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Systems: Urinary AB > Benign Prostate Disease > Flashcards

Benign Prostate Disease Flashcards

1
Q

How big is the prostate?

A
  • It increases with age

- For a 20 year old it is approximately 15cc

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2
Q

What are the McNeal’s prostatic zones?

A
  • Transition zone
  • Central zone
  • Anterior fibromuscular stroma
  • Peripheral zone
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3
Q

What does BPE stand for?

A

Benign prostatic enlargement

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4
Q

What does BPH stand for?

A

Benign prostatic hyperplasia

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5
Q

What does BPO stand for?

A

Benign prostatic obstruction

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6
Q

What does BOO stand for?

A

Bladder outflow obstruction

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7
Q

What does LUTS stand for?

A

Lower urinary tract symptoms

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8
Q

What are the 3 components of the Hald diagram?

A
  • LUTS
  • BOO
  • BPE
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9
Q

What is BPH characterised by?

A

Fibromuscular and glandular hyperplasia

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10
Q

What zone does BPH predominantly affect?

A

Transitions zone

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11
Q

What evidence is there that BPH is part of the aging process in men?

A
  • 50% have it at 60 years

- 90% have it at 85 years

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12
Q

What do 50% of men with BPH experience?

A

Moderate to severe LUTS

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13
Q

What can BPH lead to?

A

BOO

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14
Q

How is the effect of BPH investigated?

A 
International prostate symptom score sheet
-Total score out of 35
-Mild 0-7
-Moderate 8-19
Severe 20-35
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15
Q

How can LUTS be assessed?

A
  • IPSS

- Frequency volume charts

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16
Q

What voiding (obstructive) LUTS are there?

A
  • Hesitancy
  • Poor stream
  • Terminal dribbling
  • Incomplete emptying
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17
Q

What storage (irritative) LUTS are there?

A
  • Frequency
  • Nocturia
  • Urgency +/- urge incontinence
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18
Q

What may be found on examination of someone with LUTS

A

Abdomen
-Palpable bladder

Penis

  • External urethral meatal stricture
  • Phimosis

Digital rectal examination

  • Asses prostate size
  • Suspicious nodules of firmness

Urinalysis

  • Blood
  • Signs of UTI
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19
Q

What investigations may be carried out fro someone with LUTS?

A
  • MSSU
  • Flow rate study
  • Post-void bladder residual USS
  • Bloods : (PSA, urea and creatinine (if chronic retention))
  • Renal tract USS if renal failure or bladder stone suspected
  • Flexible cystoscopy if haematuria
  • Urodynamic studies in selected cases
  • TRUS-guided prostate biopsy if PSA raised or abnormal DRE
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20
Q

What does a Qmax <10ml/s in a flow rate study suggest?

A

90% chance the patient has BOO

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21
Q

How can uncomplicated BPO be treated?

A
  • Watchful waiting
  • Medical therapy
  • Surgical intervention
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22
Q

What medical therapy can be used to treat uncomplicated BPO?

A
  • Alpha blockers
  • 5 alpha reductase inhibitors (Finasteride or Dutasteride)
  • Combination
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23
Q

What surgical intervention can be used to treat uncomplicated BPO?

A
  • TURP (prostate size <100cc)
  • Open retropubic or transvesical prostatectomy (prostate size >100cc)
  • Endoscopic ablative procedures
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24
Q

What is the main treatment for LUTS caused by BPO?

A

Alpha blockers

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25
Q

What is the smooth muscle of the bladder neck and prostate innervated by?

A

Sympathetic alpha adrenergic nerves (mostly alpha-1a subtype)

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26
Q

What do alpha blockers cause?

A

Smooth muscle relaxation and antagonise the dynamic element to prostatic obstruction

27
Q

What types of alpha blockers are there?

A
  • Non selective (alpha 1+2)
  • Selective short acting
  • Selective long acting
  • Highly selective (i.e. alpha-1a)
28
Q

Give an example of a non-selective alpha blocker.

A

Phenoxybenzamine

29
Q

Give examples of selective short acting alpha blockers

A
  • Prazosin

- Indoramin

30
Q

Give examples of selective long acting alpha blockers.

A
  • Alfuzosin
  • Doxazosin
  • Terazosin
31
Q

Give an example of a highly selective alpha blocker.

A

Tamsulosin

32
Q

How do different types of alpha blockers differ in effectiveness?

A

All a-blockers appear to be equally effective but differences in side effect profiles and pharmacodynamic properties

33
Q

What does 5a-reductase do?

