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S2.6 Renal > Prostate Disease and Urinary Obstruction > Flashcards

Prostate Disease and Urinary Obstruction Flashcards

1
Q

What is the prevalence of benign prostatic hyperplasia in men?

A

50% of men at 60

90% of men at 85

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2
Q

How many people with BPH have symptoms, and what are these symptoms?

A

50% of men with BPH have moderate to severe LUTS

Voiding - obstructive

  • hesitancy
  • poor stream
  • terminal dribbling
  • incomplete emptying

Storage

  • frequency
  • nocturia
  • urgency +/- urge incontinence
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3
Q

What might be found on examination of a person with diseases of the prostate?

A

Palpable bladder
External urethral meatal stricture, phimosis

Enlarged prostate on rectal exam, suspicious nodules or firmness

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4
Q

What investigations might be performed in suspected prostate disease?

A

MSSU
Flow rate study (Qmax <10mL/s = 90% chance of having BOO)
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 haematuriaUrodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE

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5
Q

How are prostate symptoms scored?

A

International prostate symptom score sheet (IPSS)

  • out of 35
  • 0-7 = mild
  • 8-19 = moderate
  • 20+ = severe
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6
Q

How is uncomplicated prostate disease treated?

A

Watchful waiting
Medical therapy
Surgical intervention

medical therapy- alpha blockers, 5-alpha reductase inhibitors (finasteride/dutasteride), combination

surgical - TURP (gold standard, used when prostate <100cc), open retropubic or transvesical prostatectomy (prostate >100cc), endoscopic ablative (urolift)

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7
Q

What are some examples of alpha-blockers used to treat LUTS/BPO?

A 
Non selective - phenoxybenzamine
Selective short - prazosin, indoramin
Selective long - alfuzosin, doxazosin, terazosin
Highly selective (e.g. 1a) - tamsulosin
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8
Q

When is BPO considered complicated?

A 
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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9
Q

How is complicated BPO treated?

A

Medical therapy
Most patients will require surgery e.g. cystolitholapaxy, and TURP for patients with BPO and bladder stones

Alternative treatment options (e.g. 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
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10
Q

What are the most common prostate zones for benign prostatic hyperplasia, and prostate cancer?

A

BPH (fibromuscular and glandular hyperplasia) - transition zone
Cancer - peripheral zone

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11
Q

What are the possible areas of upper and lower urinary tract obstruction?

A

Upper

  • pelviureteric junction
  • ureter
  • vesicoureteric junction

Lower (BOO)

  • bladder neck
  • prostate
  • urethra
  • urethral meatus
  • foreskin e.g. phimosis
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12
Q

Who are most at risk of kidney stones?

A

M:F 3:1
Peak age at 30
Bimodal female peak - 35 and 55
50% recurrence within 10Y

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13
Q

What are some examples of causes of PUJ obstruction?

A

Intrinsic

  • obstruction (physiological)
  • stone
  • tumour (TCC)
  • blood clot
  • fungal

Extrinsic

  • obstruction (crossing vessel)
  • lymph nodes
  • abdominal mass
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14
Q

What are some examples of causes of ureter obstruction?

A

Intrinsic

  • stone
  • tumour
  • scar tissue
  • blood clot
  • fungal

Extrinsic

  • lymph nodes
  • iatrogenic
  • abdo/pelvic mass
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15
Q

What are some examples of causes of VUJ obstruction?

A

Intrinsic

  • stone
  • tumour (bladder/ureter)

Extrinsic

  • cervical tumour
  • prostate cancer
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16
Q

How does upper urinary tract blockage generally present?

A

Symptoms

  • Pain
  • Frank haematuria
  • Symptoms of complications (e.g. infection, sepsis, renal failure)

Signs

  • Palpable mass
  • Microscopic haematuria
  • signs of complications
17
Q

How do kidney stones present?

A 
Renal pain - fixed in loin
Ureteric colic (radiating to groin)
Dysuria/haematuria/testicular or vulval pain
Urinary infection
Loin tenderness
Pyrexia
18
Q

How does lower urinary tract obstruction present?

A 
LUTS inc incontinence
Acute urinary retention
Chronic urinary retention
Recurrent UTI and sepsis
Frank haematuria
Formation of bladder stones
Renal failure
19
Q

How do bladder stones present?

