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Les inhibiteurs de la phosphodiestérase de type 5 : une révolution dans le traitement des symptômes du bas appareil urinaire?

Phosphodiesterase type 5 inhibitors: a revolution in the treatment of lower urinary tract symptoms?

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Résumé

Contexte

L’incidence des symptômes du bas appareil urinaire (SBAU) liés à une hypertrophie bénigne de prostate (HBP) augmente avec l’âge puisqu’ils touchent 50 % des patients âgés de plus de 50 ans et 90 % de ceux âgés de plus de 80 ans. La prévalence et la sévérité de la dysfonction érectile (DE) augmentent également avec l’âge. Sa prévalence est évaluée à 31,6 % dans une population générale d’adultes âgés de plus de 40 ans. Les SBAU comme la DE altèrent de façon significative la qualité de vie (QdV) des patients et de leur partenaire. Plusieurs études ont montré que les SBAU constituent un facteur de risque de DE indépendant de l’âge et des autres comorbidités. La sévérité des SBAU est corrélée à celle de la DE. Les hypothèses physiopathologiques pour expliquer le lien entre SBAU et DE sont : une augmentation du tonus sympathique, une altération du système NO/cGMP, une altération du système rho-kinase et une athéromatose pelvienne.

Objectif

Évaluer les résultats et comprendre le mécanisme d’action de l’administration d’un inhibiteur de la phosphodiestérase de type 5 (IPDE 5) sur les SBAU liés à une HBP.

Matériels et méthodes

Une revue de la littérature a été réalisée à partir des articles originaux et des articles de synthèse déjà disponibles, sélectionnés par le moteur de recherche Pubmed de la National Library of Medecine. Les mots clés utilisés pour cette recherche ont été : benign prostatic hyperplasia; cyclic nucleotide phosphodiesterase type 5; LUTS; erectile dysfunction.

Résultats

Cette revue de la littérature montre que l’administration d’un inhibiteur de la phosphodiestérase de type 5 améliore les SBAU de manière significative dans 12 essais cliniques randomisés, avec un bénéfice également sur la DE et l’absence d’effets secondaires indésirables graves rapportés.

Conclusion

Le traitement des SBAU par les IPDEs 5 semble très prometteur, même s’il ne dispose pas d’une AMM dans cette indication en France. Récemment, le tadalafil à la posologie de 5 mg a été approuvé aux États-Unis par la FDA dans les troubles mictionnels liés à l’HBP, avec ou sans DE.

Abstract

Context

The incidence of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) increases with age, affecting 50% of patients aged over 50 years and 90% of those aged over 80 years. The prevalence and severity of erectile dysfunction (ED) also increase with age. Its prevalence is estimated to be 31.6% in men over 40 years. LUTS as well as ED significantly affect the quality of life of patients and their partners. Several studies have shown that LUTS represent an independent risk factor for ED. The severity of LUTS is correlated with that of ED. The pathophysiological hypothesis linking LUTS to ED are an increase in sympathetic tone, alteration of NO/cGMP system, alteration of rho kinase system, and pelvic atherosclerosis.

Goal

Some treatments of LUTS have adverse effects on the erectile function. The phosphodiesterase type 5 inhibitors (IPDE 5) revolutionized the treatment of ED.

Material and methods

Several recent clinical studies evaluated the effect of daily treatment by IPDE 5 on LUTS secondary to BPH among patients with or without ED.

Results

This review shows that IPDE 5 administration improves LUTS significantly in 12 randomized clinical trials, as well as in both storage and voiding parts of the international prostate symptom score (IPSS) and in quality of life questionnaire. No adverse events were observed, and ED, which has a high prevalence among this population, was also improved.

Conclusion

The treatment of LUTS by IPDE 5 looks very promising, even though they are not yet approved for this indication in France.

Abbreviations

AMM:

autorisation de mise sur le marché

CGI-I:

clinical global impression of improvement

DE:

dysfonction érectile

GC:

guanylate-cyclase

GMPc:

guanosine monophosphate phosphate cyclic

GTP:

guanosine triphosphate

HAV:

hyperactivité vésicale

HBP:

hyperplasie bénigne de prostate

IIEF-EF:

international index of erectile function-erectile function domain

IPDE 5:

inhibiteur de la phosphodiestérase de type 5

IPSS:

international prostate symptom score

IPSS-Qol:

international prostate symptom score quality of life

NO:

monoxyde d’azote

NOS:

monoxyde d’azote synthase

QdV:

qualité de vie

RPM:

résidu postmictionnel

SBAU:

symptômes du bas appareil urinaire

TSS-BPH:

treatment satisfaction scale, benign prostatic hyperplasia

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Correspondence to R. Caremel.

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Mots clés

  • Symptômes du bas appareil urinaire
  • Dysfonction érectile
  • Épidémiologie
  • Hypertrophie bénigne de prostate
  • Inhibiteur de phosphodiestérase de type 5

Keywords

  • Phosphodiesterase type 5 inhibitors
  • Lower urinary tract symptoms
  • Erectile dysfunction
  • Epidemiology
  • Benign prostatic hyperplasia