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CMS250 > week 13- LUTS and BPH > Flashcards

week 13- LUTS and BPH Flashcards

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1
Q

Lower Urinary Tract Symptoms (LUTS)

voiding/obstructive sx
postvoid sx
storage/irritative sx

A

voiding/obstructive: hesitancy. straining, prolonged micturition, poor/weak or intermittent stream

post void: dribble, double void, sensation of incomplete bladder emptying

storage/irritative: frequency, urgency, urge incontinence, nocturia

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2
Q

causes of LUTS

A

BPH
urethral strictures
bladder dysfunction
UTI
malignancies
medications
nervous system dysfunction
etc

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3
Q

physical exams for LUTS

A

ab exam
external genital
DRE
neurological: assessment of sphincter
tone, perianal sensation, bulbocavernosus reflex, gait, lower
extremity reflexes

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4
Q

testing for LUTS

A

urinalysis
kidney (BUN, creatinine)
diabetes (glucose, Hba1c)
Prostate specific antigen (PSA) testing

urological testing:
* Cystoscopy
* Postvoid residual volume (PVR) (with bladder scanner or
catheterization)
* Uroflowmetry (assesses average and peak urine flow rates)
* Transrectal ultrasound
* Urodynamic testing

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5
Q

urological consultation/ referral for LUTS

A
  • Failure of LUTS to respond to medical treatment
  • Renal insufficiency
  • Acute or chronic urinary retention
  • Evidence of bladder stone
  • Evidence of hydronephrosis
  • Suspicious digital rectal examination
  • Hematuria
  • Abnormal PSA level
  • Pain with urination
  • Recurrent UTI
  • Palpable bladder on physical examination
  • LUTS with a known neurological disease
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6
Q

Benign Prostatic Hyperplasia (BPH)

when most common

A

men >60yoa

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7
Q

Benign Prostatic Hyperplasia (BPH) sx

A

LUTS

Benign smooth muscle and epithelial cell proliferation within
transition zone of prostate gland → compression of the urethra →
bladder outlet obstruction → lower urinary tract symptoms
(commonly nocturia, poor stream, hesitancy, prolonged micturition)

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8
Q

definitions
benign prostatic hyperplasia
benign prostatic hypertrophy
benign prostatic enlargement
benign prostatic obstruction

A
  • Benign prostatic hyperplasia (BPH) – increase in total of number of cells within the prostate transition zone
  • Benign prostatic hypertrophy – increase in size of individual prostatic cells
  • Both lead to benign prostatic enlargement (BPE)
  • Benign prostatic obstruction (BPO) results from BPE obstructing the bladder neck (in the absence of prostate cancer)
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9
Q

risk factors for BPH

A
  • Age
  • Genetic predisposition
  • Obesity
  • Diabetes and antidiabetic medications
  • Metabolic syndrome
  • Dietary factors (excessive alcohol ingestion, heavy caffeine
    intake, high dose supplemental vitamin C)
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10
Q

BPH physical exam

A

DRE: smooth, firm/rubbery, elastic enlargements of prostate gland (Ddx: induration in prostate cancer)

focused neurological exam

ab exam

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11
Q

American Urological Association (AUA)
Symptom Index aka International Prostate
Symptom Score (IPSS)

questions for prostate

A

how often not complete voiding?
how frequent do urinate?
stop and start when voiding?
cant postpone urination?
weak stream?
strain?
nocutira?

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12
Q

American Urological Association (AUA)
Symptom Index aka International Prostate
Symptom Score (IPSS)

scores for BPH

A
  • Score 0-7 = mild symptoms
  • Score 8-19 = moderate symptoms
  • Score 20-35 = severe symptoms
  • Symptom score ≥ 8 suggests BPH treatment should be initiated/increased/modified to provide additional relief
  • Severe symptom score may require surgical intervention
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13
Q

AUA Symptom Index / IPSS

good for diagnosing bladder outlet obstruction?

