Benign Disease of The Prostate and Urinary Tract Obstruction Flashcards
How big is an unenlarged prostate?
20 cc
What are the different parts of the prostate?
What are does benign prostatic hyperplasia affect?
Predominantly affects the transition zone
Characterised by fibromuscular and glandular hyperplasia
Who does benign prostatic hyperplasia affect?
•Part of aging process in men :
- 50% of men at 60 years
- 90% of men at 85 years
- 50% of men with BPH have moderate to severe LUTS
- Progressive condition resulting Bladder Outflow Obstruction (BOO)
What is the prostate symptom score sheet based on?
Incomplete emptying
Frequency
Intermittency
Urgency
Weak Stream
Straining
Nocturia
What are the voiding (obstructuve LUTs)?
- Hesitancy
- Poor stream
- Terminal dribbling
- Incomplete emptying
What are the storage (irritative) LUTs?
Frequency
Nocturia
Urgency +/- urge incontinence
What physical examinations are possible for BPH?
Abdomen - palpable bladder
Penis - External urethral meatal stricture, phimosis
Digital rectal examination - assessment of the prostate size, suspicious nodules or firmness
Urinalysis - blood, signs of UTI
What are the relevant investigations for Benign Prostate Hypertrophy?
•MSSU
- Flow rate study
- 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 haematuria
- Urodynamic studies in selected cases
- TRUS-guided prostate biopsy if PSA raised or abnormal DRE
What are the two categories of BPO?
Uncomplicated
Complicated
What is the treatment of uncomlpicated BPO?
•Watchful waiting
•Medical therapy
– Alpha blockers
–5 alpha reductase inhibitors (Finasteride or Dutasteride)
–Combination
•Surgical intervention
–TURP (prostate size <100cc) (transurethral resection of the prostate)
–Open retropubic or transvesical prostatectomy (prostate size >100cc)
–Endoscopic ablative procedures
What is the function of alpha blockers?
•Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction
Here are some types of alpha blockers
non-selective (i.e. alpha 1 and 2) : phenoxybenzamine
- selective short acting : prazosin, indoramin
- selective long acting : alfuzosin, doxazosin, terazosin
- highly selective (i.e. alpha-1a) : tamsulosin
•All a-blockers appear to be equally effective but differences in side effect profiles and pharmacodynamic properties
What is the function of 5a reductase inhibitors?
Converts testosterone to dihydrotestosterone
•Role of 5ARIs :
- reduces prostate size and reduces risks of progression of BPE
(but only if >25cc prostate)
- also reduces LUTS (but not as effective as alpha blockers)
- combination therapy of 5ARIs + alpha blockers most effective
in reducing risk of progression of BPE
- can also reduce prostatic vascularity and hence reduces
haematuria due to prostatic bleeding
- potential role in prostate cancer prevention
What is the gold standard for surgical intervention of BPH?
TURP
What are complications of TURP?
bleeding, infection, retrograde ejaculation, stress urinary
incontinence, prostatic regrowth causing recurrent haematuria
or BOO
What are the complications of BPO?
Progression of LUTS
Acute urinary retention
Chronic urinary retention
Urinary incontinence (overflow)
UTI
Bladder stone
Renal Failure from ibstructed ureteric outflow due to high bladder pressure
What is the treatment of complicated BPO?
Most require surgery - cystolitholapaxy and TURP for patients with BPO and bladder stones
If unfit for surgery:
- urethral / suprapubic cathaterisation
- CISC (Clean intermittent self-cathaterisation)
What are the complications of cathaterisation?
Catheter trauma, blockages, frank haematuria or recurrent UTI
What is acute urinary retention?
Painful inability to void with a palpable and percussible bladder
What are the causes of acute urinary retention?
BPO (main risk factor)
UTI, urethral stricture, alcohol excess, post - operative causes
What is immediate treatment of acute urinary retention?
- Immediate treatment is catheterisation (either urethral or suprapubic)
- If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)
What are complications of acute urinary retention?
