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URINARY > Benign diseases of the Prostate > Flashcards

Benign diseases of the Prostate Flashcards

1
Q

what is the average size of the prostate

A

15cc

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2
Q

where does the prostate lie

A

sits underneath the bladder - surrounded by important structures

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3
Q

why is the prostate referred to as a secondary sexual organ

A

secretes an alkaline milky fluid that makes up around 30% of semen - alkalinity of sperm allows it to survive longer in acidic environment of the vagina - so without the prostate you could still ejaculate but sperm won’t work

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4
Q

what is terminal dribbling and how does it occur

A

when after voiding and walking away a small amount of urine passes out - as you get older the angle of the urethra in men becomes more acute - creates a “bulb” - bulb of urethra collects a puddle of fluid - pressure from walking causes last bit of urine to be pushed out

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5
Q

can you differentiate different parts of the prostate under the microscope

A

no - all look the same

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6
Q

what are the 4 zones of the prostate

A

transition zone, central zone, peripheral zone, anterior fibromuscular zone

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7
Q

what is clinically important to know about the peripheral zone

A

85% of prostate cancers form here - reason for rectal examination in identifying them

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8
Q

what are the three types of benign prostatic disease

A

BPE - benign prosatatic enlargement
BPH - benign prostatic hyperplasia
BPO - benign prostatic obstruction

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9
Q

of the three types of benign prostatic disease, which one can be seen histologically under a microscope

A

Benign prostatic hyperplasia

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10
Q

what are the two group of symptoms referred to as

A

BOO - bladder outflow obstuction

LUTS - lower urinary tract symptoms

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11
Q

what does the half diagram show

A

venn diagram showing cross over between LUTS, BOO and BPE

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12
Q

what are the characteristics of benign prostatic hyperplasia

A

fibromuscular and glandular hyperplasia

  • predominantly in the transition zone
  • progressive condition resulting in blader outflow obstruction (BOO)
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13
Q

what % of men have BPH at 60yrs and 85yrs respectively

A

50%

90%

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14
Q

how can prostate growth be stopped

A
  1. removal of prostate

2. block testosterone

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15
Q

what indicator can differentiate between fibromuscular and glandular hyperplasia

A

the size of the prostate and how it responds to different treatments

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16
Q

what system is used to give an indication of prostate health

A

International prostate symptom score sheet

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17
Q

what are the two groups LUTS symptoms can be divide into

A
  1. voiding (obstructive) symptoms

2. Storage (irritative) symptoms

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18
Q

list the common voiding (obstructive) LUTS

A

hesitancy, poor stream, terminal dribbling, incomplete emptying

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19
Q

list the common storage (irritative) LUTS

A

frequency, nocturia, urgency +/- urge incontinence

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20
Q

what can be used to track frequency

A

frequency volume chart

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21
Q

what is the normal average capacity for men and women respectively

A

~500

~400

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22
Q

what is the average frequency of urination per day

A

4-6 times

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23
Q

what are the 3 areas to be examined for BPH

A
  1. abdomen - palpable bladder
  2. penis - external urethral metal stricture, phimosis
  3. digital rectal exam - assess prostate size,suspicious nodules to firmness
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24
Q

what should be looked for in a urinalysis for BPH

A

blood, signs of UTI

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25
Q

what 8 investigations should be undertake for BPH

A
  1. MSSU (mid stream sample urine)
  2. flow rate study
  3. post-void bladder residual USS
  4. Bloods - PSA, urea+creatinine (if chronic retention)
  5. renal tract USS if renal failure or bladder stone suspected
  6. flexible cystoscopy if haematuria
  7. urodynamic studies in selected cases
  8. TRUS- guided prostae biopsy if PSA raised or abnormal DRE
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26
Q

what is PSA

A

Prostate Specific Antigen - a serum protease - something in the blood specific to prostate but not to prostate cancer

  • in benign disease can help determine size
  • in malignant disease can help determine response to treatment
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27
Q

what do the top and bottom lines in a flow rate study show

A

top - max flow rate ml/s

bottom - volume urinated

28
Q

what are the two common causes for a pathological flow rate reading

A
  1. problem with pressure exerted from bladder

2. problem with opening

29
Q

what are the two types of BPO

A

uncomplicated and complicated

30
Q

what are the three treatment groups of uncomplicated BPO

A
  1. watchful waiting
  2. medical therapy
  3. surgical intervention
31
Q

what medical therapy is used for uncomplicated BPO

A
  1. Alpha blockers
  2. 5 alpha reductase inhibitors (finasteride or dutasteride)
  3. combination
32
Q

what surgical intervention is used for uncomplicated BPO

A
  1. TURP - transurethral resection of prostate (prostate <100cc)
  2. open retropubic or transvesical prostatectomy (prostate size >100cc)
  3. endoscopic ablative procedures
33
Q

what is the mainstay treatment for uncomplicated BPO

A

ALPHA BLOCKERS

  • work fast - within 48hrs see improvement
  • cause smooth muscle relaxation and antagonise the “dynamic” element to prostatic obstruction

