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*Urinary System > Benign Diseases of the Prostate > Flashcards

Benign Diseases of the Prostate Flashcards

1
Q

How big is the average prostate (of a relativley young, healthy person)?

A

15cc

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2
Q

Where lies superior to the prostate?

A

Bladder

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3
Q

What is the function of the prostate?

A

Secondary sexual organ; allows sperm to be fertilised

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4
Q

What zones are the prostate divided into?

A

McNeal’s Prostatic Zones

Transition; central; peripheral; anterior fibromuscular stroma

(peripheral - highest incidence of prostate cancer)

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5
Q

Terminology for benign prostatic diseases: BPE, BPH, BPO, BOO, LUTS

A

BPE = benign prostatic enlargement

BPH = benign prostatic hyperplasia

BPO = benign prostatic obstruction

BOO = benign outflow obstruction

LUTS = lower urinary tract obstruction (generic catchall term)

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6
Q

What is BPH characterised by?

A

Fibromuscular and glandular hyperplasia

(hypertrophied fibres)

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7
Q

Which zone does BPH predominantly affect?

A

Transition zone

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8
Q

Is BPH part of the aging process in men?

A

Yes

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9
Q

What percentage of men with BPH have moderate/severe LUTS?

A

50%

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10
Q

BPH is a progressive condition which may result in what?

A

Bladder Outflow Obstruction (BOO)

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11
Q

What 7 domains of LUTS does the international prostate symptoms score sheet include?

A

Incomplete emptying

Frequency

Intermittency

Urgency

Weak stream

Straining

Nocturia

(Score each from 0-5; mild 0-7; moderate 8-19; severe >20)

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12
Q

What are the 2 broad categories of LUTS?

A

Voiding (obstructive)

Storage (irritative)

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13
Q

What are the 4 obstructive LUTS?

A

Hesitancy

Poor stream

Terminal dribbling

Incomplete emptying

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14
Q

What are the 3 irritative LUTS?

A

Frequency

Nocturia

Urgency +/- urge incontinence

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15
Q

What does the frequency volume chart tell us about?

A

Functional capacity of bladder

(also helps to draw patients attention to how often they are going)

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16
Q

3 physical examinations which can be done for BPH are abdomen, penis and DRE; what should be assessed/looked for in these?

A

Abdomen = palpable bladder

Penis = external urethral meatal stricture; phimosis

Digital rectal examination = assess prostate size; suspicious nodules or firmness; anal tone

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17
Q

What should be looked for in urinalysis for BPH?

A

Blood

Signs of UTI

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18
Q

What are the relevant investigations in BPH?

A

MSSU

Flow rate study

Post-voidal bladder residual USS

  • Bloods*: PSA, urea and creatinne (if chronic retention)
  • Flexible cytoscopy* (if haematuria)
  • Urodynamic studies* (selected cases)
  • TRUS-guided prostate biopsy* (if PSA raised of abnormal DRE)
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19
Q

In uroflowmetry results, what are the chances of having BOO if Qmax <10ml/s?

A

90%

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20
Q

What is this?

A

Cytoscopic appearance of BPE causing BOO?

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21
Q

2 types of BPO?

A

Uncomplicated BPO

Complicated BPO

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22
Q

What are the types of 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
23
Q

What is the mainstay treatment for LUTS due to BPO?

A

Alpha blockers

24
Q

What innervates the smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate? Therefore how to alpha blockers work?

A

Sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)

Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

25
Q

What are the 4 types of alpha blockers? And examples of each?

A
  • Non-selective (i.e. alpha 1 and 2)* - phenoxybenzamine
  • Selective short acting* - proazosin, indoramin
  • Selective long acting* - alfuzosin, dozazosin, terazosin
  • Highly selective (i.e. alpha-1a)* - tamsulosin

(all are equally effective but differences in side effect profiles and pharmacodynamic properties)

26
Q

Alpha blockers can have significant side effects, what type are better in terms of this?

A

More specific; esp for elderly (even tho tamsulosin can cause retrograde ejaculation)

27
Q

How do 5a-reductase inhibitors work?

A

Convert testosterone to dihydrotestosterone

28
Q

What are the 2 5a-reductase inhibitors currently available?

A

Finasteride (5AR Type II inibitor)

Dutasteide (5AR Type I and II inhibitor)

29
Q

Give the role of 5ARIs

A
  • Reduce prostate size and reduces risks of progression of BPE (if prostate >25cc)
  • Also reduces LUTS (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
30
Q

Are there significant side effects associated with 5ARIs?

A

Yes; inc impaired sexual function and breats growth

31
Q

What is TURP?

A

Transurethral resection of prostate

32
Q

Is TURP effective?

A

Remains GOLD STANDARD (however it should be a last resort in uncomplicated)

V effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 yr)

33
Q

Complications of TURP?

A

Bleeding

Infection

Retrograde ejaculation

Stress urinary incontinence

Prostatic regrowth causing recurrent haematuria

BOO

34
Q

Give 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 P)

35
Q

Most patients with complications of BOO will require surgery, for example what?

A

Cystolitholapaxy and TURP for patients with BPO and bladder stones

36
Q

If residuals are relatively low, asymptomatic and has no complications - would the patient need treatment?

A

Nope

37
Q

If the patient is unfit for surgery, what are 2 alternative treatment options?

A
  • Long term urethral or suprapubic catheterisation*
  • Clean intermittent self-catheterisatoin*
38
Q

What are problems which can be developed with difficult catheterisation?

A

Catheter trauma

Blockages

Frank haematuria

Recurrent UTI

39
Q

What is acute urinary retention defined as?

A

Painful inability to void with a palpable and percussable bladder

40
Q

What is the main risk factor for acute urinary retention?

A

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

41
Q

What is the immediate treatment for acute urinary retention?

A

Catheterisation

42
Q

Name some complications of acute urinary retention

A

UTI

post-decompression haematuria

pathological disease

renal failure

electrolyte abnormalities

43
Q

What is further treatment for acute urinary retention?

A

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 wks)

44
Q

What is chronic urinary retention defined as?

A

Painless, palpable and percussible bladder after voiding

45
Q

Are patients with chronic urinary retention able to void?

A

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

46
Q

What is the main aetiological factor for chronic urinary retention? What are its 2 categories?

A

Detrusor underactivity

Can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

47
Q

What does chronic urinary retention present as?

A

LUTS

Complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure)

Or can be incidental finding

48
Q

What occurs in chronic urinary retention when bladder capacity is reached and bladder pressure is in excess of 25cm water?

(i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or high P chronic urinary retention)

A

Overflow incontinence and renal failure

49
Q

What patients do vs do not need treatment?

A

Asymptomatic patients with low residuals do not necessarily need treatment

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

50
Q

Immediate treatment for chronic urinary retention?

A

Catheterisation (followed by CISC is necessary)

51
Q

Complications from chronic urinary retention?

A

UTI

Post-decompression haematuria

Pathological diuresis

Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)

Persistent renal dysfunction due to ATN

52
Q

Features of pathological diuresis:

A

Urine output >200ml/hr

+

Postural hypotension (systolic diferential >20mmHg between lyiing and standing)

+

Weight loss

+

Electrolyte abnormalities

53
Q

Management of chronic urnary retention?

A

IV fluids and monitor closely (liase with renal team)

Subsequent treatment is either longterm urethral/suprapubic catheter, CISC or TURP

(better outcome from TURP in high P patients than low P)

*Urinary System (26 decks)

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