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Urinary System > Benign Diseases of the Prostate > Flashcards

Benign Diseases of the Prostate Flashcards

1
Q

What does BPE stand for?

A

Benign prostatic enlargement

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2
Q

What does BPH stand for?

A

Benign prostatic hyperplasia

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3
Q

What does BPO stand for?

A

Benign prostatic obstruction

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4
Q

What does BOO stand for?

A

Bladder outflow obstruction

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5
Q

What does LUTS stand for?

A

Lower urinary tract symptoms

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6
Q

What is BPH characterised by?

A

Fibromuscular and glandular hyperplasia

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7
Q

What area is predominantly affected by BPH?

A

Transition zone

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8
Q

What is the incidence of BPH?

A

50% of men at 60 years and 90% of men at 85 years will be affected

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9
Q

What percentage of men with BPH will have moderate-to-severe LUTS?

A

50%

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10
Q

What does BPH result in?

A

Bladder outflow obstruction

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11
Q

How are LUTS assessed?

A

Symptom scoring system - IPSS
Frequency-volume charts
Determine whether voiding (obstructive) LUTS or storage (irritative) LUTS

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12
Q

What are the voiding LUTS?

A

Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying

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13
Q

What are the storage LUTS?

A

Frequency
Nocturia
Urgency +/- urge incontinence

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14
Q

What physical examinations might be indicated when investigating BPH?

A

Abdomen - palpable bladder
Penis - external urethral meatal stricture, phimosis
DRE - assess prostate size, any suspicious nodules and firmness
Urinalysis - any blood/signs of UTI

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15
Q

What investigations might be indicated for BPH?

A

MSSU
Flow rate study
Post-void bladder residual USS
Bloods - PSA, urea and creatinine if chronic retention
Renal tract USS if renal failure/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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16
Q

What does the treatment of BPH depend on?

A

Whether it is complicated or uncomplicated

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17
Q

What are the treatment methods for uncomplicated BPO?

A

Watchful waiting
Medical therapy
Surgical intervention

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18
Q

What medical therapy is available for treatment of uncomplicated BPO?

A

Alpha blockers
5-alpha reductase inhibitors e.g. finasteride or dutasteride
Combination

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19
Q

What are the surgical options for treatment of uncomplicated BPO?

A

TURP, when prostate size < 100cc
Open retropubic or transvesical prostatectomy, when prostate size > 100cc
Endoscopic ablative procedures

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20
Q

What is the main treatment for LUTS due to BPO?

A

Alpha blockers

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21
Q

How do alpha blockers work?

A

Smooth muscle of the bladder neck (intrinsic urethral sphincter) and prostate are innervated by sympathetic alpha-adrenergic nerves
Alpha blockers cause smooth muscle relaxation and antagonise the dynamic element to prostatic obstruction

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22
Q

Give an example of a non-selective alpha blocker (1 and 2)

A

Phenoxybenzamine

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23
Q

Give an example of a selective short-acting alpha blocker

A

Prazosin

Indoramin

24
Q

Give an example of a selective long-acting alpha blocker

A

Alfuzosin
Doxazosin
Terazosin

25
Q

Give an example of a highly selecting alpha 1a blocker

A

Tamsulosin

26
Q

All alpha blockers appear to be equally effective, but there are differences in what?

A

Side effect profiles and pharmacodynamic properties

27
Q

How do 5-alpha reductase inhibitors work?

A

Convert testosterone to dihydrotestosterone
Reduces prostate size and the risk of progression of BPE (if prostate > 25cc)
Also reduces LUTS, but not as effectively as alpha blockers
Can also reduce prostatic vascularity and hence reduce haematuria due to prostatic bleeding

28
Q

What are the 5-alpha reductase inhibitors currently available?

A

Finasteride (5AR type II inhibitor)

Dutasteride (5AR type I and II inhibitor)

29
Q

What is the most effective treatment for reducing the risk of progression of BPE?

A

Combination therapy of 5ARIs and alpha blockers

30
Q

What is TURP?

A

Transurethral resection of prostate

31
Q

What is the gold standard surgical treatment for BPH?

32
Q

How effective is TURP?

