Lecture 18 + 19: Benign Diseases of the Urinary Tract Flashcards
1
Q
How big is the prostate?
A
About the size of a walnut
2
Q
2/3rd of the prostate is ____. 1/3rd is ____
A
Glandular
Fibromuscular
3
Q
What surrounds the prostate gland?
A
Thin fibrous capsule
4
Q
What is the clinical histological division of the prostate (McNeal’s zones)?
A
Central zone
Transitional zone
Peripheral zone
5
Q
Which of McNeal’s zones is the biggest?
A
Peripheral
6
Q
What does the central zone surround?
A
Ejaculatory ducts
7
Q
Where is the transitional zone?
A
It is central and surrounds the urethra
8
Q
Which zone’s glands typically undergo hyperplasia in BPH?
A
Transitional zone
9
Q
In which zone is prostate cancer most common?
A
Peripheral zone
10
Q
Which zone is felt most on DRE?
A
Peripheral
11
Q
What is the arterial supply to the prostate?
A
Prostatic arteries (mainly derived from internal iliacs)
12
Q
What is the venous drainage of the prostate?
A
Prostatic venous plexus (drained by internal iliac veins)
13
Q
What is BPH characterised by?
A
Fibromuscular and glandular hyperplasia
14
Q
What % of men have BPH at age 60 and age 85?
A
60 - 50% men
85 - 90%
15
Q
BPH is a progressive condition leading to what?
A
Bladder outflow obstruction
16
Q
How is the severity of BPH scored?
A
International prostate symptom score
Mild 0-7, moderate 8-19, severe is 20+
17
Q
How does BPH tend to present?
A
LUTS (lower urinary tract symptoms)
18
Q
How are LUTS categorised?
A
Voiding symptoms (obstructive) - weak/intermittent urinary flow, straining, hesitancy, terminal dribbling + incomplete emptying Storage symptoms (irritative) - urgency, frequency, urgency incontinence, nocturia Post-micturition - dribbling Complications - UTI, retention, obstructive uropathy
19
Q
What investigations may be useful in BPH?
A
Urinalysis
PSA
International Prostate Symptom Score
Frequency volume charts
20
Q
What things should you look for on examination of someone with suspected BPH?
A
Abdomen - ?palpable bladder
Penis - ?external urethral meatal stricture, ?phimosis
DRE - assess prostate size, ?suspicious nodules/firmness
Urinalysis - ?blood, ?UTI
21
Q
What other investigations might you consider in someone with BPH?
A
MSSU Flow rate study Post-void bladder residual USS PSA, urea/cr if chronic retention Renal tract USS if renal failure/bladder stone suspected Flexible cystoscopy if haematuria Urodynamic studies in selected cases
22
Q
What investigation should be done is PSA is raised or DRE is abnormal?
A
TRUS-guided prostate biopsy
23
Q
What are management options for BPH?
A
Watchful waiting
Medications
Surgery
24
Q
What medications can be used to treat BPH?
A
Alpha-1-antagonists
5 alpha-reductase inhibitors
Often used in combination
25
What surgery is used to treat BPH?
TURP - transurethral resection of prostate
26
Give e.g.s of alpha-1 antagonists
Tamsulosin, alfuzosin
27
How do alpha-1 antagonists work in treating BPH?
Decrease smooth muscle tone of bladder + prostate, thus antagonising the dynamic element to prostatic obstruction
28
What drugs are considered first line for BPH?
Alpha-1 antagonists
29
What AEs are associated with alpha-1 antagonists?
Dizziness, postural hypotension, dry mouth, depression
30
Give an e.g. of a 5-alpha reductase inhibitor
Finasteride
31
How do 5 alpha-reductase inhibitors work?
Block conversion of testosterone to dihydrotestosterone (which is known to induce BPH)
NB unlike alpha-1 antagonists they reduce prostate volume and decrease PSA but takes up to 6 months but doesn't reduce LUTS as much as alpha-1 antagonists
32
What adverse effects are associated with 5 alpha-reductase inhibitors?
Erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
33
What surgical intervention is recommended if the prostate is <100cc?
TURP
34
What surgical intervention is recommended if the prostate is >100cc?
Open retropubic/transvesicular prostatectomy
35
Apart from TURP/open/transvesicular surgery what other surgical options are there for BPH?
Endoscopic ablative procedures
36
The smooth muscle fo the bladder neck (internal urethral sphincter) and prostate is innervated by what nerves?
Sympathetic alpha-adrenergic nerves
37
Is it best to use alpha-1 antagonists, 5 alpha-reductase inhibitors or a combination of both?
Combination of both
38
What are additional benefits of 5a-reductase inhibitors besides reducing prostate volume?
Reduces prostate vascularity --> reduced haematuria due to prostatic bleeding
Potential role in prostate cancer prevention
39
What is the gold standard treatment for BPH?
TURP
40
What are complications of TURP?
```
Bleeding
Infection
Retrograde ejaculation
Stress urinary incontinence
Prostatic regrowth leading to recurrent haematuria or BOO
```
41
What are alternative new endoscopic ablative procedures that can be used instead of TURP?
Transurethral laser vaporisation
42
What are complications of benign prostatic obstruction?
```
Progression of LUTS
Acute/chronic urinary retention
Urinary incontinence (overflow)
UTI
Bladder stone
Renal failure from obstructed ureteric outflow due to high bladder pressure
```
43
What are treatment options for those with complicated BPO who are unfit for surgery?
Long term urethral/suprapubic catheterisation
| CISC
44
Define acute urinary retention
Painful inability to avoid with a palpable and percussible bladder
45
What do the residuals in acute urinary retention vary from?
500ml to 1L
46
What is the main risk factor for acute urinary retention?
BPO
47
What are other aetiologies for acute urinary retention?
```
UTI
Urethral stricture
Alcohol excess
Post-op causes
Acute surgical/medical problems
```
48
How can acute urinary retention happen for those who have BPO?
Spontaneously i.e. natural progression of BPO
| Triggered by unrelated event, e.g. constipation, alcohol excess, post-op causes, urological procedure
49
What is the immediate treatment of urinary retention?
Catheterisation (urethral/suprapubic)
50
What are complications of acute urinary retention?
```
UTI
Post-decompressive haematuria
Pathological diuresis
Renal failure
Electrolyte abnormalities
```
51
How do you manage acute urinary retention in someone with BPO as the underlying cause?
If no renal failure, start alpha blocker immediately, remove catheter in 2 days
If failure to void, recatheterize and organise TURP
52
Define chronic urinary retention
Painless, palpable + percussible bladder after voiding
53
What do the residuals in chronic urinary retention vary from?
400ml to >2L depending on stage of condition
54
What is the main aetiological factor in chronic urinary retention?
Detrusor inactivity - can be primary (i.e. primary bladder failure) or secondary (e.g. due to longstanding BOO, e.g. BPO or urethral stricture)
55
How does chronic urinary retention present?
LUTS or complications (e.g. UTI, stones, overflow incontinence, post-renal/obstructive renal failure)
56
What patients with chronic urinary retention require treatment?
Those with symptoms/complications
57
How is chronic urinary retention managed?
Immediately with catheterisation then CISC if appropriate
58
What are complications of chronic urinary retention?
UTI
Post-decompressive haematuria
Pathological diuresis
Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)
Persistent renal dsyfunction due to acute tubular necrosis
59
What are features of pathological diuresis?
Urine output >200ml/hr + postural hypotension (systolic >20mmHg between lying and standing), + wt loss + electrolyte abnormalities
60
How is pathological diuresis managed?
IV fluids
| Close monitoring
61
What is the future management of chronic urinary retention?
Long term urethral/suprapubic catheter
CISC
TURP
62
What are causes of urinary tract obstruction at the PUJ?
```
Instrinsic -
Physiological PUJ obstruction
Stone
Ureteric tumour
Blood clot
Fungal ball
```
Extrinsic -
PUJ obstruction, e.g. crossing vessel
Tumour
63
What are causes of obstruction of the ureter?
