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Additional Urinary Cards > Benign Disease Of The Prostate And Urinary Tract Obstruction > Flashcards

Benign Disease Of The Prostate And Urinary Tract Obstruction Flashcards

1
Q

What is benign prostatic hyperplasia characterised by?

A

fibromuscular and glandular hyperplasia

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2
Q

What area is affected in BPH?

A

Transition zone

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3
Q

What happens in BPH?

A

Disordered regulation of dihydrotestosterone

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4
Q

What is the prevalence of BPH?

A

50% of men at 60 years
90% of men at 85 years

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5
Q

What can occur in BPH?

A

50% of men with BPH have moderate to severe LUTS

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6
Q

What can BPH lead to?

A

Progressive condition resulting in Benign Prostatic Obstruction (BPO) or Bladder Outflow Obstruction (BOO)

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7
Q

What is the scoring system for LUTS?

A

IPSS

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8
Q

What are factors considered in voiding assessment?

A

Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying

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9
Q

What are the factors assessed in storage of LUTS?

A

Frequency
Nocturia
Urgency +/- urge incontinence

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10
Q

What is the scoring of IPSS?

A

Total score (out of 35) :
Mild : 0-7
Moderate : 8-19
Severe : ≥ 20

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11
Q

What is seen in an examination of LUTS?

A

Abdomen
? palpable bladder

Penis
? external urethral meatal stricture
? phimosis

Digital rectal examination (DRE)
assess prostate size
? suspicious nodules or firmness

Urinalysis
? blood
? signs of UTI

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12
Q

What investigation are done for LUTS?

A

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

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13
Q

What are the two typed of BPO?

A

Uncomplicated
Complicated

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14
Q

What is the treatment of BPO?

A

Watchful waiting

Medical therapy
-5 alpha reductase inhibitors (Finasteride or -Dutasteride)
-Alpha blockers
-Combination

Surgical intervention
-TURP (prostate size <100cc)
-Open retropubic or transvesical prostatectomy (prostate size >100cc)
-Endoscopic ablative procedures

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15
Q

What is the main treatment of LUTS due to BPO?

A

Alpha blockers

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16
Q

How do alpha blockers work?

A

Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

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17
Q

What are the types of alpha blockers?

A
  • 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
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18
Q

What do 5a-reductase do?

A

5a-reductase converts testosterone to dihydrotestosterone.

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19
Q

What two drugs are available for 5a-reductase inhibitors?

A
  • Finasteride (5AR Type II inhibitor)
    • Dutasteride (5AR Type I and II inhibitor)
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20
Q

What is the role of 5ARIs?

A
  • 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
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21
Q

What is TURP?

A

Transurethral resection of prostate

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22
Q

What is TURP?

A

gold standard for surgical management of BPE causing BOO (except for prostate size >100cc)

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23
Q

What can TURP be done using?

A

Can be done using glycine (monopolar TURP) or saline (bipolar TURP)

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24
Q

What can TURP help in?

A

Very effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 year)

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25
Q

What are complications of TURP?

A
  • bleeding, infection, retrograde ejaculation, stress urinary
    incontinence, prostatic regrowth causing recurrent haematuria
    or BOO
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26
Q

What prostate size is too large for TURP?

A

> 100 cc

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27
Q

What complication can come from using TURP on too large prostates?

A

high risk of intra-operative or post-operative complications, including:
- bleeding
- fluid overload
- hypothermia
- TUR syndrome (triad of dilutional hyponatraemia, fluid overload and glycine toxicity)

28
Q

What are complication of BPO?

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

29
Q

What is the treatment of complicated BPO?

A

No role for medical therapy (except for acute urinary retention)

Most patients will require surgery
eg. cystolitholapaxy and TURP for patients with BPO and bladder stones

Alternative treatment options (eg. patients 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

30
Q

What is the alternative treatment options for complicated BPO?

A

long term urethral or suprapubic catheterisation
clean intermittent self-catheterisation
may develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI

31
Q

What is acute urinary retention?

A

painful inability to void with a palpable and percussible bladder

32
Q

What is the main risk factor of acute urinary retention?

33
Q

When can acute urinary retention occur?

A

For those with BPO, can occur spontaneously (i.e. natural progression of BPO) or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)

34
Q

What is the immediate treatment of AUR?

A

Catheterisation

35
Q

What are the complications of AUR?

A

UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities

36
Q

What is the treatment of AUR?

A

Treat underlying trigger if present

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)

37
Q

What is chronic urinary retention?

A

painless, palpable and percussible bladder after voiding

38
Q

Is the patient able to void in CUR?

A

Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)

39
Q

What is the main etiological of CUR?

A

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)

40
Q

How does CUR present?

A

Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

41
Q

What occurs at severe ends of the spectrum?

A

Overflow incontinence and renal failure

42
Q

Who does and doesn’t need treatment in CUR?