A

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

33
Q

What are the potential complications of TURP?

A 
Bleeding
Infection 
Retrograde ejaculation 
Stress urinary incontinence
Prostate regrowth causing recurrent haematuria or BOO
34
Q

What are the alternative new endoscopic ablative procedures available?

A

Transurethral laser vaporisation
Transurethral holmium laser enucleation of prostate (HoLEP)
Transurethral needle ablation of prostate using RFA
Transurethral microwave therapy of prostate

Most have lack of long-term efficacy or lack of long-term data

35
Q

What are the potential complications 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
36
Q

What are the treatment options for complicated BPO?

A

Medical therapy
Most will require surgery
Some do not need any treatment, especially if residuals are relatively low, asymptomatic and no complications

37
Q

What are the alternative treatment options for complicated BPO available for patients unfit for surgery/medical therapy?

A

Long-term urethral or suprapubic catheterisation

Clean intermittent self-catheterisation

38
Q

What are the possible complications of the alternative treatments for complicated BPO?

A 
Difficult catheterisation
Catheter trauma 
Blockages
Frank haematuria
Recurrent UTI
39
Q

What is acute urinary retention?

A

Painful inability to void with a palpable and percussible bladder

40
Q

What is the variation in residuals in acute urinary retention?

A

Vary from 500ml to > 1 litre, depending on time lag in seeking medical attention

41
Q

What is the main risk factor for acute urinary retention?

A

BPO, but it can also occur independently e.g. UTI, urethral stricture, alcohol excess, post-op causes, acute surgical or medical problems

42
Q

In patients with BPO, how might acute urinary retention occur?

A

Spontaneously, as a natural progression, or it can be triggered by an unrelated event e.g. constipation, alcohol excess, urological procedure

43
Q

What is the immediate treatment for acute urinary retention?

A

Catheterisation

44
Q

What are the potential complications of acute urinary retention?

A 
UTI 
Post-decompression haematuria
Pathological diuresis
Renal failure 
Electrolyte abnormalities
45
Q

What is the treatment of acute urinary retention?

A

Catheterisation
Treat any underlying trigger
If no renal failure - start alpha blocker immediately and remove catheter after 2 days
If failure to void at this point - recatheterise and organise TURP

46
Q

What percentage of men will void successfully 2 days after catheterisation due to acute urinary retention?

47
Q

What is chronic urinary retention?

A

Painless, palpable and percussible bladder after voiding

48
Q

What is the variation in residuals in chronic urinary retention?

A

Patients are often able to void but have residuals ranging from 400ml to > 2 litres, depending on the stage of the condition

49
Q

What is the main aetiological factor in chronic urinary retention?

A

Detrusor muscle under-activity

May be primary e.g. primary bladder failure or secondary e.g. due to long-standing BOO

50
Q

How does chronic urinary retention present?

A

As LUTS or complications e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure
May be incidental finding

51
Q

When do overflow incontinence and renal failure occur due to chronic urinary retention?

A

At the severe end of the spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water

52
Q

What is the treatment of chronic urinary retention?

A

Asymptomatic patients with low residuals may not need treatment
Immediate treatment is catheterisation, followed by CISC if appropriate

53
Q

What are the complications of chronic urinary retention?

A

UTI
Post-decompression haematuria
Pathological diuresis
Electrolyte abnormalities e.g. hyponatraemia, hyperkalaemia
Persistent renal dysfunction due to acute tubular necrosis

54
Q

What is pathological diuresis? How does it present?

A

Urine output > 200ml/hour
Postural hypotension (systolic differential > 20mmHg between lying and standing)
Weight loss
Electrolyte abnormalities

55
Q

What is the management of pathological diuresis?

A

IV fluids
Close monitoring and liaise with renal team
Subsequent treatment either long-term urethral or suprapubic catheter, CISC or TURP

56
Q

Does TURP have a better outcome in chronic or acute urinary retention?

A

Acute urinary retention

57
Q

Does TURP have a better outcome in patients with high-pressure chronic retention or low-pressure chronic retention?

A

High-pressure chronic retention

Urinary System (22 decks)

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