```
Intrinsic -
Stone
Ureteric tumour (TCC)
Scar tissue
Blood clot
Fungal ball
```
```
Extrinsic -
LNs
Iatrogenic
Pregnancy
Tumour
```
64
What are causes of obstruction at the VUJ?
Intrinsic -
Stone
Bladder/ureteric tumour
Extrinsic
Cervical tumour
Prostate cancer
65
What are symptoms/signs of upper urinary tract obstruction?
Pain
Haematuria
Palpable mass
66
What are complications of urinary tract obstruction?
Infection, sepsis
| Renal failure
67
In men what does acute urinary retention most commonly occur secondary to?
BPH (enlarged prostate presses on urethra, which makes bladder wall thicker + less able to empty)
68
What other things apart from BPH can cause acute urinary retention?
Urethral obstructions - strictures, calculi, cystocele, constipation, masses
Rarer causes incl. neurological causes
69
What medications can cause acute urinary retention and how do they do this?
```
Affects nerve signals to the bladder -
Anticholingerics
TCAs
Antihistamines
Opioids
Benzos
```
70
When does acute urinary retention often occur?
Post-op
| Postpartum in women
71
How do patients in acute urinary retention typically present?
Inability to pass urine
Lower ab discomfort
Considerable pain/distress
72
What is a big difference in the presentation of acute vs chronic urinary retention?
Chronic usually painless
73
What signs are typical of acute urinary retention?
Palpable distended bladder
| Lower ab tenderness
74
All women and men in urinary retention should have what examinations?
Both - DRE, neurological - assess for causes
| Women - pelvic
75
What investigations should be done in acute urinary retention?
Urinalysis + culture
Serum UE, Cr to check for kidney injury
FBC, CRP to check for infection
76
What investigation should be done to confirm a diagnosis of acute urinary retention?
Bladder USS
| Volume >300cc confirms diagnosis
77
What is the management of acute urinary retention?
Catheterisation
78
How should the patient in acute urinary retention be assessed after they are catheterised?
Measure volume of urine produced after 15m
<200 = not in acute urinary retention
>400cc = leave catheter in lace
79
If there is no obvious cause for acute urinary retention what should happen next?
Send to urologist to assess for of anatomical and urological causes
80
What are the two types of chronic urinary retention?
High pressure: impaired renal function + bilateral hydronephrosis, typically due to bladder outflow obstruction
Low pressure: no hydronephrosis, normal renal function
81
What commonly occurs after catheterisation for chronic urinary retention?
```
Decompression haematuria (due to rapid decrease in pressure in bladder --> shearing of small vessels)
It does not req. treatment usually
```
82
What emergency treatments may be needed for upper urinary tract obstruction leading to retention?
Percutaneous nephrostomy insertion
| Retrograde stent insertion
83
What does a nephrostomy involve?
Percutaneous puncture under LA + sedation
US/X-Ray guidance
It temporarily collects urine while the urinary tract is blocked
84
What kind of ureteric stents can be inserted?
Silicone
Polyurethane
Nickle titanium
85
How is lower tract obstruction leading to urinary retention managed?
Urethral catheterisation or suprapubic catheterisation
86
What is involved in 'resus' when a patient is in acute urinary retention?
```
ABC
IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
IV fluids, antibiotics
Analgesia
HDU care +/- renal replacement therapy
```
87
What things may cause lower urinary tract obstruction and how would you treat them?
BPH - TURP
Urethral stricture - optical urethrotomy
Meatal stenosis - meatal dilatation
Phimiosis - circumcision
88
How does high pressure chronic urinary retention present?
Painless
Incontinent
Raised Cr
Bilateral hydronephrosis
89
How does low pressure chronic urinary retention present?
Painless
Dry
Normal Cr and kidneys
90
Define post-obstructive diuresis
Prolonged urine production >= 200ml for at least 2h immediately following the relief of urinary retention or similar obstructive uropathy