UTI
Post decompression haematuria
Pathological diuresis
Renal failure
Electrolyte abnormalities
What is chronic urinary retention defined as?
Painless, palpable and percussable bladder after voiding
What is the main aetiological factor for chronic urinary retention?
•Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)
What does chronic urinary retention present with?
LUTS
Complications (e.g. UTI, bladder stones, overflow incontinence, post - renal or obstructive renal failure) or incidental finding
What are complications of chronic urinary retention?
UTI
Post decompression haematuria
Pathological diuresis
Electrolyte abnormalities
Renal dysfunction - as a result of acute tubular necrosis
What are the electrolyte abnormalities seen in chronic urinary retention?
Hyponatraemia
Hyperkalaemia
Metabolic acidosis
What are the features of pathological diuresis?
•Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities
What is the longer term treatment for chronic urinary retention?
•Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP
What are the types of urinery tract obstruction?
•Upper tract (i.e. supra-vesical)
- PUJ
- ureter
- VUJ
•Lower tract (i.e. bladder outflow obstruction)
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin (e.g. phimosis)
What are the intrinsic causes of upper tract obstruction?
PUJ, ureter and VUJ:
Stone
Ureteric tumour
PUJ and ureter: blood clot and fungal ball
What are the extrinsic causes of upper tract obstruction?
PUJ - PUJ obstruction by crossing vessel, lymph nodes, abdominal mass
Ureter - Lymph nodes, abdominal / pelvic mass, iatrogenic
VUJ - cervical tumour, prostate cancer
What is the presentation of upper tract obstruction?
Symptoms: Pain, frank haematuria, symptoms of complications
Signs: Palpable mass, microscopic haemauria, signs of complications
What are the complications of upper tract obstruction?
Infection and sepsis
Renal failure
What is management of upper urinary tract obstruction?
•Resuscitation
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
- Investigations (including imaging)
- Emergency treatment of obstruction (for unremitting pain or complications)
- Percutaneous nephrostomy insertion OR
- Retrograde stent insertion
•Definitive treatment of obstruction
- Treat underlying cause
- e.g. stone – ureteroscopy and laser lithotripsy +/- basketing or ESWL - Extracorpeal shockwave lithotripsy
- e.g. ureteric tumour – radical nephro-ureterectomy
- e.g. PUJ obstruction – laparoscopic pyeloplasty
pyeloplasty - Pyeloplasty is the surgical reconstruction or revision of the renal pelvis to drain and decompress the kidney
Define nephrostomy
Urinary diversion from the kidney to the skin
How is nephrostomy carried out?
- Usually under LA + sedation
- US or xray guidance
What is the presentation of lower tract obstruction?
•Lower urinary tract symptoms
- including urinary incontinence
- Acute urinary retention
- Chronic urinary retention
- Recurrent urinary tract infection and sepsis
- Frank haematuria
- Formation of bladder stones
- Renal failure
What is the difference between acute and chronic urinary retention in patient presentation?
Acute - Can’t pee, in agony, creatinine - 70
Chronic - Peeing fine, pain free, creatinine - 170
What is the management for lower tract obstruction?
•Resuscitation
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
- Investigations (including imaging: Bladder scan, USS renal tract)
- Emergency treatment of obstruction (for unremitting pain or complications)
- Urethral catheterisation OR
- Suprapubic catheterisation
•Definitive treatment of obstruction
- Treat underlying cause
- e.g. BPE – TURP
- e.g. Urethral stricture – Optical urethrotomy
- e.g. Meatal stenosis – Meatal dilatation
- e.g. Phimosis – Circumcision
What is decompression haematuria?
Shearing of small vessels due to differing compliance of tissue layers
Usually self - liiting
What is post obstructive diuresis
Postobstructive diuresis. Postobstructive diuresis is a polyuric state in which copious amounts of salt and water are eliminated after the relief of a urinary tractobstruction. In most patients, the diuresis will resolve once the kidneys normalize the volume and solute status and homeostasis is achieved.
