BLADDER OUTFLOW OBSTRUCTION

Question 1

What percentage of men in their fifties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?

Answer 1

30%

Question 2

What percentage of men in their eighties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?

Answer 2

50%

Question 3

What’s the difference between BPE, BPH and BOO?

Answer 3

BPE - Benign Prostatic Enlargement - this is a clinical finding of which BPH is a leading cause

BPH - Benign Prostatic Hyperplasia - this is a histological diagnosis characterised by an increase in the number of cells

BOO - Bladder Outflow Obstruction - This is a clinical finding which does not take cause into account

Question 4

How do we divide up the male lower urinary tract symptoms (LUTS)?

Answer 4

Storage symptoms

Voiding symptoms

Question 5

What are the male lower urinary tract symptoms (LUTS) associated with storage problems?

Answer 5

Frequency

Nocturia

Urgency

Urgency incontinence

Question 6

What are the male lower urinary tract symptoms (LUTS) associated with voiding problems?

Answer 6

Weak urinary stream

Prolonged voiding

Abdominal straining

Hesitancy

Intermittency

Incomplete bladder emptying

Terminal and post-void dribbling

Question 7

What is the different diagnosis for male lower urinary tract symptoms (LUTS)?

Answer 7

BPH

Bladder cancer

Prostate cancer

UTI

Overactive bladder syndrome (OAB)

Urethral strictures

Neurological disease

Question 8

What investigations would you do in a man who presents with LUTS?

Answer 8

Validated symptom score such as International Prostate Symptom Score (IPSS) - used to assess response to treatment

Urine analysis - blood, infection or diabetes

PSA when appropriate

Urodynamic studies

Detrusor pressure

Question 9

Why do we perform a DRE (digital rectal examination) of men with LUTS?

Answer 9

To make a rough estimate of prostate size

To detect locally invasive prostate cancer

Question 10

What is the normal upper limit of PSA for someone in their 40s above which we would worry about prostate cancer? 50s? 60s? 70s?

Answer 10

40s: Less than 2.5
50s: Less than 3.5
60s: Less than 4.5
70s: Less than 6.5

Question 11

In a urodynamic study, what is the normal maximum flow rate?

Answer 11

About 25 ml per second

Question 12

In a urodynamic study, what would be considered a significantly reduced flow rate?

Answer 12

Less 10 ml per second

Question 13

How do we measure detrusor pressure in patients with LUTS? Why is this useful?

Answer 13

Measure intravesical pressure and rectal pressure

Detrusor pressure then calculated by subtracting rectal pressure from intravesical pressure.

Helps to distinguish between high-pressure low-flow obstructed systems, detrusor dysfunction or atonic bladder as the cause of LUTS

Question 14

What are the indications for urological referral and intervention in someone presenting with LUTS?

Answer 14

Acute urinary retention

Obstructive nephropathy

Large post-void residual volume causing UTIs

Bladder stones

Failure of medical treatment to help with LUTS

Question 15

What are the four categories of management options available for treatment of bladder outflow obstruction?

Answer 15

Conservative

Medical

Surgical

Catheter

Question 16

What are the details of conservative management of bladder outflow obstruction?

Answer 16

Advice on fluid intake

Reduction in caffeine and alcohol ingestion

Bladder retraining

Continence products

Question 17

What are the first line medical management options for bladder outflow obstruction?

Answer 17

Alpha blockers

5-alpha reductase inhibitors

Question 18

What are the two physiological elements involvement in bladder outflow obstruction due to BPE?

Answer 18

Static element - mechanical obstruction due to enlargement

Dynamic element - increased tone of prostate smooth muscle

Question 19

How do alpha blockers work to reduce LUTS caused by BPE?

Answer 19

Relax prostatic smooth muscle

Question 20

Name 5 alpha blockers used in the treatment of bladder outflow obstruction.

Answer 20

Terazosin

Doxazosin

Tamsulosin

Alfuzosin

Silodosin

Question 21

What are the side effects of alpha blockers used in the treatment of bladder outflow obstruction?

Answer 21

Postural hypotension

Lethargy

Gastrointestinal disturbance

Nasal congestion

Ejaculatory dysfunction

Question 22

How do 5-alpha reductase inhibitors work to reduce LUTS caused by BPE?

Answer 22

Reduce size by inhibiting conversion of testosterone into its active metabolite dihydrotestosterone.

Question 23

What is the minimum prostate size and PSA level beyond which 5-alpha reductase inhibitors are recommended as first line treatment for BPE even without moderate symptoms?

Answer 23

30 cc (about the size of a ping pong ball)

PSA more than 1.4 ng/ml

Question 24

Name 2 5-alpha reductase inhibitors used in the treatment of bladder outflow obstruction.

Answer 24

Finasteride

Dutasteride

Question 25

In which patients do we recommend combination therapy of an alpha blocker and a 5-alpha reductase inhibitor?

Answer 25

Severe symptoms Risk factors for progression

Question 26

What are the risk factors for progressive BPH?

Answer 26

Age over 70 with LUTS Moderate to severe symptoms ie IPSS of more than 7 PSA or more than 1.4 ng/ml Prostate volume over 30 cc Maximum flow rate of less than 12 ml/second

Question 27

What is the most popular and widely available herbal medication used in the treatment of symptomatic BPH?

Answer 27

Saw Palmetto, extracted from berries of the American dwarf palm

Question 28

In which patients with LUTS would we use anticholinergics as opposed to alpha blockers or 5-alpha reductase inhibitors?

Answer 28

Those with overactive bladder syndrome

Question 29

What are the surgical management options for bladder outflow obstruction?

Answer 29

Transurethral resection of the prostate (TURP) Laser surgery

Question 30

What percentage of men will receive good symptomatic relief from transurethral resection of the prostate (TURP)?

Answer 30

90% - gold standard

Question 31

How is transurethral resection of the prostate (TURP) performed?

Answer 31

Electrocautery through endoscopic instruments introduced via the urethra. Tissue is resected in small chips until obstruction is removed.

Question 32

After transurethral resection of the prostate (TURP), how long must patients be catheterised for?

Answer 32

2-3 days

Question 33

What are the complications of transurethral resection of the prostate (TURP)?

Answer 33

UTI 2% Blood transfusion 6% Retrograde ejaculation 70% TUR syndrome 2% Impotence 8% Incontinence 1% Failure to void 5%

Question 34

What are the two types of laser surgery used in treatment of bladder outflow obstruction?

Answer 34

Holmium laser enucleation of the prostate Laser ablation of the prostate

Question 35

What are the complications of acute urinary retention?

Answer 35

Hydronephrosis Chronic retention Obstructive nephropathy Bladder stones

Question 36

What are the other non-malignant causes of bladder outflow obstruction?

Answer 36

Urethral strictures Bladder neck dysfunction

Question 37

What is the classic sign of urethral stricture seen on investigation of LUTS?

Answer 37

Flow rate shows a plateau with a prolonged voiding cycle

Question 38

How do we treat short urethral strictures?

Answer 38

Endoscopic urethrotomy

Question 39

In which group of men is bladder neck dysfunction typically seen as the cause of LUTS?

Answer 39

Younger men

Question 40

How do we treat bladder neck dysfunction?

Answer 40

Alpha blockers Surgical bladder neck incision

Question 41

What are the complications of surgical bladder neck incision?

Answer 41

Retrograde ejaculation so this will affect fertility