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R - Urinary System (Liam Lennox) > Benign Diseases of the Prostate > Flashcards

Benign Diseases of the Prostate Flashcards

1
Q

What is the size of the normal prostate in cc?

A

20cc

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2
Q

What are the zones called that the prostate can be divided into?

A

McNeal’s prostatic zones

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3
Q

What are the 4 McNeal’s prostatic zones called?

A

Transitional zone

Central zone

Peripheral zone

Anterior fibromuscular stroma

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4
Q

What are examples of benign prostatic diseases?

A
  • Benign prostatic enlargement (BPE)
  • Benign prostatic hyperplasia (BPH)
  • Benign prostatic obstruction (BPO)
  • Bladder outflow obstruction (BOO)
  • Lower urinary tract symptoms (LUTS)
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5
Q

What does BPE stand for?

A

Benign prostatic enlargement (BPE

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6
Q

What does BPH stand for?

A
  • Benign prostatic hyperplasia (BPH)
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7
Q

What does BPO stand for?

A
  • Benign prostatic obstruction (BPO)
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8
Q

What does BOO stand for?

A
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9
Q

What does LUTS stand for?

A
  • Lower urinary tract symptoms (LUTS)
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10
Q

What does the Hald diagram show?

A

Symptoms come hand in hand

(LUTS, BOO and BPE)

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11
Q

What is penign prostatic hyperplasia characterised by?

A

Fibromuscular and glandular hyperplasia

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12
Q

What McNeal zone does BPH primarily affect?

A

Transitional zone

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13
Q

BPH is considered to be part of the ageing process in men, what percentage of men at 60 and 85 years experience this?

A

50% of men at 60 years

90% of men at 85 years

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14
Q

What are different ways of assessing LUTS?

A

Symptoms scoring system (IPSS)

Frequency volume charts

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15
Q

What is an example of a symptom scoring system for LUTS?

A

IPSS

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16
Q

Describe the IPSS scoring?

A

MIld 0-7

Moderate 8-19

Severe 20-35

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17
Q

What are the different LUTS symptoms?

A
  • Voiding (obstructive)
    • Hesitancy
    • Poor stream
    • Terminal dribbling
    • Incomplete emptying
  • Storage (irritative)
    • Frequency
    • Nocturia
    • Urgency with or without urge incontinence
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18
Q

What parts of examination are important for BPH?

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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19
Q

What investigations should be done for BPH?

A
  • MSSU
  • Flow rate study
    • If max flow rate (Qmax<10ml/s)
  • 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 PSE raised or abnormal DRE
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20
Q

What bloods should be done for BPH?

A
  • PSA
  • Urea and creatinine (if chronic retention
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21
Q

What max flow rate in a flow rate study indicates BPO?

A

Qmax<10ml/s

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22
Q

What does treatment of BPO depend on?

A

Treatment depends on the type of BPO:

  • Uncomplicated BPO
    • Watchful waiting
    • Medical therapy
      • Alpha blockers
      • 5 alpha reductase inhibitors
        • Finasteride or dutasteride
      • Combination
    • Surgical intervention
      • TURP (prostate size <100cc)
      • Open retropubic or transvesical prostatectomy (prostate size >100cc)
      • Endoscopic ablative procedures
  • Complicated BPO
    • Medical therapy
    • Most patients will require surgery
      • Such as cystolitholapaxy and TURP for patients with BPO and bladder stones
    • Some patients do not require any treatment
    • Alternative treatment options (for 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
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23
Q

What are the 2 different broad categories of BPO?

A

Uncomplicated BPO

Complicated BPO

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24
Q

What is the treatment for uncomplicated BPO?

A
  • Watchful waiting
  • Medical therapy
    • Alpha blockers
    • 5 alpha reductase inhibitors
      • Finasteride or dutasteride
    • Combination
  • Surgical intervention
    • TURP (prostate size <100cc)
    • Open retropubic or transvesical prostatectomy (prostate size >100cc)
    • Endoscopic ablative procedures
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25
Q

What is the medical therapy for uncomplicated BPO?

A
  • Alpha blockers
  • 5 alpha reductase inhibitors
    • Finasteride or dutasteride
  • Combination
26
Q

What surgical intervention can be done for uncomplicated BPO?

A
  • TURP (prostate size <100cc)
  • Open retropubic or transvesical prostatectomy (prostate size >100cc)
  • Endoscopic ablative procedures
27
Q

What determines whether TURP or open prostatectomy us done as surgical intervention for BPO?

A

TURP if prostate size <100cc

Open prostatectomy if prostate size >100cc

28
Q

What is the treatment for complicated BPO?

A
  • Most patients will require surgery
    • Such as cystolitholapaxy and TURP for patients with BPO and bladder stones
  • Some patients do not require any treatment
  • Alternative treatment options (for 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
29
Q

What is some alternative treatment for patients of complicated BPO who are unfit for surgery?

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
30
Q

What is the main medical treatment of LUTS due to BPO?

A

Alpha blockers

31
Q

What is alpha blockers mechanism of action?

A

Smooth muscle of bladder neck (ie 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

32
Q

What are different types of alpha blockers?

