Urinary Incontinence and Benign Prostatic Hyperplasia

Question 1

embryology of the prostate

Answer 1

between 10-16 weeks of gestation from epithelial buds which branch out from the posterior aspect of the urogenital sinus to invade the mesenchyme

Question 2

main influencing hormone of the prostate

Answer 2

dihydrotestosterone

Question 3

arterial blood supply of the prostate

Answer 3

branches of inferior vesical artery > prostatic artery > urethral + capsular groups of arteries > urethral group give rise to Flock’s + Badenoch’s arteries

Question 4

venous drainage of the prostate

Answer 4

via peri-prostatic venous plexus > drains into internal iliac vein

Question 5

lymph drainage of the prostate

Answer 5

to the obturator nodes and then the internal iliac chain

Question 6

list the McNeal’s zones

Answer 6

transition
central
peripheral

Question 7

transition zone

Answer 7

10% of the glandular tissue of the prostate

site of origin of benign prostate hyperplasia

Question 8

peripheral zone

Answer 8

65% of the glandular tissue of the prostate

Question 9

central zone

Answer 9

25% of the glandular tissue

Question 10

benign prostatic hyperplasia

Answer 10

prostatism (lower urinary tract symptoms)
benign prostatic enlargement
benign prostatic hyperplasia
bladder outflow obstruction
benign prostatic obstruction
benign prostatic hypertrophy

Question 11

describe benign prostate hyperplasia

Answer 11

increase in number of epithelial and stromal cells in peri urethral area of the prostate in response to androgens (testosterone) and growth factors

Question 12

bladder changes in BPH

Answer 12

decreased urinary flow

urinary frequency, urgency, nocturia

Question 13

function of the prostate

Answer 13

liquefy ejaculate

Question 14

pathophysiology of BPH

Answer 14

enlarged prostate > increased urethral resistance > compensatory changes in bladder fx

Question 15

in regards to BPH, what change is required to maintain urinary flow?

Answer 15

increased detrusor pressure

Question 16

the ______ transmits the ‘pressure’ of tissue expansion to the urethra

Answer 16

capsule

Question 17

is the size of the prostate equal to the degree of the obstruction?

Answer 17

no

Question 18

what is the most abundant adrenoreceptor subtype in the human prostate?

Answer 18

alpha1A

Question 19

are lower urinary tract symptoms in men with BPH related to obstruction induced changes in bladder function or direct outflow obstruction?

Answer 19

obstruction induced changes in bladder function

Question 20

list obstruction induced changes

Answer 20

detrusor instability/decreased compliance > frequency /urgency
decreased detrusor contractility > hesitancy, intermittency, increased residual urine, detrusor failure

Question 21

symptoms of benign prostatic hyperplasia

Answer 21

voiding: reduced flow, hesitancy, incomplete emptying, strangury
storage: frequency (day/night), urgency, incontinence
other: infection, visible haematuria

Question 22

examination for BPH includes?

Answer 22

general (ask about fluid intake)
palpable bladder
ballotable kidneys
phimosis
meatal stenosis
enlarged prostate on DRE, size, consistency, nodules, anal tone, sensation

Question 23

investigations for BPH includes?

Answer 23

urine dipstick
flow rate + PVR
IPSS questionnaire
bladder diary
PSA, creatinine
flexible cytoscopy
USS KUB
TRUS prostate
urodynamic studies

Question 24

management of benign prostate hyperplasia

Answer 24

watchful waiting
lifestyle changes
pharmacological treatment
surgery

Question 25

list pharmacological treatment options for BPH

Answer 25

alpha adrenergic antagonists 5-alpha reductase inhibitors combination therapy

Question 26

list examples of alpha adrenergic antagonists

Answer 26

tamsulosin alfuzosin doxazosin

Question 27

list examples of 5-alpha reductase inhibitors

Answer 27

finasteride | dustasteride

Question 28

alpha adrenergic antagonists are used to?

Answer 28

reduce symptoms | improve flow rate

Question 29

5-alpha reductase inhibitors are used to?

