Urology Flashcards
BPH/ prostate cancer. Hydrocele/ epididymitis/ orchitis/ testicular cancer (tumour markers). Haematuria, renal tract tumours and stones. Testicular torsion.
What is benign prostatic hyperplasia?
- A histological diagnosis.
- Benign enlargement of prostate [transitional zone of prostate]
- Common- over twenty percent of males over seventy
- May be associated with urinary symptoms, due to resulting in bladder outflow obstruction
What are the different types of lower urinary tract symptoms?
> Poor flow- BOO- bladder outflow obstruction (BPH).
Voiding symptoms (obstructive):
- hesitancy,
- intermittency,
- poor stream,
- incomplete emptying,
- straining
Detrusor muscle works harder to compensate- hypertrophy
> Strong flow- detrusor overactivity- overactive bladder
Storage symptoms (irritative):
- frequency
- urgency
- nocturia
Define lower urinary tract symptoms (LUTS).
Non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding).
Define benign prostatic enlargement (BPE).
CLINICAL finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia.
Define bladder outflow obstruction (BOO).
Bladder outlet obstruction caused by benign prostatic enlargement (clinical finding).
Define benign prostatic hyperplasia (BPH).
Properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction.
What are the risk factors for BPH?
- Age
- Obesity
- Androgens
- Functional androgen receptors
- Diabetes (&elevated fasting glucose)
- Dyslipidaemia
- Genetic
- Afro-Caribbean
What are the important aspects of a BPH history and examination?
- LUTS.
- IPSS questionnaire.
- FREQUENCY VOLUME CHART- objective
- Haematuria
- Dysuria.
- Full medical history (co-morbidities [eligible for surgical treatment or not?], drug history and family history).
- Examination of abdomen (is bladder palpable?).
- DRE.
What are the important investigations to order for BPH?
Urine dipstick (exclude infection).
Flow rate [if in hospital- bad if below 12ml/sec] + post void residual bladder scan in clinic.
Blood tests (U&E, PSA, need to counsel patient).
? Renal tract ultrasound.
? Flexible cystoscopy.
What is the management plan for patients with voiding symptoms/ BPH?
Conservative management:
Reassure
Fluid intake advice (reduce evening fluid intake).
Medical management:
alpha blockers (tamsulosin, alfuzosin)
5-alpha-reductase inhibitors (finasteride, dutasteride).
[alpha-blockers= relax smooth muscle,
5-alpha-reductase inhibitors= shrink prostate [add if prostate size more than thirty ml, slower acting- weeks/months instead of two days]
Surgical management:
TURP (transurethral resection of prostate)
- Seventy percent resolve
Alternatives include laser surgery, rezum/steam [atrophy of prostate], urolift [staples prostate], embolization [cause ischaemia of prostate], catheter options.
If unsuitable/unwilling for surgery- can catheterise for urinary retention- indwelling, self catheterise, suprapubic
What is the treatment for overactive bladder/ storage symptoms?
Conservative management:
reassure
[treat triggering UTI]
dietary advice- cut out caffeine/citrus fruit
bladder retraining exercises (NICE recommended)- 6 weeks
Medical management:
anticholinergics (oxybutinin, detrusitol, solifenacin)
Beta agonists- betmiga [less side effects]
Surgical management:
intravesical botox injection [if botox too strong- need to self catheterise- lasts 6 months]
bladder augmentation
urinary diversion/conduit.
Case 1: 70y/o man presents with inability to pass urine for 10hrs. Previous history of BPH (on tamsulosin and finasteride). Pain. How do you assess and manage this patient? a) give analgesia b) advise the patient to drink less, especially in evening c) start an alpha blocker d) catheterise patient e) advise TURP surgery
d] Catheterise patient
How should you proceed in the case of a patient with urinary retention?
Catheterise.
Dipstick/CSU - infection
FBC, U and E - renal failure-back pressure on kidneys
Measure residual urine- bladder scan
Neurological examination if necessary.
DRE- check for constipation
ADMIT IF ABNORMAL U+E
Prescribe: antibiotics, laxatives, alpha blocker if necessary.
What are the different types of urinary retention?
Acute retention (AUR) = painful.
Chronic retention (CUR) = postvoid residual >800mL- gradual increase over months and years.
Acute on chronic.
Can all be either high pressure or low pressure
How is low pressure urinary retention (LPR) managed?
Normal U and Cr, no hydronephrosis.
Consider starting alpha blockers.
Trial without catheter (TWOC).
How is high pressure urinary retention (HPR) managed?
Admit to hospital
Raised U and E; Cr, bilateral hydronephrosis.
Measure UO, BP, body weight.
Only 10% need IV fluid replacement- if more than 200ml/hr urine output Never TWOC.
BOO surgery or longterm catheter.
Case 2: 67y/o male. Urgency, frequency, poor flow. DRE 40g BPE. PSA 1.2 MSU -ve. US normal, postovoid residual 40mL. What do you prescribe? a) alpha blocker b) 5-alpha-reductase inhibitor c) anticholinergic
Alpha blocker [+5 alpha reductase inhibitor-large prostate] Anticholinergic can be added later to address urgency- not immediately b/c could cause urinary retention- relax detrusor activity + already obstructed flow
What are the presenting symptoms of prostate cancer?
Asymptomatic; raised PSA.
LUTS- sometimes
Urinary retention/ renal failure.
(Pelvic pain).
Haematuria.
Bone pain/ weight loss/ spinal cord compression (metastases).
What are the risk factors for prostate cancer?
Age
Race (Afro-Caribbean)
Family history (2 1st degree relatives)
BRCA 2 gene.
What are the causes of raised PSA (prostate specific antigen)?
BPH.
Urinary retention.
Urinary infection.
Catheterisation/ instrumentation of urethra.
Prostate cancer.
DRE is not a significant risk factor.
How do you assess a patient with suspected prostate cancer? What are the investigations needed in prostate cancer?
Counselling.
History: LUTS? bone pain? weight loss? blood in urine?
Family history.
Examination.
DRE!
Check PSA.
MRI: can differentiate between high risk and low risk prostate cancer-PIRADS classification 1-5.
TRUS {transrectal ultrasound guided] biopsy- Gleason Score [high risk if above four]
Take multiple samples
(risk of infection, bleeding- so can also do transperineal, template, or saturation biopsy).
How is prostate cancer histologically analysed?
Grading: Gleason score.
Low risk 3+3, high risk 5+5.
Staging: TNM- MRI/bone scan.
[t2 confined to prostate, common mets=lymph nodes, bone]
Case 3: 70y/o man referred by GP with PSA 18ug/L (upper limit 7.2). How are you going to assess?
Pick 2.
a) repeat PSA and check MSU
b) organise MRI prostate and TRUS biopsies
c) explain likely diagnosis of prostate cancer
d) advise radical prostatectomy or radiotherapy
Repeat PSA and check MSU.
Then: Organise MRI prostate and TRUS biopsies.
What is the management plan for a patient with prostate cancer?
Active surveillance (low risk low volume disease) - offered treatment if worsens
Surgery: radical prostatectomy - remove prostate completely + join bladder to urethra via anastomosis - (robotic or laparoscopic).
Radical radiotherapy- better for older patients
[Surgery and radiotherapy have similar outcomes]
Watchful waiting (elderly/comorbid patient).
Hormones- only useful if metastases- shrinks cancer by reducing testosterone- works for a few months
Chemotherapy.