A

Asymptomatic patients with low residuals do not necessarily need treatment

Patients with symptoms or complications need treatment (but no role for medical therapy!)

43
Q

What is the treatment of CUR?

A

Immediate treatment is catheterisation

Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP

TURP in chronic retention has a less successful outcome than for acute retention; however, patients with high pressure chronic retention has better outcome with TURP than patients with low pressure chronic retention

44
Q

What is the complications of CUR?

A

Complications : UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis

Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities

45
Q

Where do upper tract obstruction occur?

A

PUJ
ureter
VUJ

46
Q

Where do lower tract obstruction occur?

A
  • bladder neck (i.e. primary bladder neck obstruction, in men only)
    - prostate (men only)
    - urethra (e.g. urethral stricture in men and women; pelvic mass causing extrinsic compression of urethra in women)
    - urethral meatus (i.e. meatal stenosis in men and women)
    - foreskin (e.g. phimosis in men only)
47
Q

What are intrinsic causes of PUJ obstruction?

A

PUJ obstruction (scar tissue)
Stone
Ureteric tumour (UCC/TCC)
Blood clot
Fungal ball

48
Q

What are intrinsic causes of ureter obstruction?

A

Stone
Ureteric tumour (UCC/TCC)
Scar tissue
Blood clot
Fungal ball

49
Q

What are intrinsic causes of VUJ obstruction?

A

Stone
Bladder tumour
Ureteric tumour
Prostate cancer

50
Q

What are extrinsic causes of PUJ obstruction?

A

PUJ obstruction (crossing vessel)
Lymph nodes (tumour)
Abdominal mass (tumour)

51
Q

What are extrinsic causes of ureter obstruction?

A

Lymph nodes (tumour, retroperitoneal fibrosis)
Iatrogenic (eg. inadvertently tied off or diathermied during pelvic surgery)
Abdominal/pelvic mass (tumour, pregnant uterus)

52
Q

What are presenting symptoms of upper tract obstruction?

A
  • Pain
  • Frank haematuria
  • Symptoms of complications
53
Q

What are presenting signs of upper tract obstruction?

A
  • Palpable mass
  • Microscopic haematuria
  • Signs of complications
54
Q

What are complications of upper tract obstruction?

A
  • Infection and sepsis
  • Renal failure (only if bilateral obstruction, single kidney or concurrent systemic upset e.g. sepsis, dehydration, nephrotoxicity)
55
Q

What investigations are used for upper tract obstruction?

56
Q

What is seen on USS in UUTO?

A

Hydronephrosis
- Hydroureter

57
Q

What imaging types are used in UUTO?

A

CT-KUB
CT-urogram

58
Q

When is nuclear isotope scan used?

A

Not used in acute setting, nor for stones nor tumour

Used for chronic unilateral upper urinary tract obstruction, esp. chronic PUJ obstruction

59
Q

When is CT - KUB used?

A
  • For investigation of urinary tract stones and obstruction in emergency setting
    • Quick and lower radiation exposure (2-3 milliSieverts)
    • No risk of contrast nephrotoxicity
    • Can be used in renal failure
    • Lower sensitivity for assessing obstructing masses (except for stones)
    • Less useful if ureter and collecting system is undilated
60
Q

When is CT-urogram used?

A
  • Higher radiation exposure (15-20 milliSieverts)
    • Risk of contrast nephrotoxicity and contraindicated in renal failure
    • Higher sensitivity for obstructing masses (e.g. ureteric UCC/TCC, pelvic mass)
61
Q

What is the management of UUTO?

A

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
- e.g. ureteric tumour – radical nephro-ureterectomy
- e.g. PUJ obstruction – laparoscopic pyeloplasty

62
Q

What is the presentation of Lower urinary tract obstruction?

A

Lower urinary tract symptoms
- voiding and storage, and urinary incontinence (overflow or urge)

Acute urinary retention

Chronic urinary retention

Recurrent urinary tract infection and sepsis

Frank haematuria

Formation of bladder stones

Renal failure (only for chronic high-pressure urinary retention)

PV bleeding (for women)

63
Q

What is seen on physical examination of lower urinary tract obstruction?

A

Abdomen
? palpable bladder

Penis
? external urethral meatal stricture
? phimosis

Digital rectal examination (DRE)
assess prostate size
? suspicious nodules or firmness

Per vaginal examination (PV)
? history of PV bleeding
? pelvic mass
Obtain pelvic/transvaginal USS if suspicious for pelvic mass

Urinalysis
? blood
? signs of UTI

64
Q

What investigations are used in LUTO?

A

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; pelvic/transvaginal USS in women if pelvic mass suspected

Flexible cystoscopy if haematuria

Urodynamic studies in selected cases

TRUS-guided prostate biopsy if PSA raised or abnormal DRE

65
Q

What is the Management of Lower Urinary Tract Obstruction in emergency setting

A

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, etc.)

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

Additional Urinary Cards (1 decks)

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