Answer 29

prevent disease progression | reduce development of AUR/requirement for surgery

Question 30

list surgical treatment options for BPH

Answer 30

``` TURP Rezum UroLIFT Millin's prostatectomy embolisation HoLEP ```

Question 31

what is urine incontinence?

Answer 31

complaint of any involuntary loss of urine

Question 32

list types of urine incontinence

Answer 32

``` stress incontinence urge incontinence mixed urinary incontinence continuous incontinence overflow incontinence nocturnal enuresis post-micturition dribble ```

Question 33

what is stress incontinence?

Answer 33

the complaint of involuntary leakage on exertion /sneezing/coughing

Question 34

what is urge incontinence?

Answer 34

the complaint of an involuntary leakage accompanied by or immediately preceded by urgency

Question 35

what is mixed urinary incontinence?

Answer 35

the complaint of an involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing

Question 36

what is continuous incontinence?

Answer 36

continuous leakage

Question 37

what is overflow incontinence?

Answer 37

leakage associated with urinary retention

Question 38

what is nocturnal enuresis?

Answer 38

the complaint of loss of urine occurring during sleep

Question 39

what is micturition dribble?

Answer 39

the complain of an involuntary loss of urine immediately after passing urine

Question 40

risk factors for urine incontinence

Answer 40

``` increasing age pregnancy and vaginal delivery obesity constipation drugs e.g. ACE inhibitors smoking family hx prolapse/hysterectomy/menopause ```

Question 41

investigations for urine incontinence

Answer 41

``` urine dipstick flow rate + post-void/residual Bladder diary Pad tests Patient symptom scores/validated QoL questionnaire Urodynamic/video-urodynamic studies ```

Question 42

stress urinary incontinence is more common in?

Answer 42

women of young to middle age

Question 43

stress urinary incontinence is uncommon in?

Answer 43

men who have not had prostate surgery

Question 44

list 5 causative theories of stress incontinence in women

Answer 44

``` urethral position theory intrinsic sphincter deficiency integral theory hammock theory trampoline theory ```

Question 45

non-surgical treatments for stress urinary incontinence in men and women

Answer 45

supervised pelvic floor exercises bladder re-training lifestyle changes: weight loss, cessation of smoking, modification of high/low fluid intake

Question 46

pharmacological treatment for stress urinary incontinence in women

Answer 46

oestrogen therapy is evidence of atrophy | oral medical therapy in rare cases

Question 47

surgical treatments for stress urinary incontinence in women

Answer 47

occlusive e.g. bulking, compressive (AUS) supportive (midurethral sling, colposuspension) ileal conduit diversion

Question 48

list 3 causative theories for stress incontinence in men

Answer 48

sphincter incompetence reduction in urethral sphincter length post-operative strictures

Question 49

list structures that control continence

Answer 49

``` detrusor muscle internal sphincter ureterotrigonal muscles levator muscles rhabidosphincter (external sphincter) ```

Question 50

pharmacological treatment for stress urinary incontinence in men

Answer 50

oral medical therapy in rare cases

Question 51

surgical treatments for stress urinary incontinence in men

Answer 51

Occlusive e.g. bulking, compressive (AUS) Supportive (suburethral sling) Ileal conduit diversion

Question 52

what is overactive bladder?

Answer 52

symptom syndrome: urinary frequency, urgency, nocturia with or without leak

Question 53

prevalence of overactive bladder

Answer 53

16% in men and women

Question 54

men have a higher prevalence in what type of overactive bladder?

Answer 54

OAB-dry

Question 55

women have a higher prevalence in what type of overactive bladder?

Answer 55

OAB-wet

Question 56

differential diagnosis for urge urinary incontinence

Answer 56

``` UTI DO Urethral syndrome Urethral divertivulum Interstitial cystitis Bladder cancer Large residual volume ```

Question 57

management for urge urinary incontinence

Answer 57

lifestyle changes: decrease caffeine, smoking cessation, weight loss bladder retraining pelvic floor muscle exercise pharmacotherapy

Question 58

list examples of pharmacotherapy for urge urinary incontinence

Answer 58

anti-cholinergics e.g. e.g. solifenacin, tolterodine, trospium beta-3-agonists e.g. betmiga

Question 59

surgical treatment for urge urinary incontinence

Answer 59

Posterior tibial nerve stimulation (PTNS) Intravesical injection of botulinum toxin A Neuromodulation Clam (augmentation) cystoplasty Urinary diversion is an option if all else fails in very severe cases