A

Suprapubic/groin/penile pain

Dysuria, frequency, haematuria

Urinary infection (persistent)
Sudden interruption of urinary stream
Usually secondary to outflow obstruction
20
Q

What investigations might be done in urinary tract obstruction?

A 
Blood tests - FBC, U&amp;E, Creatinine
Calcium, albumin, urate
Parathormone
Urine analysis and cultre
24hr urine collections

Radiology

  • KUB xray - kidneys/ureter/bladder
  • USS
  • IVU (IV urogram)
  • CT KUB
21
Q

What are the different presentations of upper urinary tract obstruction in acute vs chronic?

A

Acute

  • renal function could be normal
  • pain?

Chronic

  • renal function may be normal
  • high pressure vs low pressure
22
Q

What is the difference in presentation between low pressure and high pressure chronic upper urinary obstruction/retention?

A

High pressure

  • painless
  • incontinent
  • raised cr
  • bilateral hydro-nephrosis

Low pressure

  • painless
  • dry
  • normal cr
  • normal kidneys
23
Q

What are the general treatments for urinary tract obstruction, whether upper or lower?

A

Resuscitation

  • ABC
  • IV access, bloods, ABG, urine and blood cultures, fluid balance
  • IV fluids, broad-spectrum antibiotics if appropriate
  • analgaesia
  • HDU care +/- renal replacement therapy
24
Q

How are upper obstructions treated?

A

Emergency treatment of obstruction (for unremitting pain or complications)

  • percutaneous nephrostomy insertion OR
  • retrograde stent insertion

Definitive treatment of obstruction

  • stone - ureteroscopy and laser lithotripsy +/- basketing or ESWL
  • ureteric tumour - radical nephro-ureterectomy
  • PUJ obstruction - laparoscopic pyeloplasty
25
Q

How is a nephrostomy usually performed?

A

Percutaneous puncture
Usually under LA + sedation
US or xray guidance
Be aware of adjacent organ bleeding

26
Q

How is a lower obstruction usually treated?

A

Immediate catheterisation if urinary retention - record residual volume

Emergency treatment of obstruction (for unremitting pain or complications)

  • urethral catheterisation OR
  • suprapubic

Definitive treatment of obstruction

  • BPE > TURP
  • urethral stricture - optical urethrotomy
  • meatal stenosis - meatal dilatation
  • phimosis - circumcision

Bladder stones mostly treated endoscopically, larger stones can be done by open excision

27
Q

When is surgery indicated in urinary stones? What are the different techniques?

A 
Obstruction
Recurrent gross haematuria
Recurrent pain and infection
Progressive loss of kidney function
Patient occupation

Techniques

  • open surgery - now rare - but lowest recurrence rate
  • endoscopic surgery - PCNL, flexible/rigid ureteroscope (main technique for lower ureter stones)
  • ESWL - extracorporeal shockwave lithotripsy (main technique for kidney)
28
Q

When is open surgery in kidney stones indicated?

A

Generally when kidney non functioning with particularly large/complex stones

29
Q

When is PCNL indicated in kidney stones?

When should it not be used

A
  • large stone burden (risk of Steinstrasse)
  • associated PUJ stenosis
  • infundibular stricture
  • calyceal diverticulum
  • morbid obesity or skeletal deformity
  • ESWL resistant stones e.g. cystine
  • lack of availability of ESWL

Don’t use if coagulopathy, UTI, obese
Avoid if small kidneys, severe perirenal fibrosis

30
Q

What are the different types of kidney stones, which is the most common?

A 
Calcium oxalate - 45%
Calcium oxalate + phosphate - 25%
Triple phosphate (infective) - 20%
Uric acid - 5%
Calcium phosphate - 3%
Cystine - 3% (ESWL often ineffective)
31
Q

What is post-obstructive diuresis, how is it managed?

A

Greater than 150-200mL/hr

  • 0.5-50%
  • osmotic diuresis secondary to urea; ADH; altered tubular function
  • can lead to life-threatening sodium and water depletion
  • normal saline at input = output-30mL/hr

S2.6 Renal (8 decks)

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