A

LR+ of around 1 - 1.5

not good for BPH diagnosis
-Lacks specificity for identifying other causes for LUTS and bladder outlet obstruction
but can help see treatment response

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14
Q

BPH evaulation

A

urinalysis
serum PSA
postvoid residual volume
urine flow studies

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15
Q

BPH complications

A
  • Acute or chronic urinary retention
  • Urinary tract infections due to incomplete bladder emptying
  • Bladder calculi
  • Hematuria
  • Elevated PSA levels (not related to prostate cancer)
  • Long-term untreated BPH
    –>* Chronic high-pressure retention leading to hydronephrosis
    and acute kidney injury (potentially life-threatening)
    –>* Permanent changes to bladder detrusor muscle
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16
Q

BPH treatment

A

watching
lifestyle
behavioural (keels, timed voiding)

medical: alpha blockers for prostatic smooth muscle, 5 alpha reductase inhibitors to reduce prostate volume, foley catheterization

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17
Q

gold standard surgery for BPH

A

transurethral resection of the prostate (TURP)

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18
Q

BPH indications for referral

A

1) suspicion of urinary retention,
2) need for further evaluation (e.g., cystoscopy) or surgical intervention,
3) patient is dissatisfied with current medical treatment

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19
Q

DDX for BPH is

A

prostate cancer
prostatitis

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20
Q

prostate cancer (males >50yoa) risk facrors

A

age, African descent, high dietary fat, family history, positive BRCA
mutation

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21
Q

prostate cancer sx

A

Storage and voiding symptoms, erectile dysfunction

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22
Q

DRE of prostate cancer

A

hard irregular nodule or diffuse dense induration

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23
Q

PSA in prostate cancer

Study These Flashcards
A

Increased total PSA with decreased fraction of free PSA

24
Q

histology of prostate cancer

Study These Flashcards
A

Gleason grade (glandular architecture)

