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Y2 BRS (Haroop) > 7.7 Urinary Incontinence and BPH > Flashcards

7.7 Urinary Incontinence and BPH Flashcards

1
Q

When does the prostate develop during gestation?

A

10-16 weeks of gestation from epithelial buds

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2
Q

Which sinus does the prostate develop from during gestation?

A

Posterior aspect of the urogenital sinus, to invade the mesenchyme

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3
Q

What is the main influencing hormone of the prostate?

A

Dihydrotestosterone

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4
Q

Which receptors does dihydrotestosterone act upon?

A

Mesenchymal androgen receptors

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5
Q

Which artery does the prostatic artery branch from?

A

Inferior vesicular artery

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6
Q

The prostatic artery divides into which arteries?

A

Urethral and capsular groups of arteries

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7
Q

Which two arteries arise from the urethral group?

A

Flock’s and Badenoch’s arteries

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8
Q

Describe venous drainage of the prostate?

A

Peri-prostatic venous plexus
Drains into the internal iliac vein

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9
Q

What is the lymphatic drainage of the prostate gland?

A

Obturator nodes and interna liliac chain

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10
Q

What zone classification is used to categorise the prostate gland?

A

McNeal’s Zones

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11
Q

What are the zones of the prostate gland?

A

Transition zone
Central zone
Peripheral zone
Anterior fibromuscular stroma

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12
Q

What % of the prostate gland is represented by the transition zone?

A

10%

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13
Q

Which prostate zone is implicated in the site of origin for benign prostatic hyperplasia?

A

Transition zone

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14
Q

Which zone represents the majority of the prostate gland?

A

Peripheral zone

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15
Q

What is the overall function of the prostate gland?

A

Liquify the ejaculate

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16
Q

What are lower urinary tract symptoms (prostatism)?

A

Non-specific term for symptoms which may be attributed to lower urinary tract dysfunction

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17
Q

What is benign prostatic enlargement?

A

Clinical finding of enlarged prostate

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18
Q

What is benign prostatic hyperplasia?

A

Histological diagnosis

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19
Q

What is bladder outflow obstruction?

A

Urodynamically proven obstruction to passage of urine

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20
Q

What is BPH?

A

• Increased number of epithelial and stromal cells in the peri-urethral area of the prostate in response to androgen (testosterone) and growth factors.

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21
Q

What is the consequent effect of BPH to urethral resistance?

A

Increased urethral resistance

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22
Q

What happens to detrusor pressure in BPH?

A

Detrusor pressure increased, in order to maintain urinary flow

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23
Q

What are the symptoms of BPH?

A

Decreased urinary flow, urinary frequency, urgency and nocturia

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24
Q

What is the correlation between prostate size and degree of obstruction?

A

There is no correlation

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25
Q

How is active smooth muscle tone regulated?

A

Adrenergic nervous system

Alpha-1 adrenoceptor subtype

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26
Q

What is first phase BPH?

A

Characterised by increased number of nodules - growth is slow (glandular nodules are larger than stromal nodules)

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27
Q

Which type of nodules are dominant in the second phase of BPH?

A

Glandular nodule

28
Q

What is the second phase of BPH?

A

Significant increase in larger nodules (size of each nodule increasing)

29
Q

What are the two obstruction induced changes in urinary inconinence?

A

Detrusor instability/decreased compliance - frequency and urgency

Decreased detrusor contractility - further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine and detrusor failure

30
Q

What is voiding?

A

Reduced flow, hesitancy, incompletely emptying and strangury

31
Q

What is storage in terms of BPH?

A

Frequency (daytime and nocturia), urgency, incontinence

32
Q

What is examined in patients with urinary incontinence?

A 
Palpable bladder
Ballotable kidneys
Phimosis 
Meatal  stenosis
Enlarged prostate on DRE, size, consistency, nodules, anal tone and sensation
33
Q

What investigations are conducted in a patient with BPH?

A
  • Urine dipstick
  • Flow rate + Post void residual (PVR) – Measures the velocity of passing urine, in addition to the volume.
  • IPSS Questionnaire – Designed to assess symptoms of prostate enlargement.
  • Bladder diary – Objective way to identify how much the patient is drinking, volume and times.
  • Ultrasound KUB – Impaired renal function, loin pain, haematuria, renal mass on examination.
  • PSA, creatinine
  • Flexible cystoscopy
  • TRUS prostate
  • Urodynamic studies
34
Q

What is PVR?

A

Post-void residual - measures the velocity of passing urine, in addition to the volume

35
Q

What is the initial management and treatment for patients with BPH?

A

Watchful waiting
Lifestyle changes (Caffeine exclusion)
Pharmacological treatment

36
Q

What drugs are recommended in patients with diagnosed BPH?

A

Alpha-adrenergic antagonists - minimise smooth muscle contraction (relaxation allows urine to pass easily).

5-alpha reductase inhibitors

37
Q

What are three examples of alpha-adrenergic antagonists?

A

Tamsulosin
Alfuzosin
Doxazosin

38
Q

How do alpha-adrenergic antagonists work in BPH?

