Benign Diseases of the Prostate Flashcards
What is the average size of the prostate gland in men aged 25-30 years?
20cc
What are the McNeal’s prostatic zones?
Transition, central, peripheral and anterior fibromuscular
What are some benign prostate diseases?
Benign prostate enlargement - BPE
Benign prostate hyperplasia - BPH
Benign prostatic obstruction - BPO
Benign outflow obstruction - BOO
Lower Urinary Tract Symptoms - LUTS
What 3 benign diseases can be linked together?
LUTS
Bladder outflow obstruction
Benign prostatic enlargement
Describe benign prostatic hyperplasia
Characterised by fibromuscular and glandular hyperplasia
Predominantly affects transition zone
Disordered regulation of dihydrotestosterone
Part of ageing process in men - 50% at 60 yrs and 90% at 85yrs
What does BPH present as?
50% have moderate to severe LUTS
Progressive condition can result in BPO or BOO
How is LUTS assessed?
Symptoms scoring systems - IPSS total score is out of 35
Frequency volume charts
What are the LUTS - voiding?
Hesitancy, poor system, terminal dribbling, and incomplete emptying
What are the LUTS - irritative?
Nocturia, frequency, urgency and possible urge incontinence
What is included in the physical examination?
Abdomen - palpable bladder
Penis - external urethral meatal stricture and phimosis
Digital rectal exam - assess prostate size and suspicious nodules and firmness
Urinalysis - blood and signs of UTI
What investigations are done?
MSSU, flow rate study, post-void bladder residual USS, bloods - PSA, urea and creatinine, renal tract USS, flexible cystoscopy if haematuria, urodynamic studies and TRUS guided prostate biopsy if PSA raised
What are the types of BPO?
Uncomplicated BPO - no complications
Complicated BPO
What is the treatment for uncomplicated BPO?
Watchful waiting if mild symptoms
Medical therapy - 5 alpha reductase inhibitors, alpha blockers and combo. therapy
Surgical intervention
What is the surgical intervention for uncomplicated BPO?
TURP - prostate size is less than 100cc
Open retropubic or trans vesical prostatectomy
Endoscopic ablative procedures
Describe alpha blockers
Main treatment for LUTS due to BPO
Smooth muscle of bladder neck and prostate innervated by sympathetic alpha adrenergic nerves
Cause smooth muscle relaxation and antagonise dynamic element to prostatic obstruction
What are the types of alpha blockers?
Non selective - phenoxybenzamine
Selective short acting - prazosin and indoramin
Selective long acting - alfuzosin, doxazosin and terazosin
Highly selective - Tamsulosin
Equally effective but different side profiles
Describe 5a reductase inhibitors
Converts testosterone to dihydrotestosterone
2 drugs available - finasteride and dutasteride
Combo. of 5ASI and alpha blocker is most effective in reducing risk of progression of BPE
What are the roles of 5ARIs?
Reduces size of prostate and reduces risk of progression of BPE
Also reduces LUTS but no as effective as alpha blockers
Can reduce prostatic vascularity and haematuria
Potential role in prostate cancer prevention
What is the gold standard for surgical management of BPE causing BOO?
TURP - transurethral resection of prostate
Describe TURP
Transurethral resection of the prostate
Can be done using glycine or saline
Very effective in relieving symptoms and improves dynamic parameters
What are the complications of TURP?
Bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO
What prostate size is TURP used?
> 100cc is too large for TURP - high risk of bleeding, fluid overload, hypothermia and TUR syndrome
What is TUR syndrome?
Triad of dilutional hyponatraemia, fluid overload and glycine toxicity
What are the complications of BPO?
Progression of LUTS, acute and chronic urinary retention, urinary incontinence, UTI, bladder stone and renal failure from obstructed ureteric outflow
What is the treatment for complicated BPO?
No role for medical therapy except acute urinary retention
Most patients require surgery
What are some alternative treatment options for complicated BPO?
Long term urethral or suprapubic catheterisation
Clean intermittent self-catheterisation
Can develop catheter problems, blockages, frank haematuria and recurrent UTIs
What is the definition of acute urinary retention?
Painful inability to void with a palpable and percussable bladder
Residuals vary from 500ml-1l
What is the immediate treatment of acute urinary retention?
Catheterisation
If no renal failure then start on alpha blocker immediately and remove catheter in 2 days
What are the complications of acute urinary retention?
UTI, post-decompression haematuria, pathological diuresis, renal failure and electrolyte abnormalities
What is the definition of chronic urinary retention?
Painless, palpable and precussible bladder after voiding
Patients often void and have residuals with 400ml-2l
What is the main aetiological factor for chronic urinary retention?
Detrusor muscle underactivity
How does chronic urinary retention present?
LUTS or complications
Outflow obstruction and renal failure occur at severe stage
What is the treatment for chronic urinary retention?
No treatment for asymptomatic
Symptoms and complications - catheterisation
Long term is TURP or CISC
What are the complications of chronic urinary retention?
UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities and persistent renal dysfunction
What are the features of pathological diuresis?
Urine output more than 200ml/hr, postural hypertension, weight loss and electrolyte abnormalities
What are some absolute indications for surgical intervention in patients with BPO?
Refractory acute urinary retention
Renal failure
Recurrent UTI
Failure of medical therapy to control symptoms
What are common causes of acute urinary retention in men?
Spinal cord decompression
UTI
Constipation
Pain from laparotomy wound
Short term urethral catheters should not be left in-situ for longer than?
4 weeks
Long term urethral catheters should not be left in-situ for longer than?
12 weeks
