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2ND YEAR SYSTEMS: Urinary > Urinary tract obstruction > Flashcards

Urinary tract obstruction Flashcards

1
Q

Which 3 overlapping symptoms contribute to Benign prostatic hyperplasia (prostate gland enlargement)?

A

Lower urinary tract symptoms

Bladder outflow obstruction

Benign prostatic enlargement

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2
Q

What is prostate gland enlargement?

A

A common condition as men get older - 50% of men at 60 years

Characterised by fibromuscular and glandular hyperplasia

Can cause uncomfortable urinary symptoms - for example blockage of outflow tract

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3
Q

How are LUTS symptoms scored?

A

International Prostate Symptom Score

7 questions related to voiding and storage symptoms - Incomplete emptying, Frequency, Intermittency, Urgency, Weak Stream, Straining + Nocturia

Total score out of 35

Mild - 0-7
Moderate - 8-19
Severe - >20

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4
Q

What voiding symptoms are assessed?

A

Hesitancy

Poor stream

Terminal dribbling

Incomplete emptying

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5
Q

What storage symptoms are assessed?

A

Frequency

Nocturia

Urgency
+/- urge incontinence

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6
Q

Physical examinations done for suspected urinary tract obstruction?

A

Abdomen - do they have a palpable bladder

Penis - is there an external urethral meatal stricture or phimosis

Rectal examination - assess prostate size, feel for any suspicious nodules or firmness

Urinalysis - ? blood, ? signs of UTI

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7
Q

Investigations for urinary tract obstruction

A

MSSU - mid stream urine sample

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 (camera to look at bladder)

Urodynamic studies in selected cases

TRUS-guided prostate biopsy => >do this if PSA raised or abnormal rectal exam

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8
Q

What is a PSA blood test?

A

Prostate specific antigen

Produced by both cancerous and noncancerous tissue - it is age dependent

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9
Q

2 classes of Benign prostate obstruction (BPO)

A

Complicated

Uncomplicated

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10
Q

Treatment of uncomplicated BPO

A

Watchful waiting

Medical therapy - 5 alpha reductase inhibitors (Finasteride or Dutasteride), Alpha blockers or Combination

Surgical intervention - TURP, Open retropubic or transvesical prostatectomy, Endoscopic ablative procedures

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11
Q

What is TURP?

A

Transurethral resection of the prostate - surgery to remove part of the prostate - remains gold standard

Done if prostate size is <100cc

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12
Q

What is the main treatment of LUTS associated with prostate enlargement? Why?

A

Alpha blockers - help give relief of symptoms and improve QOL

Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction.

Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)

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13
Q

What are the different types of alpha blockers?

A

Non-selective (i.e. alpha 1 and 2) : phenoxybenzamine

Selective short acting : prazosin, indoramin

Selective long acting : alfuzosin, doxazosin, terazosin

Highly selective (i.e. alpha-1a) : tamsulosin

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14
Q

What do 5a-reductase inhibitors do?

A

They convert testosterone to dihydrotestosterone which reduces prostate size and the risk of progression of prostate enlargement.

They also reduce LUTS (but not as effective as alpha blockers)

Can also reduce prostatic vascularity and hence reduces haematuria due to bleeding

Potential role in prostate cancer prevention

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15
Q

What is the most effective therapy for reducing the risk of benign prostate enlargement?

A

Combination therapy of 5ARIs + alpha blockers

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16
Q

What is the gold standard surgery for prostate enlargement?

A

Transurethral resection of prostate (TURP)

17
Q

Complications with TURP (5)

A

Bleeding
Infection
Retrograde ejaculation
Stress urinary incontinence - coughing, sneezing or exercising can cause urine to leak out
Prostatic regrowth causing recurrent haematuria or Bladder Outflow Obstruction

18
Q

Complications of Benign prostatic obstruction

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
19
Q

Treatment of complicated obstruction caused by enlarged prostate?

A

No role for medical therapy (except for acute urinary retention)

Most patients will require surgery eg. cystolitholapaxy (breaks up bladder stones into smaller pieces) and TURP for patients with BPO and bladder stones

Alternative treatment options (eg. patients unfit for surgery) = long term urethral or suprapubic catheterisation, clean intermittent self-catheterisation

May develop problems with difficult catheterisation - catheter trauma, blockages, frank haematuria or recurrent UTI

20
Q

Upper urinary tract obstruction (3)

A

PUJ - pelvic ureteric junction obstruction

Ureter

VUJ - vesico ureteric junction obstruction

21
Q

Intrinsic causes of ureter obstruction

A 
Stone
Ureteric tumour (TCC)
Scar tissue
Blood clot
Fungal ball
22
Q

Intrinsic cause of Vesico-ureteric junction (VUJ) obstruction

A

Stone
Bladder tumour
Ureteric tumour
Prostate cancer

23
Q

Intrinsic cause of Pelvi-ureteric junction (PUJ)

obstruction

A 
PUJ obstruction (scar tissue)
 Stone
 Ureteric tumour (TCC)
 Blood clot
 Fungal ball
24
Q

Extrinsic causes for obstruction of the ureter

A

Lymph nodes (tumour, retroperitoneal fibrosis)

Iatrogenic

Abdominal/pelvic mass (tumour, pregnant uterus)

25
Q

Extrinsic causes for obstruction of the Pelvi-ureteric junction (PUJ)

A

Pressure from a crossing vessel

Tumour - LN enlargement putting pressure on the PUJ

Abdominal mass (tumour)

26
Q

Symptoms of urinary tract obstruction

A

Pain

Frank haematuria (macroscopic)

Symptoms of complications

27
Q

Signs of urinary tract obstruction

A

Palpable mass

Microscopic haematuria

Signs of complications

28
Q

Complications of urinary tract obstruction

A

Infection and sepsis

Renal failure

29
Q

Management of emergency upper urinary tract obstruction

A

Resus - ABCs, IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring, IV fluids, broad-spectrum antibiotics (if appropriate), Analgesia, HDU care +/- renal replacement therapy (if appropriate)

Investigations (including imaging: Bladder scan, USS renal tract)

Emergency treatment of obstruction (for unremitting pain or complications) -
Urethral catheterisation OR Suprapubic catheterisation

30
Q

What are some alternative new endoscopic ablative procedures done insetad of TURP

A

Transurethral laser vaporisation

Urolift

2ND YEAR SYSTEMS: Urinary (25 decks)

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