerves. Postganglionic neurons in the bladder release the neurotransmitter acetylcholine Peripheral cholinergic (ie, muscarinic) receptors in the detrusor muscle bind acetylcholine, which initiates a cascade of intracellular events that results in contraction of the detrusor muscle
- This slide shows the distribution of peripheral cholinergic (ie, muscarinic) receptors throughout the body Muscarinic receptors are located in the CNS, iris and ciliary body, lacrimal gland, salivary glands, heart, gallbladder, stomach, colon, and bladder Blockade of muscarinic receptors outside the bladder may result in undesired side effects such as dry mouth (the most common side effect), constipation, and CNS side effects (such as dizziness, somnolence, and cognitive impairment), and effects on the stomach and eyes Agents that are selective for the bladder are preferable over agents that block receptors in other regions of the body as they will result in fewer side effects, this is called “uroselectivity”
- Darifenacin is indicated for both the pure OAB patients and those with mixed incontinence. It will not help those with pure stress incontinence.
- In patients with stress incontinence, the detrusor muscle does not contract inappropriately. Rather, in these patients, the cause is external pressures on the bladder, such as coughing or straining, that lead to urine escaping from the urethra. The pathology lies in the condition of the support muscles around the urethra: they have been weakened (usually by childbirth in female patients or prostate surgery in male patients) and cannot prevent the leakage from occurring. When the increased pressure stops, the leaking stops, so these patients tend to lose only small volumes of urine on each occasion. Treatment focuses on pelvic-floor strengthening through exercise, physiotherapy, and surgery.
- In summary, antimuscarinic agents inhibit involuntary bladder contractions and are effective in relieving the symptoms of OAB, but may be associated with treatment-limiting anticholinergic side effects Selectively blocking the M 3 receptor may not be the best approach to improving tolerability, because M 3 receptors are predominant in a number of other organs and the role of M 2 receptors in bladder contraction may increase in some disease states and in ageing Bladder selectivity—in which the anticholinergic effects are largely confined to the bladder—may represent the best approach to optimizing efficacy and tolerability
- At present, the gold standard of therapy for overactive bladder (OAB) is antimuscarinics. Current and imminent therapeutic agents have proven efficacious through objective and subjective parameters, but many of these treatments may be limited by systemic side effects. The ideal treatment for OAB should demonstrate a balance between efficacy and tolerability. This balance is based on specific characteristics of the compound including receptor profile, pharmacokinetics/pharmacodynamics (PK/PD), and the ability to act on the affected area (bladder selectivity).
- Tolterodine is an anticholinergic agent that shows no selectivity for any muscarinic subtype In contrast to most other agents, it was developed specifically for use in OAB. Most other agents were initially developed for other uses, frequently bowel overactivity, and were found in studies to have side effects on the lower urinary tract that were thought to be potentially useful Tolterodine shows selectivity for inhibiting bladder contractility over salivary gland secretion