**work best for fibromuscular prostate blockage (due to nature of acting on alpha-1a receptors in smooth muscle of prostate

34
Q

what is the main alpha blocker used for BPO in the UK

A

tamsulosin - as it is highly selective to alpha-1a

35
Q

what are the 4 groups o alpha blockers

A
  1. non-selective (ie alpha 1 and 2) phenoxybenzamine
  2. selective short acting - parson, indoramin
  3. selective long acting - alfuzosin, doxazosin, terazosin
  4. highly selective (i.e. alpha-1a) tamsulosin
36
Q

what are contraindication for tamsulosin

A

if going for cataract surgery

parkinsons - can lower BP

37
Q

what is the action of 5a-reductase inhibitors

A

convert testosterone to dihydrotestosterone

38
Q

what are the two 5a-reductase inhibitors currently available

A
  1. finasteride (5AR Type II inhibitor)

2. dutasteride (5AR Type I and II inhibitor)

39
Q

what are the roles of 5ARIs

A
  1. reduce prostate size - esp on larger prostates
  2. reduce risk of progression to BPE
  3. reduces LUTS
  4. can reduce prostatic vascularity and therefore reduce haematuria due to prostatic bleeding
  5. potential role in reducing rate of low and intermediate prostate cancer BUT rate of high prostate cancer goes up
40
Q

what is the gold standard surgery for BPO

A

TURP - very effective in receiving symptoms - improves urodynamic parameters (90% efficacy at 1 year)

41
Q

what are complications of TURP

A

bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO

42
Q

what are complications of BPO

A
  1. progression of LUTS
  2. acute urinary retention
  3. chronic urinary retention
  4. urinary incontinence (overflow)
  5. UTI
  6. bladder stone
  7. renal failure from obstructed ureteric outflow die to high bladder pressure
43
Q

what is a red flag sign for chronic retention

A

sudden onset bed wetting - may be no further symptoms

44
Q

what is the treatment for complicated BPO

A

SURGICAL intervention - medical therapy will usually not suffice

eg cystolitholapaxy and TURP for patients with BPO and bladder stones

45
Q

when may BPO patients NOT need treatment

A

if residuals relatively low, asymptomatic and no complications

46
Q

what treatments could be given to BPO patients that are unfit for surgery

A
  1. long term urethral/suprapubic catheterisation

2. clean intermittent self catheterisation

47
Q

what are the complications of long term catheterisation

A

may develop problems with catheter trauma, blockages, frank haematuria, recurrent UTI

48
Q

what is the definition of acute urinary retention

A

painful inability to void with a palpable and permissible bladder

49
Q

what are the residuals of acute urinary retention

A

vary from 500ml to >1 depending on time lag seeking treatment

50
Q

what is the main causes of acute urinary retention

A

main risk factor BPO BUT can also occur independently of BPO e.g. UTI, urethral stricture, post op causes, excess alcohol, acute surgical or medical problems

51
Q

for people with BPO, how can acute urinary retention occur

A
  1. spontaneously - i.e. natural progression

2. triggered by unrelated event e.g. constipation, alcohol excess, post operative causes, urological procedure

52
Q

what is the immediate treatment for acute urinary retention

A

catheterisation (either urethral or suprapubic)

53
Q

what other treatments should be considered

A
  1. treatment of the underlying trigger if one present
  2. if no renal failure start alpha blocker immediately and remove catheter in 2 days - 60% will void successfully
  3. if failure to void after 2 days recatheterise and organise TURP - after 6 weeks
54
Q

what are the complications of acute urinary retention

A
  1. UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities
55
Q

what is the definition of chronic urinary retention

A

painless, palpable and percussible bladder after voiding

56
Q

what are the residuals of chronic urinary retention

A

patients able to void but can have residuals from 400ml to >2 L depending on stage of condition i.e. wide spectrum

57
Q

what is the main etiological factor for chronic urinary retention

A

detrusor underactivity

  1. primary - ie primary bladder failure
  2. secondary - ie due to longstanding BOO, such as BPO or urethral stricture
58
Q

how does chronic urinary retention usually present

A

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

59
Q

what patients with chronic urinary retention mayn’t need treatment

A

asymptomatic patients with low residuals

60
Q

what is the immediate treatment for chronic urinary retention

A

catheterisation (either urethral or suprapubic)

61
Q

what are complications of chronic urinary retention

A

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

62
Q

what are the features of pathological diuresis

A
  1. urine output >200mk/hr
  2. postural hypotension (systolic differential >20mmHg between lying and standing)
  3. weight loss
  4. electrolyte abnormalities
63
Q

How can pathological diuresis be treated

A

IV fluids (total input = 90% of output) and monitor closely - liaise with renal team

64
Q

what is further treatment for chronic urinary retention

A

long term urethral or suprapubic catheterisation, CISC or TURP

65
Q

when is TURP more successful - acute or chronic renal retention

A

more successful in ACUTE
BUT
within chronic:
patients with HIGH pressure chronic more successful than patients with LOW pressure chronic

URINARY (27 decks)

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