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Benign Disease Of The Prostate And Urinary Tract Obstruction Flashcards

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1
Q

What is benign prostatic hyperplasia characterised by?

A

fibromuscular and glandular hyperplasia

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2
Q

What area is affected in BPH?

A

Transition zone

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3
Q

What happens in BPH?

A

Disordered regulation of dihydrotestosterone

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4
Q

What is the prevalence of BPH?

A

50% of men at 60 years
90% of men at 85 years

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5
Q

What can occur in BPH?

A

50% of men with BPH have moderate to severe LUTS

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6
Q

What can BPH lead to?

A

Progressive condition resulting in Benign Prostatic Obstruction (BPO) or Bladder Outflow Obstruction (BOO)

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7
Q

What is the scoring system for LUTS?

A

IPSS

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8
Q

What are factors considered in voiding assessment?

A

Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying

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9
Q

What are the factors assessed in storage of LUTS?

A

Frequency
Nocturia
Urgency +/- urge incontinence

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10
Q

What is the scoring of IPSS?

A

Total score (out of 35) :
Mild : 0-7
Moderate : 8-19
Severe : ≥ 20

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11
Q

What is seen in an examination of LUTS?

A

Abdomen
? palpable bladder

Penis
? external urethral meatal stricture
? phimosis

Digital rectal examination (DRE)
assess prostate size
? suspicious nodules or firmness

Urinalysis
? blood
? signs of UTI

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12
Q

What investigation are done for 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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13
Q

What are the two typed of BPO?

A

Uncomplicated
Complicated

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14
Q

What is the treatment of BPO?

A

Watchful waiting

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

Surgical intervention
-TURP (prostate size <100cc)
-Open retropubic or transvesical prostatectomy (prostate size >100cc)
-Endoscopic ablative procedures

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15
Q

What is the main treatment of LUTS due to BPO?

A

Alpha blockers

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16
Q

How do alpha blockers work?

A

Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

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17
Q

What are the 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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18
Q

What do 5a-reductase do?

A

5a-reductase converts testosterone to dihydrotestosterone.

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19
Q

What two drugs are available for 5a-reductase inhibitors?

A
  • Finasteride (5AR Type II inhibitor)
    • Dutasteride (5AR Type I and II inhibitor)
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20
Q

What is the role of 5ARIs?

A
  • reduces prostate size and reduces risks of progression of BPE
    (but only if >25cc prostate)
    • also 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 also reduce prostatic vascularity and hence reduces
      haematuria due to prostatic bleeding
    • potential role in prostate cancer prevention
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21
Q

What is TURP?

A

Transurethral resection of prostate

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22
Q

What is TURP?

A

gold standard for surgical management of BPE causing BOO (except for prostate size >100cc)

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23
Q

What can TURP be done using?

A

Can be done using glycine (monopolar TURP) or saline (bipolar TURP)

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24
Q

What can TURP help in?