A
  • Non selective (ie alpha 1 and 2)
    • Phenoxybenzamine
  • Selective short acting
    • Prazosin, indoramin
  • Selective long acting
    • Alfuzosin, doxazosin, terazosin)
  • High selective (ie alpha 1a)
    • Tamsulosin
33
Q

What do the different types of alpha blockers differ in?

A

All types appear to be equally effective but differences in side effect profiles and pharmacodynamic properties

34
Q

What is 5a-reductase inhibitors mechanism of action?

A

Converts testosterone to dihydrotestosterone

35
Q

What 2 types of 5a-reductase inhibitors are available?

A
  • Finasteride (5AR type II inhibitor)

Dutasteride (5AR type I and II inhibitor

36
Q

What does 5ARIs stand for?

A

5a-reductase inhibitors

37
Q

What are the roes of 5ARIs?

A
  • Reduces prostate size and reduces risks of progression of PE (only if >25cc prostate)
  • Reduces LUTS (but not as effective as alpha blockers)
  • Combination therapy of 5ARIs and 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 cancer prevention
38
Q

Are alpha blockers or 5a-reductase inhibitors more effective for reducing LUTS?

A

Alpha blockers

39
Q

What is TURP?

A

Transurethral resection of prostate

40
Q

What is the gold standard treatment for benign prostate problems?

A

TURP

41
Q

What are some complications of TURP?

A
  • Bleeding
  • Infection
  • Retrograde ejaculation
  • Stress urinary incontinence
  • Prostatic regrowth causing recurrent haematuria
42
Q

What is an alternative new endoscopic ablative procedure to TURP?

A
  • Transurethral laser vaporisation
43
Q

What are some complications of BOO?

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
44
Q

What is acute urinary retention defined as?

A

Defines as “painful inability to void with a palpable and persuasible bladder”

45
Q

What size is the residuals in acute urinary retention?

A

Residuals vary from 500ml to 1L depending on time lag in seeking medical attention

46
Q

Which of acute and chronic urinary retention is painful?

A

Chronic

47
Q

What is the main risk factor for acute urinary retention?

A
  • BPO
    • Can occur spontaneously (ie natural progression of BPO) or triggered by an unrelated event (such as constipation, alcohol excess, post-operative causes or urological procedure)
  • But can also occur independently of BPO
    • Such as UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems
48
Q

What are some events that can trigger BPO to lead to acute urinary retention?

A

Constipation, alcohol excess, post-operative causes or urological procedure

49
Q

What is the immediate treatment of acute urinary retention?

A

Immediate treatment is catheterisation (either urethral or suprapubic), treat underlying trigger if present:

  • If no renal failure start alpha blocker immediately and remove catheter in 2 days
  • If fail to void, recatheterise and organise TURP (after 6 weeks
50
Q

What are complications of acute urinary retention?

A
  • UTI
  • Post-decompression haematuria
  • Pathological diuresis
  • Renal failure
  • Electrolyte abnormalities
51
Q

What is chronic urinary retention defined as?

A

Defined as “painless, palpable and persuasible bladder after voiding”

52
Q

What size is the residual in chronic urinary retention?

A

Patients often able to void but with residuals from 400ml to more than 2L depending on stage of condition (wide spectrum)

53
Q

What is the main risk factor for chronic urinary retention?

A
  • Detrusor underactivity which can be primary (such as primary bladder failure) or secondary (such as due to longstanding BOO, such as BPO or urethral stricture)
54
Q

What is the presentation of chronic urinary retention?

A
  • LUTS or complications (such as UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

Overflow incontinence and renal failure occur at severe end of spectrum:

  • When bladder capacity is reached and bladder pressure is in excess of 25cm water (ie decompensated chronic urinary retention or acute-on-chronic urinary retention or high pressure chronic urinary retention)
55
Q

What can occur at the severe end of the chronic urinary retention spectrum?

A

Overflow incontinence and renal failure occur at severe end of spectrum:

  • When bladder capacity is reached and bladder pressure is in excess of 25cm water (ie decompensated chronic urinary retention or acute-on-chronic urinary retention or high pressure chronic urinary retention)
56
Q

Is treatment always needed for chronic urinary retention?

A

Asymptomatic patients with low residuals do not necessarily need treatment

57
Q

Is there a role for medical therapy in chronic urinary retention?

A

No

58
Q

What is the treatment of chronic urinary retention?

A
  • Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)
  • Complications
    • UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatremia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis)
    • Pathological diuresis features
      • Urine output >200ml/hour and postural hypotension and weight loss and electrolyte abnormalities
    • Manage with IV fluids and monitor closely
    • Subsequent treatment is either long term urethral or suprapubic catheter, CISC or TURP
      • TURP in chronic retention has less successful outcome than for acute, but better outcome for patients with high pressure urinary retention than low pressure urinary retention
59
Q

What are complications of treating chronic urinary retention with catheterisation?

A
  • UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatremia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis)
60
Q

What are the pathological diuresis features as a complication for catheterisation for chronic urinary retention?

A
  • Urine output >200ml/hour and postural hypotension and weight loss and electrolyte abnormalities

R - Urinary System (Liam Lennox) (29 decks)

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