Siapa yang tidak pernah

BESER
 Beser
pada
Menopause
Edy A
Medan, 8 Des 2018
 Beser = sekali sekali berkemih

ICS : Inkontinensia Urin

Keluhan
berkemih tanpa
disadari
(involunter),
dapat diamati
secara objektif,
menyebabkan
masalah sosial
dan higiene
Abrams P, 2002
 Survey in RSCM (2006) (Geriatric Clinic), n = 92 elderly
Prevalensi ▪ OAB 23.9%
▪ Stress UI (when cough, jump, wheezing) : 37.0%
▪ Frekuensi: > 8x / day 41.6%
▪ Nocturia : 79.3%

35.6%11.8%
11.8% 16,6%
16,6%
16.6% 11.8% 16,6%
35.6% 35.6% 11.8% 16,6%
11.8% 16,6%
16,6%

15.6%
Milsom NOBLE EPIC EpiLUTS
Geography France, Germany, Italy, USA Canada, Germany, USA,
Spain, Sweden,UK Italy, Sweden, UK Sweden, UK
Overall OAB prevalence (%) 16,6 16,5 11,8 35,6
Female 17,4 16,9 12,8 43,1
Male 15,6 16,0 10,8 27,2
 Reported prevalence of “any” UI in women
by age range
Age UI (All Types) SUI UUI MUI

20-39 (7%-37%) 4%-23% 1%-6% 1%-11%

(4%-50%) (1%-33%)
40-59 31%-48% 16%-36% 4%-11% 13%-26%
(10%-61%) (8%-70%) (1%-58%) (2%-26%)

60-79 30%-61% 8%-23% 3%-16% 21%-30%

(14-61%) (8%-68%) (3%-71%) (4%-30%)
80 + 37%-63% (8%-32%) (3%-30%) 28%-29%
(25%-63%) (4%-29%)

Buckley et al, 2010

OAB is syndrome :
Urgency, with or without urge
incontinence, usually with
frequency and nocturia

Abrams P, 2002
Toilet dependence
Diagnosis simptomatik OAB

Frekuensi: 22%

Urgensi: 15%

Urge
incontinence:
3%

Stewart W et al. World J Urol. 2002.

 Problem karena OAB
70
60
50
40
Patients(%)

30
20
10
0
Urinary tract Skin infection Fall Fracture Depression
infection

Thiiroff, 2003
 Annual disease-specific costs for OAB
Reference Country Total annual cost
Europe
Irwin, et al 2009 Germany, Italy, Spain, € 9.7 milyar
Sweden, UK, Canada
Klotz, et al 2007 Germany € 4.0 milyar
Reeves, et al 2006 Germany, Italy, Spain, € 4.2 milyar
Sweden, UK

North America
Ganz, et al 2010 United States $US 65.9 milyar
Hu, et al 2003 United States $US 12.0 milyar
Onukwugha, et al 2009 United States $US 24.9 milyar

Asia
Inoue, et al 2008 Japan ¥ 956.2 milyar
Sung, et al 2012 South Korea KRW 117.5 milyar
Najir . 2017
 Faktor Risiko
Fak.Interna
Usia lanjut
Riwayat pembedahan panggul dan abdomen
Obesitas
Aktivitas fisik yang berat
Riwayat mengompol pada masa kanak-kanak

Penyakit penyerta OAB

Obat-obat yang digunakan
 Possible neurogenic causes of OAB
Stroke
Dementia
Cortical Tumour
micturition centre Trauma
Multiple sclerosis

Brain Parkinson’s disease

stem Stroke
Multiple sclerosis
Childbirth
Peraplegia Straining at stool
Spinal cord Spina bifida Diabetes
Multiple sclerosis
Pelvic surgery
Tumour

Sensory

Spinal injury S2
Tumour S3 Motor
Spina bifida S4
Mekanisme pengisian dan pengeluaran
(Adrenergik) (Kolinergik)

Reseptor
Jaringan Koli Adre Lain

+ Purinergik (Px2)
- VIP
Badan KK + (M2) - (β2)
+ Substance P
- Neuropeptide Y

Dasar KK + (M2)

- (α2)
Ganglia + (N) - (α2) - VIP
+ (M1) - Neuropeptide
- (β2)