A

Converts testosterone to dihydrotestosterone

34
Q

What 2 5a reductase inhibitors are currently available?

A
  • Finasteride (5AR Type II inhibitor)

- Dutasteride (5AR Type I and II inhibitor

35
Q

What is the role of 5a-reductase inhibitors?

A
  • Reduces prostate size and reduces risks of progression of BPE (but only if >25cc prostate)
  • Reduces LUTS (but not as effective as alpha blockers)
  • Combination therapy of 5ARIs + alpha blockers most effective in reducing risk of progression of BPE
  • Can reduce prostatic vascularity and hence reduces haematuria due to prostatic bleeding
  • Potential role in prostate cancer prevention
36
Q

What does TURP stand for?

A

Transurethral resection of prostate

37
Q

What is the gold standard surgical treatment?

A

TURP

38
Q

What are the possible complications of TURP?

A
  • Bleeding
  • Infection
  • Retrograde ejaculation
  • Stress urinary incontinence
  • Prostatic regrowth causing recurrent haematuria or BOO
39
Q

How effective is TURP?

A

Very effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 year)

40
Q

What alternative endoscopic ablative procedures are available?

A
  • Transurethral laser vaporisation

- Urolift

41
Q

What are the possible complications of BPO?

A
  • Progression of LUTS
  • Acute urinary retention
  • Chronic urinary retention
  • Urinary incontinence (overflow)
  • UTI
  • Bladder stone
  • Renal failure from obstructed ureteric outflow due to high bladder pressure
42
Q

Who does not need treatment for complicated BPO?

A

Some patients do not need any treatment (especially if residuals are relatively low, asymptomatic and no complications)

43
Q

How is complicated BPO normally treated?

A
  • Medical therapy

- Most patients will require surgery (e.g. cystolitholapaxy and TURP for patients with BPO and bladder stones)

44
Q

What alternative treatment options are there if patients with complicated BPO are unfit for surgery?

A
  • Long term urethral or suprapubic catheterisation
  • Clean intermittent self-catheterisation
  • May develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI
45
Q

Define acute urinary retention

A

Painful inability to void with a palpable and percussible bladder

46
Q

How can residual volumes vary in AUR?

A

Residuals vary from 500ml to >1 litre depending on time lag in seeking medical attention

47
Q

What are the risk factors for AUR?

A
  • BPO: main risk factor
  • UTI
  • Urethral stricture
  • Alcohol excess
  • Post-operative causes
  • Acute surgical or medical problems
48
Q

How can AUR occur in BPO?

A

For those with BPO, can occur spontaneously (i.e. natural progression of BPO) or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)

49
Q

What is the immediate treatment for AUR?

A

Catheterisation (either urethral or suprapubic)

50
Q

What are the possible complications of AUR?

A
  • UTI
  • Post decompression haematuria
  • Pathological diuresis
  • Renal failure
  • Electrolyte abnormalities
51
Q

What is it important to treat in AUR?

A

Underlying cause

52
Q

How should AUR be managed following catheterisation if there is no renal failure?

A

If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)

53
Q

How is chronic urinary retention defined?

A

Painless, palpable and percussible bladder after voiding

54
Q

How can residual volumes vary in CUR?

A

Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)

55
Q

What is the main aetiological factor for CUR?

A

Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

56
Q

How does CUR present?

A

Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

57
Q

What occurs at the severe end of CUR?

A

Overflow incontinence and renal failure occur at severe end of spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or high pressure chronic urinary retention)

58
Q

Who does not necessarily need treated for CUR?

A

Asymptomatic patients with low residuals do not necessarily need treatment

59
Q

What is the immediate treatment for CUR?

A

Catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)

60
Q

What are the possible complications of CUR?

A
  • UTI
  • Post decompression haematuria
  • Pathological diuresis
  • Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)
  • Persistent real dysfunction due to tubular necrosis
61
Q

What are the features of pathological diuresis?

A 
Urine output <200ml/hr
\+
Postural hypotension (systolic differential >20mm Hg between lying and standing)
\+
Weight loss
\+
Electrolyte abnormalities
62
Q

How should CUR be managed?

A
  • Manage with iv fluids (total input = 90% of output) and monitor closely; liaise with renal team
  • Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP
63
Q

How does the effectiveness of TURP differ in the treatment of urinary retention?

A

TURP in chronic retention has a less successful outcome than for acute retention; however, patients with high pressure chronic retention has better outcome with TURP than patients with low pressure chronic retention

Systems: Urinary AB (26 decks)

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