Benign Diseases of the Prostate Flashcards
What type of organ is the prostate?
A secondary sexual organ
How many sphincters do men and women have?
Men - 2
Women - 1
Function of prostate
Capacitation - makes the sperm work
What are McNeals Prostatic Zones?
Transition zone
Central zone
Peripheral zone
Which McNeals zone does prostate cancer usually lie in?
Peripheral zone
What are the benign prostatic diseases?
Benign prostatic enlargement (BPE)
Benign prostatic hyperplasia (BPH)
Benign prostatic obstruction (BPO)
Benign outflow obstruction (BOO)
What does LUTS stand for?
Lower urinary tract symptoms
What is benign prostatic hyperplasia?
Fibromuscular and glandular hyperplasia of the prostate. A progressive condition that results in BOO
What % of men have BPH at 60 and 85 y/o?
60 y/o = 50%
85 y/o = 90%
What are the LUTS?
Hesitancy Poor stream Terminal dribbling Incomplete emptying Frequency Nocturia Urgency +/- urge incontinence
Types of LUTS
Voiding
Storage
What is the scoring system for the assessment of LUTS?
IPSS
What is a normal peeing frequency?
4-6x a day
Normal urine capacity for women vs men
Women - 400ml
Men - 500ml
Examination for LUTS
Abdomen - palpable bladder Penis - external urethral meatal stricture - phimosis DRE - prostate size - nodules or firmness Urinalysis - bloods - UTI
Investigations of LUTS
MSSU
Flow rate study
Post void bladder residual USS
Bloods
- PSA
- urea and creatinine (if chronic retention)
Renal tract USS (if renal failure or bladder stone suspected)
Flexible cystoscopy haematuria
Urodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE
What is PSA?
Serum protease which is in the blood, specific to the prostate NOT cancer - used to detect size
Types of BPO
Uncomplicated
Complicated
Treatment for uncomplicated BPO
Watchful waiting
Alpha blockers
5 alpha reductase inhibitors (finasteride or dutasteride)
Surgery
- TURP
- Open retropubic or transvesical prostatectomy
- endoscopic ablative procedures
When is TURP done vs open retropubic or transvesical prostatectomy to treat BPO?
TURP = prostate size < 100cc
Other one = Prostate size > 100cc
Complications of BPO
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
What are alpha blockers the main treatment of?
LUTS due to BPO
What does the sympathetic alpha-adrenergic nerves innervate?
Smooth muscle of the bladder neck (i.e. intrinsic urethral sphincter) and prostate
What do alpha blockers cause?
Smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction
Types of alpha blockers
Non selective (alpha 1 and 2); phenoxybenzamine Selective short acting; prazosin, indoramin Selective long acting; alfuzosin, doxazosin Highly selective (alpha 1a - Tamsulosin)
What do 5-reductase inhibitors do?
Convert testosterone to dihydrotestosterone
Examples of 5-reductase inhibitors
Finasteride
Dutasteride
Role of 5AIRs
Reduce prostate size and reduces risk of progression of BPE
Reduces LUTS
Reduces prostatic vascularity and reduces haematuria due to prostatic bleeding
Potential role in prostate cancer prevention
What does TURP stand for?
Transurethral resection of prostate
What is the gold standard surgery for prostate surgery?
TURP
Complications of TURP
Bleeding Infection Retrograde ejaculation Stress urinary incontinence Prostatic regrowth causing haematuria or BOO
Treatment of complicated BPO
Medical therapy
Surgery
Some patients do not need any treatment (especially if residuals are relatively low, asymptomatic and no complications)
What are some alternative treatment options for e.g. if patients are unfit for surgery
Long term urethral or suprapubic catheterisation
Clean intermittent self-catheterisation
Definition of acute urinary retention
Painful inability to void with a palpable and percusable bladder
Residuals In acute urinary retention
Vary from 500ml > 1 litre depending on lag time in seeking medical attention
What is the main risk factor for acute urinary retention?
BPO
For those with BPO, what can acute urinary retention be caused by?
Spontaneously
Triggers
What are some triggers for acute urinary retention in people with BPO?
Constipation
Alcohol excess
Post op cases
Urological procedures
Immediate treatment of acute urinary retention
Catheterisation (either urethral or suprapubic)
Complications of acute urinary retention
UTI Post decompression haematuria Pathological diuresis Renal failure Electrolyte abnormalities
Longer term treatment of acute urinary retention
Treat underlying trigger if present
If no renal failure start alpha blocker immediately
Remove catheter in 2 days
60% will void successfully, if fail to void, catheterise and organise TURP (after 6 weeks)
Definition of chronic urinary retention
Painless, palpable and percusable bladder after voiding
Residuals in chronic urinary retention
Patients often able to void but with residuals ranging from 400ml to > 2 litres depending on the stage of the condition (i.e. wide spectrum)
Main causative factor of chronic urinary retention
Detrusor underactivity
Types of detrusor underactivity
Primary
Secondary
Causes of primary detrusor underactivity
Primary bladder failure
Causes of secondary detrusor underactivity
Longstanding BOO e.g. due to BPO or urethral stricture
Presentation of chronic urinary retention
LUTS
Complications
Complications of chronic urinary retention
UTI Bladder stones Overflow incontinence Post renal or obstructive renal failure Post decompression haematuria Pathological diuresis Electrolyte abnormalities - hyponatraemia - hyperkalaemia - metabolic acidosis Persistent renal dysfunction due to acute tubular necrosis
When does overflow incontinence and renal failure occur in chronic urinary retention?
At the severe end of the spectrum, 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 pressure chronic urinary retention)
Patients with chronic urinary retention who are asymptomatic with low residuals, do they always need treatment?
No
Immediate treatment of chronic urinary retention
Catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)
Features of pathological diuresis
Urine output > 200ml/hr
Postural hypotension (systolic differential >200mmHg between lying and standing)
Weight loss
Electrolyte abnormalities
Treatment of chronic urinary retention
IV fluids (total input = 90% of output)
Long term urethral or suprapubic catheter
CISC
TURP