A

Minimise smooth muscle contraction (relaxation allows urine to pass easily)

39
Q

What is TUPR?

A

Cystoscope inserted through the urethra and bladder to ablate the prostate tissue

40
Q

What is rezum?

A

Eject steam into the prostate

41
Q

What is UroLIFT?

A

Pinning of the prostate lobes

42
Q

What is a Millin’s prostateectomy?

A

Open invasive operation to remove the prostate through the bladder

43
Q

What is embolisation?

A

Coils into the vessels, which provide the main blood supply - prostate shrinkage

44
Q

What is HoLEP?

A

Laser to core out the entire prostate

45
Q

What is stress incontinence?

A

The complaint of involuntary leakage on exertion/sneezing/coughing

46
Q

What is urge incontinence?

A

The complaint of an involuntary leakage accompanied by or immediately preceded by urgency

47
Q

What is mixed urinary incontinence?

A

Complaint of an involuntary leakage of urine associated with urgency and exertion, effort, sneezing or coughing

48
Q

What is continuous incontinence?

A

Continuous leakage

49
Q

What is nocturnal enuresis?

A

Complaint of loss of urine occurring during sleep

50
Q

What is post-micturition dribble?

A

Complain of an involuntary loss of urine immediately after passing urine.

51
Q

What factors affect incontinence?

A 
Factors: 
•	Increasing age 
•	Pregnancy & Vaginal delivery 
•	Obesity 
•	Constipation 
•	Drug: ACE inhibitors
•	Smoking
•	Family History 
•	Prolapse/hysterectomy/menopause
52
Q

What is a pad test?

A

Weight 24 hours of pads and compare with the weight of a dry pad to objectively identify the volume of urine that is leaking.

53
Q

What investigations are conducted in patients with incontinence?

A
  • Urine dipstick
  • Flow rate and post-void residual
  • Bladder diary
  • Pad tests – Weight 24 hours of pads and compare with the weight of a dry pad to objectively identify the volume of urine that is leaking.
  • Patient symptom scores/validated QoL questionnaire
  • Urodynamic/video urodynamic studies
54
Q

Stress incontinence is common in which sex?

A

Women of young to middle age

55
Q

What are the non-surgical treatments for incontinence?

A 
Lifestyle changes
•	Weight loss
•	Cessation of smoking
•	Modification of high/low fluid intake
Supervised pelvic floor exercises with pelvic floor physiotherapists. 
Bladder re-training.
56
Q

What are the pharmacological treatments for incontinence?

A

Oestrogen therapy – if evidence of atrophy.
Oestrogen receptors reside within the urethra, pelvic, floor, vagina and the base of the bladder.
Oral medical therapy in rare cases.

57
Q

What surgical treatments are available for incontinence?

A
  • Occlusive (bulking, compressive (AUS)
  • Supportive (mid-urethral sling, colposuspension) – Prevents movement of the urethra, and supports the urethral sphincter.
  • Ileal conduit diversion- In end stage cases
58
Q

What 5 structures control continence?

A

1) Detrusor muscle
2) Internal sphincter
3) Ureterotrigonal muscles
4) Levator muscles
5) Rhabdosphincter (external sphincter muscle).

59
Q

What surgery is available for male incontinence?

A

Occlusive (bulking, compressive (AUS).
Supportive (suburethral sling)
Ileal conduit diversion

60
Q

What is UUI?

A 
Urge Urinary Incontinence (UUI) 
•	OAB symptom syndrome: Urinary frequency, urgency, nocturia, with or without leak. 
•	16% in men and women. 
•	Prevalence men > women for OAB-dry.
•	Women > men for OAB-wet
61
Q

What is OAB syndrome?

A

Urinary frequency, urgency, nocturia with or without leak

62
Q

What are the differential diagnoses for incontinence?

A 
Differential diagnosis
•	UTI
•	DO
•	Urethral syndrome
•	Urethral diverticulum
•	Interstitial cystitis
•	Bladder cancer
•	Large residual volume
63
Q

What lifestyle changes are recommended in patients with incontinence?

A

Lifestyle changes: Decreasing, caffeine intake, stopping smoking, losing weight if obese.
• Bladder re-training
• Pelvic floor muscle exercises

64
Q

What pharmacotherapy is available for incontinence?

A

• Efficacy is 50-75%
• Anti-cholinergic (solifenacin, tolterodine, trospium)
N.B: Dry mouth, blurry vision and constipation.
• Beta-3 agonist (betmiga) – better risk profile.

65
Q

What surgical interventions are available for incontinence?

A

Surgery
• Posterior tibial nerve stimulation (PTNS)
• Intravesical injection of botulinum toxin A
• efficacy is 36-89%, mean efficacy is 70%, upto a mean time of 6 months
• Neuromodulation
• 50% cure rate, 25% significant improvement of symptoms, 25% failure rate
• Clam (augmentation) cystoplasty
• 50% cure rate, 25% significant improvement of symptoms, 25% failure rate
• Urinary diversion is an option if all else fails in very severe cases

Y2 BRS (Haroop) (62 decks)

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