A

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

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25
What are complications of TURP?
- bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO
26
What prostate size is too large for TURP?
>100 cc
27
What complication can come from using TURP on too large prostates?
high risk of intra-operative or post-operative complications, including: - bleeding - fluid overload - hypothermia - TUR syndrome (triad of dilutional hyponatraemia, fluid overload and glycine toxicity)
28
What are complication of BPO?
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
29
What is the treatment of complicated BPO?
No role for medical therapy (except for acute urinary retention) Most patients will require surgery eg. cystolitholapaxy 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
30
What is the alternative treatment options for complicated BPO?
long term urethral or suprapubic catheterisation clean intermittent self-catheterisation may develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI
31
What is acute urinary retention?
painful inability to void with a palpable and percussible bladder
32
What is the main risk factor of acute urinary retention?
BPO
33
When can acute urinary retention occur?
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)
34
What is the immediate treatment of AUR?
Catheterisation
35
What are the complications of AUR?
UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities
36
What is the treatment of AUR?
Treat underlying trigger if present 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)
37
What is chronic urinary retention?
painless, palpable and percussible bladder after voiding
38
Is the patient able to void in CUR?
Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)
39
What is the main etiological of CUR?
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)
40
How does CUR present?
Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding
41
What occurs at severe ends of the spectrum?
Overflow incontinence and renal failure
42
Who does and doesn’t need treatment in CUR?
Asymptomatic patients with low residuals do not necessarily need treatment Patients with symptoms or complications need treatment (but no role for medical therapy!)
43
What is the treatment of CUR?
Immediate treatment is catheterisation Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP 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
44
What is the complications of CUR?
Complications : UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities
45
Where do upper tract obstruction occur?
PUJ ureter VUJ
46
Where do lower tract obstruction occur?
- bladder neck (i.e. primary bladder neck obstruction, in men only) - prostate (men only) - urethra (e.g. urethral stricture in men and women; pelvic mass causing extrinsic compression of urethra in women) - urethral meatus (i.e. meatal stenosis in men and women) - foreskin (e.g. phimosis in men only)
47
What are intrinsic causes of PUJ obstruction?
PUJ obstruction (scar tissue) Stone Ureteric tumour (UCC/TCC) Blood clot Fungal ball
48
What are intrinsic causes of ureter obstruction?
Stone Ureteric tumour (UCC/TCC) Scar tissue Blood clot Fungal ball
49
What are intrinsic causes of VUJ obstruction?
Stone Bladder tumour Ureteric tumour Prostate cancer
50
What are extrinsic causes of PUJ obstruction?
PUJ obstruction (crossing vessel) Lymph nodes (tumour) Abdominal mass (tumour)
51
What are extrinsic causes of ureter obstruction?
Lymph nodes (tumour, retroperitoneal fibrosis) Iatrogenic (eg. inadvertently tied off or diathermied during pelvic surgery) Abdominal/pelvic mass (tumour, pregnant uterus)
52
What are presenting symptoms of upper tract obstruction?
- Pain - Frank haematuria - Symptoms of complications
53
What are presenting signs of upper tract obstruction?
- Palpable mass - Microscopic haematuria - Signs of complications
54
What are complications of upper tract obstruction?
- Infection and sepsis - Renal failure (only if bilateral obstruction, single kidney or concurrent systemic upset e.g. sepsis, dehydration, nephrotoxicity)
55
What investigations are used for upper tract obstruction?
USS
56
What is seen on USS in UUTO?
Hydronephrosis - Hydroureter
57
What imaging types are used in UUTO?
CT-KUB CT-urogram
58
When is nuclear isotope scan used?
Not used in acute setting, nor for stones nor tumour Used for chronic unilateral upper urinary tract obstruction, esp. chronic PUJ obstruction
59
When is CT - KUB used?
- For investigation of urinary tract stones and obstruction in emergency setting - Quick and lower radiation exposure (2-3 milliSieverts) - No risk of contrast nephrotoxicity - Can be used in renal failure - Lower sensitivity for assessing obstructing masses (except for stones) - Less useful if ureter and collecting system is undilated
60
When is CT-urogram used?
- Higher radiation exposure (15-20 milliSieverts) - Risk of contrast nephrotoxicity and contraindicated in renal failure - Higher sensitivity for obstructing masses (e.g. ureteric UCC/TCC, pelvic mass)
61
What is the management of UUTO?
Resuscitation - 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) Emergency treatment of obstruction (for unremitting pain or complications) - Percutaneous nephrostomy insertion OR - Retrograde stent insertion Definitive treatment of obstruction - Treat underlying cause - e.g. stone – ureteroscopy and laser lithotripsy +/- basketing or ESWL - e.g. ureteric tumour – radical nephro-ureterectomy - e.g. PUJ obstruction – laparoscopic pyeloplasty
62
What is the presentation of Lower urinary tract obstruction?
Lower urinary tract symptoms - voiding and storage, and urinary incontinence (overflow or urge) Acute urinary retention Chronic urinary retention Recurrent urinary tract infection and sepsis Frank haematuria Formation of bladder stones Renal failure (only for chronic high-pressure urinary retention) PV bleeding (for women)
63
What is seen on physical examination of lower urinary tract obstruction?
Abdomen ? palpable bladder Penis ? external urethral meatal stricture ? phimosis Digital rectal examination (DRE) assess prostate size ? suspicious nodules or firmness Per vaginal examination (PV) ? history of PV bleeding ? pelvic mass Obtain pelvic/transvaginal USS if suspicious for pelvic mass Urinalysis ? blood ? signs of UTI
64
What investigations are used in LUTO?
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; pelvic/transvaginal USS in women if pelvic mass suspected Flexible cystoscopy if haematuria Urodynamic studies in selected cases TRUS-guided prostate biopsy if PSA raised or abnormal DRE
65
What is the Management of Lower Urinary Tract Obstruction in emergency setting
Resuscitation - 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, etc.) Emergency treatment of obstruction (for unremitting pain or complications) - Urethral catheterisation OR - Suprapubic catheterisation Definitive treatment of obstruction - Treat underlying cause - e.g. BPE – TURP - e.g. Urethral stricture – Optical urethrotomy - e.g. Meatal stenosis – Meatal dilatation - e.g. Phimosis – Circumcision

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