25
dx of prostate cancer via
diagnosed by increased PSA and subsequent needle core biopsies (transrectal, ultrasound-guided)
26
late stages and metastases in prostate cancer
* Late stages → osteoblastic metastases in bone → low back pain, increased serum ALP and PSA * Metastasis to spine via Batson (vertebral) venous plexus
27
treatment for prostate cancer
watchful waiting, active surveillance (serial PSA, DRE, biopsies), brachytherapy, external beam radiation therapy (EBRT), radical prostatectomy (RP)
28
prostatitis sx
* Dysuria, frequency, urgency, low back pain * Warm, tender, enlarged prostate
29
acute bacterial prostatitis most common causes and signs
* In older males: caused by organisms that typically cause UTI (E. coli (80%), Staphylococcus saprophyticus, Entercoccus, Klebsiella, Proteus, Pseudomonas) * In young males: Chlamydia trachomatis, Neisseria gonorrhoeae * Systemic signs: fever, chills, malaise
30
chronic prostatitis causes and sx
* Bacterial or non-bacterial (nerve problems, chemical irritiation) * No systemic signs
31
differentiate between acute bacterial vs chronic prostatitis
acute bacterial: fever, chills, malaise chronic: no systemic signs
32
treat prostatitis w
antibiotics
33
urinary tract obstruction symptoms
variable... * May see incontinence, dribbling, decreased urine output, hematuria * e.g., flank pain with upper ureteral or renal pelvic lesions vs. pelvic pain (can radiate to groin, testicle, labium) with lower urinary tract obstruction * e.g., complete obstruction can lead to anuria (<100 mL of urine/day) vs. partial obstruction can lead to normal/increased urine output * e.g., may be painful if acute vs. painless if chronic
34
urinary tract obstruction causing AKI
if bilateral kidneys effected
35
most common cause of obstructive AKI
prostatic enlargment
36
urinary tract obstruction causing AKI
Obstruction can lead to type 4 renal tubular acidosis with hyperkalemia due to tubular injury
37
evaluation of urinary tract obstruction
best: renal ultraound noncontrast CT scan postvoid residual volume (increased if obstruction in urethra or normal if obstruction is proximal to bladder)
38
urinary tract obstruction management
relieve obstruction immediately (catheter, nephrostomy) and long term i.e. surgery for underlying cause low threshold for ND referral can recover kidney function if relieve urethral obstruction in 1 week; if not then have fibrosis and atrophy and lose function
39
urinary inconsistence
Involuntary leakage of urine * Incontinence is a symptom, not a diagnosis most common when older in women
40
different types of urinary incontinence
urge, detrusor disinhibition, stress, overflow, functional, mixed
41
urge inconteinece mechanism
Involuntary detrusor contractions before bladder is full → sensation of urgently need to void → contractions exceed bladder outlet resistance → involuntary leakage of urine
42
cause of urge incontiennce
idiopathic overactive bladder (aka detrusor hyperreflexia), benign prostatic hypertrophy, local bladder or urethral irritation (e.g., urinary tract infection, cystitis, urethritis, bladder stones, fecal impaction, other bladder irritants)
43
detrusor disinhibition/ neurogenic detrusor overactivirty
Involuntary leakage of urine caused by spontaneous triggering of spinal reflex voiding mechanism when bladder reaches a threshold volume and there is inadequate inhibition of bladder contractions by the central nervous system
44
stress incontiennce
Involuntary leakage of urine caused by increase in intra-abdominal pressure (as produced by a cough, sneeze, laughing, standing up or heavy lifting) caused by weakness of the pelvic floor (e.g., hysterectomy, pelvic floor surgery/injury, multiple vaginal births, obesity), incompetent sphincter (e.g., urethral instrumentation, transurethral resection of the prostate)
45
overflow incontinence
Urinary retention → pressure in bladder exceeds outlet/sphincter resistance → involuntary leakage of urine until bladder pressure drops below outlet resistance caused by bladder outlet obstruction (e.g., benign prostatic hypertrophy, urethral stricture, surgical overcorrection of stress incontinence, cystocele, fecal impaction), ineffective detrusor contractions (e.g., pelvic irradiation, autonomic dysfunction), diabetic neuropathy, spinal stenosis, neurodegenerative diseases, detrusor hyperactivity with impaired contractile function (DHIC), detrusor-sphincter dyssynergy
46
Detrusor Hyperactivity with Impaired Contractility (DHIC)
Subtype of overflow incontinence found mainly in elderly * Detrusor contractions are ineffective despite an overactive bladder → bladder distention → pressure in bladder exceeds outlet/sphincter resistance → involuntary leakage of urine until bladder pressure drops below outlet resistance
47
Detrusor-Sphincter Dyssynergy
Subtype of overflow incontinence * Multiple sclerosis or other conditions causing suprasacral spinal cord lesions → failure to synchronize bladder contractions with release of sphincter → urinary retention → pressure in bladder exceeds outlet/sphincter resistance → involuntary leakage of urine until bladder pressure drops below outlet resistance
48
functional incontinence
Incontinence despite a normally functioning bladder due to inability to reach a toilet in time caused by conditions causing immobility, environmental barriers (e.g., restraints or bedrails), excessive sedation, psychological disorder (e.g., refusal to go to toilet, indifference to wetting self), diuretics, metabolic disorders causing polyuria (e.g., hyperglycemia, hypercalcemia)
49
evaluate incontiennce
loss of urine when standing or when intra ab pressure -->consider incompetent urethral sphincter or sever pelvic floor prolapse continuous leakage, cant urinate when bladder full --> consider severe urinary retention with overflow leak when cough or sneeze --> consider stress incontiennce no warning, urine just comes out --> consider detrusor disinhibition etcccc slide 45- 49
50
if old or disabled and urinary inconteince is new or wrosening (possible functional or cognitive changes too)
consider UTI or other infection, acute metabolic disturbance, stroke, myocardial infarction or other acute medical condition
51
potential contributing factors to incontinece
obstetric (baby deliveries), pelvic trauma or surgery, vaginal prolapse, prostate surgery fluid intake, diabetes, CHF, meds, bowels or sex, mental status
52
****slide 46 onwards to like 52
53
Overactive Bladder Symptom Score (OABSS) for which 4 symptoms
* Daytime frequency * Nighttime frequency * Urgency * Urge incontinence
54
Overactive Bladder Symptom Score (OABSS) max score
15
55
prognosis of incontinence
Good prognosis with acute UI related to reversible causes
56
management for incontinence
* For urge incontinence and stress incontinence: * Bladder retraining exercises * Topical estrogens may improve mild UI * Anticholinergic medications for urge incontinence * Surgical interventions and artificial sphincters for severe UI due to pelvic floor dysfunction or sphincter incompetence

CMS250 (31 decks)

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