Benign Diseases of the Prostate Flashcards by Annie Caldwell

What type of organ is the prostate?

A secondary sexual organ

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How many sphincters do men and women have?

Men - 2

Women - 1

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Function of prostate

Capacitation - makes the sperm work

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What are McNeals Prostatic Zones?

Transition zone
Central zone
Peripheral zone

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Which McNeals zone does prostate cancer usually lie in?

Peripheral zone

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What are the benign prostatic diseases?

Benign prostatic enlargement (BPE)
Benign prostatic hyperplasia (BPH)
Benign prostatic obstruction (BPO)
Benign outflow obstruction (BOO)

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What does LUTS stand for?

Lower urinary tract symptoms

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What is benign prostatic hyperplasia?

Fibromuscular and glandular hyperplasia of the prostate. A progressive condition that results in BOO

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What % of men have BPH at 60 and 85 y/o?

60 y/o = 50%

85 y/o = 90%

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What are the LUTS?

Hesitancy 
Poor stream 
Terminal dribbling
Incomplete emptying 
Frequency 
Nocturia 
Urgency +/- urge incontinence

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Types of LUTS

Voiding

Storage

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What is the scoring system for the assessment of LUTS?

IPSS

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What is a normal peeing frequency?

4-6x a day

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Normal urine capacity for women vs men

Women - 400ml

Men - 500ml

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Examination for LUTS

Abdomen - palpable bladder
Penis 
- external urethral meatal stricture
- phimosis
DRE
- prostate size
- nodules or firmness
Urinalysis 
- bloods
- UTI

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Investigations of LUTS

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 haematuria
Urodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE

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What is PSA?

Serum protease which is in the blood, specific to the prostate NOT cancer - used to detect size

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Types of BPO

Uncomplicated

Complicated

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Treatment for uncomplicated BPO

Watchful waiting
Alpha blockers
5 alpha reductase inhibitors (finasteride or dutasteride)
Surgery
- TURP
- Open retropubic or transvesical prostatectomy
- endoscopic ablative procedures

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When is TURP done vs open retropubic or transvesical prostatectomy to treat BPO?

TURP = prostate size < 100cc

Other one = Prostate size > 100cc

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Complications 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

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What are alpha blockers the main treatment of?

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LUTS due to BPO

What does the sympathetic alpha-adrenergic nerves innervate?

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Smooth muscle of the bladder neck (i.e. intrinsic urethral sphincter) and prostate

What do alpha blockers cause?

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Smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

Types of alpha blockers

``` Non selective (alpha 1 and 2); phenoxybenzamine Selective short acting; prazosin, indoramin Selective long acting; alfuzosin, doxazosin Highly selective (alpha 1a - Tamsulosin) ```

What do 5-reductase inhibitors do?

Convert testosterone to dihydrotestosterone

Examples of 5-reductase inhibitors

Finasteride | Dutasteride

Role of 5AIRs

Reduce prostate size and reduces risk of progression of BPE Reduces LUTS Reduces prostatic vascularity and reduces haematuria due to prostatic bleeding Potential role in prostate cancer prevention

What does TURP stand for?

Transurethral resection of prostate

What is the gold standard surgery for prostate surgery?

TURP

Complications of TURP

``` Bleeding Infection Retrograde ejaculation Stress urinary incontinence Prostatic regrowth causing haematuria or BOO ```

Treatment of complicated BPO

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

What are some alternative treatment options for e.g. if patients are unfit for surgery

Long term urethral or suprapubic catheterisation | Clean intermittent self-catheterisation

Definition of acute urinary retention

Painful inability to void with a palpable and percusable bladder

Residuals In acute urinary retention

Vary from 500ml > 1 litre depending on lag time in seeking medical attention

What is the main risk factor for acute urinary retention?

BPO

For those with BPO, what can acute urinary retention be caused by?

Spontaneously | Triggers

What are some triggers for acute urinary retention in people with BPO?

Constipation Alcohol excess Post op cases Urological procedures

Immediate treatment of acute urinary retention

Catheterisation (either urethral or suprapubic)

Complications of acute urinary retention

``` UTI Post decompression haematuria Pathological diuresis Renal failure Electrolyte abnormalities ```

Longer term treatment of acute urinary retention

Treat underlying trigger if present If no renal failure start alpha blocker immediately Remove catheter in 2 days 60% will void successfully, if fail to void, catheterise and organise TURP (after 6 weeks)

Definition of chronic urinary retention

Painless, palpable and percusable bladder after voiding

Residuals in chronic urinary retention

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

Main causative factor of chronic urinary retention

Detrusor underactivity

Types of detrusor underactivity

Primary | Secondary

Causes of primary detrusor underactivity

Primary bladder failure

Causes of secondary detrusor underactivity

Longstanding BOO e.g. due to BPO or urethral stricture

Presentation of chronic urinary retention

LUTS | Complications

Complications of chronic urinary retention

``` UTI Bladder stones Overflow incontinence Post renal or obstructive renal failure Post decompression haematuria Pathological diuresis Electrolyte abnormalities - hyponatraemia - hyperkalaemia - metabolic acidosis Persistent renal dysfunction due to acute tubular necrosis ```

When does overflow incontinence and renal failure occur in chronic urinary retention?

At the severe end of the 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)

Patients with chronic urinary retention who are asymptomatic with low residuals, do they always need treatment?

Immediate treatment of chronic urinary retention

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

Features of pathological diuresis

Urine output > 200ml/hr Postural hypotension (systolic differential >200mmHg between lying and standing) Weight loss Electrolyte abnormalities

Treatment of chronic urinary retention

IV fluids (total input = 90% of output) Long term urethral or suprapubic catheter CISC TURP

Benign Diseases of the Prostate Flashcards

(54 cards)