Benign Diseases of the Prostate Flashcards
How big is the average prostate (of a relativley young, healthy person)?
15cc
Where lies superior to the prostate?
Bladder
What is the function of the prostate?
Secondary sexual organ; allows sperm to be fertilised
What zones are the prostate divided into?
McNeal’s Prostatic Zones
Transition; central; peripheral; anterior fibromuscular stroma
(peripheral - highest incidence of prostate cancer)
Terminology for benign prostatic diseases: BPE, BPH, BPO, BOO, LUTS
BPE = benign prostatic enlargement
BPH = benign prostatic hyperplasia
BPO = benign prostatic obstruction
BOO = benign outflow obstruction
LUTS = lower urinary tract obstruction (generic catchall term)
What is BPH characterised by?
Fibromuscular and glandular hyperplasia
(hypertrophied fibres)
Which zone does BPH predominantly affect?
Transition zone
Is BPH part of the aging process in men?
Yes
What percentage of men with BPH have moderate/severe LUTS?
50%
BPH is a progressive condition which may result in what?
Bladder Outflow Obstruction (BOO)
What 7 domains of LUTS does the international prostate symptoms score sheet include?
Incomplete emptying
Frequency
Intermittency
Urgency
Weak stream
Straining
Nocturia
(Score each from 0-5; mild 0-7; moderate 8-19; severe >20)
What are the 2 broad categories of LUTS?
Voiding (obstructive)
Storage (irritative)
What are the 4 obstructive LUTS?
Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying
What are the 3 irritative LUTS?
Frequency
Nocturia
Urgency +/- urge incontinence
What does the frequency volume chart tell us about?
Functional capacity of bladder
(also helps to draw patients attention to how often they are going)
3 physical examinations which can be done for BPH are abdomen, penis and DRE; what should be assessed/looked for in these?
Abdomen = palpable bladder
Penis = external urethral meatal stricture; phimosis
Digital rectal examination = assess prostate size; suspicious nodules or firmness; anal tone
What should be looked for in urinalysis for BPH?
Blood
Signs of UTI
What are the relevant investigations in BPH?
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)
In uroflowmetry results, what are the chances of having BOO if Qmax <10ml/s?
90%
What is this?
Cytoscopic appearance of BPE causing BOO?
2 types of BPO?
Uncomplicated BPO
Complicated BPO
What are the types of treatment for 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
What is the mainstay treatment for LUTS due to BPO?
Alpha blockers
What innervates the smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate? Therefore how to alpha blockers work?
Sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction
What are the 4 types of alpha blockers? And examples of each?
- 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)
Alpha blockers can have significant side effects, what type are better in terms of this?
More specific; esp for elderly (even tho tamsulosin can cause retrograde ejaculation)
How do 5a-reductase inhibitors work?
Convert testosterone to dihydrotestosterone
What are the 2 5a-reductase inhibitors currently available?
Finasteride (5AR Type II inibitor)
Dutasteide (5AR Type I and II inhibitor)
Give the role of 5ARIs
- 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
Are there significant side effects associated with 5ARIs?
Yes; inc impaired sexual function and breats growth
What is TURP?
Transurethral resection of prostate
Is TURP effective?
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)
Complications of TURP?
Bleeding
Infection
Retrograde ejaculation
Stress urinary incontinence
Prostatic regrowth causing recurrent haematuria
BOO
Give some complications of BOO
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)
Most patients with complications of BOO will require surgery, for example what?
Cystolitholapaxy and TURP for patients with BPO and bladder stones
If residuals are relatively low, asymptomatic and has no complications - would the patient need treatment?
Nope
If the patient is unfit for surgery, what are 2 alternative treatment options?
- Long term urethral or suprapubic catheterisation*
- Clean intermittent self-catheterisatoin*
What are problems which can be developed with difficult catheterisation?
Catheter trauma
Blockages
Frank haematuria
Recurrent UTI
What is acute urinary retention defined as?
Painful inability to void with a palpable and percussable bladder
What is the main risk factor for acute urinary retention?
BPO (but can also occur independently of it e.g. UTI, urethral stricture, alcohol excess, post-op causes, acute surgical or medical problems)
What is the immediate treatment for acute urinary retention?
Catheterisation
Name some complications of acute urinary retention
UTI
post-decompression haematuria
pathological disease
renal failure
electrolyte abnormalities
What is further treatment for acute urinary retention?
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)
What is chronic urinary retention defined as?
Painless, palpable and percussible bladder after voiding
Are patients with chronic urinary retention able to void?
Yeah; often able to void but with residuals ranging from 400ml to >2L depending on stage of condition (i.e. wide spectrum)
What is the main aetiological factor for chronic urinary retention? What are its 2 categories?
Detrusor underactivity
Can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)
What does chronic urinary retention present as?
LUTS
Complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure)
Or can be incidental finding
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)
Overflow incontinence and renal failure
What patients do vs do not need treatment?
Asymptomatic patients with low residuals do not necessarily need treatment
Patients w symptoms or complications need treatment (but no role for medical therapy !!)
Immediate treatment for chronic urinary retention?
Catheterisation (followed by CISC is necessary)
Complications from chronic urinary retention?
UTI
Post-decompression haematuria
Pathological diuresis
Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)
Persistent renal dysfunction due to ATN
Features of pathological diuresis:
Urine output >200ml/hr
+
Postural hypotension (systolic diferential >20mmHg between lyiing and standing)
+
Weight loss
+
Electrolyte abnormalities
Management of chronic urnary retention?
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)
