Benign Disease of The Prostate and Urinary Tract Obstruction Flashcards Preview

Systems - Urinary > Benign Disease of The Prostate and Urinary Tract Obstruction > Flashcards

Flashcards in Benign Disease of The Prostate and Urinary Tract Obstruction Deck (43):
1

How big is an unenlarged prostate?

20 cc

2

What are the different parts of the prostate?

3

What are does benign prostatic hyperplasia affect?

Predominantly affects the transition zone 

 

Characterised by fibromuscular and glandular hyperplasia

4

Who does benign prostatic hyperplasia affect?

•Part of aging process in men :

  -  50% of men at 60 years

  -  90% of men at 85 years

•50% of men with BPH have moderate to severe LUTS

•Progressive condition resulting Bladder Outflow Obstruction (BOO)

5

What is the prostate symptom score sheet based on?

Incomplete emptying

Frequency

Intermittency

Urgency

Weak Stream

Straining

Nocturia

6

What are the voiding (obstructuve LUTs)?

•  Hesitancy

•  Poor stream

•  Terminal dribbling

•  Incomplete emptying

7

What are the storage (irritative) LUTs?

Frequency

Nocturia

Urgency +/- urge incontinence

8

What physical examinations are possible for BPH?

Abdomen - palpable bladder

Penis - External urethral meatal stricture, phimosis

Digital rectal examination - assessment of the prostate size, suspicious nodules or firmness

Urinalysis - blood, signs of UTI

9

What are the relevant investigations for Benign Prostate Hypertrophy?

•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

10

What are the two categories of BPO?

Uncomplicated 

Complicated

11

What is the treatment of uncomlpicated BPO?

•Watchful waiting

•Medical therapy

– Alpha blockers

–5 alpha reductase inhibitors (Finasteride or Dutasteride)

–Combination

 

•Surgical intervention

–TURP (prostate size <100cc) (transurethral resection of the prostate)

–Open retropubic or transvesical prostatectomy (prostate size >100cc)

–Endoscopic ablative procedures

12

What is the function of alpha blockers?

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

13

Here are some types of alpha blockers

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

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

14

What is the function of 5a reductase inhibitors?

Converts testosterone to dihydrotestosterone

•Role of 5ARIs :

  -  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

 

15

What is the gold standard for surgical intervention of BPH?

TURP 

16

What are complications of TURP?

bleeding, infection, retrograde ejaculation, stress urinary

     incontinence, prostatic regrowth causing recurrent haematuria

        or BOO

17

What are the complications of BPO?

Progression of LUTS

Acute urinary retention

Chronic urinary retention

Urinary incontinence (overflow)

UTI

Bladder stone

Renal Failure from ibstructed ureteric outflow due to high bladder pressure

18

What is the treatment of complicated BPO?

Most require surgery - cystolitholapaxy and TURP for patients with BPO and bladder stones

 

If unfit for surgery:

- urethral / suprapubic cathaterisation

- CISC (Clean intermittent self-cathaterisation)

 

19

What are the complications of cathaterisation?

Catheter trauma, blockages, frank haematuria or recurrent UTI

20

What is acute urinary retention?

Painful inability to void with a palpable and percussible bladder

21

What are the causes of acute urinary retention?

BPO (main risk factor)

 

UTI, urethral stricture, alcohol excess, post - operative causes

22

What is immediate treatment of acute urinary retention?

•Immediate treatment is catheterisation (either urethral or suprapubic)

 

•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)

23

What are complications of acute urinary retention?

UTI

Post decompression haematuria

Pathological diuresis

Renal failure

Electrolyte abnormalities

24

What is chronic urinary retention defined as?

Painless, palpable and percussable bladder after voiding

25

What is the main aetiological factor for chronic urinary retention?

•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)

26

What does chronic urinary retention present with?

LUTS 

Complications (e.g. UTI, bladder stones, overflow incontinence, post - renal or obstructive renal failure) or incidental finding

27

What are complications of chronic urinary retention?

UTI

Post decompression haematuria

Pathological diuresis

Electrolyte abnormalities

Renal dysfunction - as a result of acute tubular necrosis

28

What are the electrolyte abnormalities seen in chronic urinary retention?

Hyponatraemia

Hyperkalaemia

Metabolic acidosis

29

What are the features of pathological diuresis?

•Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities

30

What is the longer term treatment for chronic urinary retention?

•Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP

31

What are the types of urinery tract obstruction?

•Upper tract (i.e. supra-vesical)

  -  PUJ

  -  ureter

  -  VUJ

•Lower tract (i.e. bladder outflow obstruction)

  -  bladder neck

  -  prostate

  -  urethra

  -  urethral meatus

  -  foreskin (e.g. phimosis)

32

What are the intrinsic causes of upper tract obstruction?

PUJ, ureter and VUJ:

Stone

Ureteric tumour

 

PUJ and ureter: blood clot and fungal ball

 

 

 

33

What are the extrinsic causes of upper tract obstruction?

PUJ - PUJ obstruction by crossing vessel, lymph nodes, abdominal mass

 

Ureter - Lymph nodes, abdominal / pelvic mass, iatrogenic

 

VUJ - cervical tumour, prostate cancer

34

What is the presentation of upper tract obstruction?

Symptoms: Pain, frank haematuria, symptoms of complications

 

Signs: Palpable mass, microscopic haemauria, signs of complications

35

What are the complications of upper tract obstruction?

Infection and sepsis

Renal failure

36

What is management of upper urinary tract obstruction?

•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 - Extracorpeal shockwave lithotripsy

       -  e.g. ureteric tumourradical nephro-ureterectomy

       -  e.g. PUJ obstructionlaparoscopic pyeloplasty 

 

pyeloplasty - Pyeloplasty is the surgical reconstruction or revision of the renal pelvis to drain and decompress the kidney

37

Define nephrostomy

Urinary diversion from the kidney to the skin

38

How is nephrostomy carried out?

•Usually under LA + sedation

•US or xray guidance

39

What is the presentation of lower tract obstruction?

•Lower urinary tract symptoms

  - including urinary incontinence

 

•Acute urinary retention

 

•Chronic urinary retention

 

•Recurrent urinary tract infection and sepsis

 

•Frank haematuria

 

•Formation of bladder stones

 

•Renal failure

40

What is the difference between acute and chronic urinary retention in patient presentation?

Acute - Can't pee, in agony, creatinine - 70

 

Chronic - Peeing fine, pain free, creatinine - 170

41

What is the management for lower tract obstruction?

•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)

 

•Emergency treatment of obstruction (for unremitting pain or complications)

  -  Urethral catheterisation    OR

  -  Suprapubic catheterisation

 

•Definitive treatment of obstruction

  -  Treat underlying cause

       -  e.g. BPETURP

       -  e.g. Urethral strictureOptical urethrotomy

       -  e.g. Meatal stenosisMeatal dilatation

       -  e.g. Phimosis – Circumcision

 

42

What is decompression haematuria?

Shearing of small vessels due to differing compliance of tissue layers

Usually self - liiting

43

What is post obstructive diuresis 

Postobstructive diuresis. Postobstructive diuresis is a polyuric state in which copious amounts of salt and water are eliminated after the relief of a urinary tractobstruction. In most patients, the diuresis will resolve once the kidneys normalize the volume and solute status and homeostasis is achieved.