Ureta (α) + Purinergik (Px2)

Kontraksi Relaksasi - (α1) - VIP
Uretra + (M) - (α2)
Levator ani (N) - (β2) - Substance P
- Nitric oxide
Rhabdosfingter (N)
Sfingter
+ (N)
otot lurik
Urothelium
 Prefrontal cortex Overactive Baldder
Normal berkemih
Periaquaductal gray
Pontine Micturition
Center

Sympathetic Ganglion

Afferent nerve Pelvic nerve

Pudendal nerve Hypogatric nerve

 Diagnosis
PEM. DIAGNOSTIK Dasar
Berdasarkan gejala dan tanda
Gangguan kualitas hidup yang timbul – QoL
Urinalisis – singkirkan infeksi

• Pertimbangkan:
– Jumlah urin yang hilang/hari
– Gangguan kualitas hidup yang timbul - QoL
– Gunakan Catatan harian berkemih (Voiding Diary)

Pem. DIAGNOSTIK Lanjutan

Urodinamik multikanal, sistoskopi
USG & Urografi
 Filling Cystometry (CMG) (Abnormal)

500ml 500ml 500ml

150ml 150ml 150ml

Namiki M, 1998
 Penatalaksanaan
Pemberi pelayanan OAB
Herbalist
Dokter Umum
2% 14%
15% PUSKESMAS
Spesialis
1%
Perawat
Lain-lain
Tidak terspesifikasi

26% 34%

8%

N = 5,502

Lapitan MC, Chye PL. Int Urogynecol J Pelvic Floor Dysfunct. 2001
 Sentral

Operatif: Pharmacotherapy:
Botox Anti muskarinik
PTNS Β3-Agonis
SNM

Abrams P et al, 2013

 Diagnosis dan Terapi OAB: AUA Guideline on Non-Neurogenic OAB
Diagnosis unclear or Not OAB or
History and Physical; Urinalysis additional information
+/- urine culture, post-void Complicated
residual, bladder diary, and/or OAB;
needed
Signs/symptoms of OAB, (-) urine microscopy symptom questionnaires treat or refer

Patient education: Signs/symptoms of OAB

- Normal urinary tract function
- Benefits/risks of treatment alternatives
- Agree on treatment goals Follow-up for efficacy
Patient desires treatment and/or and adverse events
treatment is in patient’s best interests

In extremely rare cases,

Behavioral Treatments Treatment goals met
(consider adding anti-muscarinic if partially effective) consider urinary diversion
or augmentation
Treatment goals not met; Patient desires further treatment cystoplasty
and/or further treatment in patient’s best interests

Anti-muscarinics with active management of

adverse events (e.g.,dry mouth, constipation);
consider dose modification or alternate anti-muscarinic
if effective but adverse events are intolerable

Treatment goals not met; Patient desires further treatment

Consider in carefully-selected patients
Signs/ (multiple therapies may be tried but they should not be combined):
and/or further treatment in patient’s best interests symptoms
Consistent FDA-Approved: Non-FDA-Approved:
Reassess and/or refer; With • Sacral neuromodulation (SNS) or • Intradetrusor
consider urine culture, post-void residual, OAB Diagnosis • Percutaneous tibial nerve onabotulinumtoxinA
bladder diary, symptom questionnaires, other diagnostic
stimulation (PTNS) or
Procedures as necessary for differentiation
 Terapi Fist Line
Hasil
Bladder training ↓ Urgensi : 42% Gomley, 2014
Otot dasar panggul
Pengurangan asupan ↓ Urgensi dan frekuensi Bryan, 2002
minum ( caffeine, 2-4
jam sebelum tidur) : 25%
Diet tinggi serat ↓ Urgensi : 42% Wyman, 2009
Pengurangan BB ↓ Urgensi : 42% Subak,2009
(6 bln)
 Current approaches to OAB treatment
The challenge is to eliminate bladder overactivity without interfering with
the function of other organ systems and without disturbing normal micturition

Antimuscarinics are currently first-line therapy for

OAB (eg tolterodine, oxybutynin [also has
Drugs licensed for antispasmodic action], trospium, propiverine)
OAB symptoms
Antispasmodics (eg flavoxate, oxybutynin [also
has antimuscarinic action])
Alpha blockers (eg doxazosin)
Beta agonists (eg tarbutaline)
Other drugs used Antidepressants (eg imipramine)
off-licence for Prostaglandin synthesis inhibitors
OAB symptoms
(eg indomethacin)
Vasopressin analogues (eg desmopressin)
Miscellaneous (eg baclofen)
Non-pharmacological Bladder retraining
methods Pelvic floor exercises
Andersson KE, Chapple C, Wein A World J Urol 2001; 19: 294-8
Garely AD and Burrows LJ Expert Opin Pharmacother 2002; 3(7):827-33
 Efek samping anti muskarinik
Confusion,Somnolen,Halusinasi
Desired Undesired
actions actions
Blurred vision
Dry eyes

Dry mouth

Tachycardia
Palpitations
Contraction ↓
Urinary retention
Dyspepsia
Constipation
 Terapi Alternatif
Anti muskarinik : Mahal, pemakaian lama dan terapi
ES juga mahal
→ ketidakpatuhan dan ketaatan pasien OAB yang
menggunakan farmakoterapi mencapai 85%, dan
menghentikan pengobatannya sebesar 73% selama
satu tahun (Daniel et al, 2016)

→ (CDC), 74,6% telah menggunakan terapi alternative.

→ (WHO), ± 80% penduduk dunia menggunakan bahan

herbal medis untuk primary health care OAB
 Terapi Alternatif
Herbal medis
*Gosha-jinki-gan, (Chughtai et al, 2013)

*Antimuskarinik alami dari hasil ekstrak tumbuhan

yang mengandung alkaloid seperti hyoscyamine,
atropine dan hyoscine seperti tumbuhan family
solanaceae yang mengandung tropane (Fowler, 2015)

* Di Indonesia ?
 Simpul

• OAB urin merupakan masalah yang umum terjadi pada

menopause, tetapi sayangnya sebagian besar wanita tidak
berobat karena malu atau dianggap sebagai hal normal
• Pendekatan terapi konservatif dapat secara signifikan
memperbaiki gejala hingga 70% dan mengurangi biaya
kesehatan
• Para klinisi di tingkat layanan kesehatan primer dapat
mengatasi sebagian besar gejala OAB pada menopause,
dan memberikan rujukan hanya bila pendekatan yang
dicoba ternyata gagal
Terima Kasih
Algorithm of initial management of IU

Ngarambe C, 2015, Abrams P. Lancet, 2000

 IU dengan Diagnosis Banding
berdasarkan gejala
Gejala-gejala OAB Stress
Urgensi Ya Tidak

Frekuensi Ya Tidak
Ngompol saat aktivitas fisik seperti batuk, bersin dll Tidak Ya
Jumlah urin yang keluar setiap episode inkontinensia Banyak Sedikit
Sampai ketoilet tepat waktu saat kebelet kencing Tidak Ya
Terbangun malam hari untuk kencing Biasanya Jarang
Tidak ada perbaikan gejala setelah terapi
awal dalam 2-3 bulan Rujuk bila :
Terdapat hematuria tanpa infeksi pada Terapi bila :
analisa urin
Ada frekuensi dengan
Gejala-gejala timbul karena gangguan
pengosongan kandung kemih (aliran
urgensi, urge incontinence
terhenti, aliran lemah, akhir kencing dan analisa urin normal
menetes). Ada frekuensi dengan
Adanya kelainan neurologis atau penyakit urgensi dan analisa urin
metabolik yang tidak dapat dijelaskan normal
 Obat-obat yang dapat mencetuskan IU
 Diuretik

 Obat yang menurunkan tonus uretra

Alfa-bloker

 Obat yang mencetuskan retensi urin dan inkontinensia tipe

overflow
Imipramin, antipsikotik, obat parkinson, antihistamin, analgesik opioid,
α-simpatomimetik, β-simpatomimetik dan antagonis kalsium

 Obat dengan mekanisme sedasi

 Anti Muskarinik
Tertiary Amines Quaternary Amines
Tolterodine Propantheline
Oxybutynin Trospium
Propiverine
Darifenacin • Not Well Absorbed
Solifenacin • Low Lipophilicity
• Well Absorbed • Higher Molecular Size
• High Lipophilicity • High Charge
• Small Molecular Size
• Low Charge