Benign Diseases of the Prostate Flashcards
picture showing prostate anatomy
What are McNeal’s Prostatic Zones?
WHat are the different terminaologies for Benign Prostatic Diseases?
- Benign prostatic enlargement (BPE)
- Benign prostatic hyperplasia (BPH)
- Benign prostatic obstruction (BPO)
- Bladder outflow obstruction (BOO)
- Lower urinary tract symptoms (LUTS)
Benign Prostatic Hyperplasia is characterised by ____________ and __________ hyperplasia
Predominantly affects _________ zone
fibromuscular and glandular
transition
who does BPH occur in?
• Part of aging process in men :
- 50% of men at 60 years
- 90% of men at 85 years
• 50% of men with BPH have moderate to severe LUTS
Progressive condition MAY result in what
Bladder Outflow Obstruction (BOO)
what is classed as mild, moderat and severe prostate symptoms?
Total score (out of 35) :
Mild : 0-7
Moderate : 8-19
Severe : ≥ 20
how do you assess LUTS?
- Symptom scoring systems - IPSS
- Frequency volume charts
what are some VOIDING (Obstructive) LUTS?
- Hesitancy
- Poor stream
- Terminal dribbling
- Incomplete emptying
what are some STORAGE (Irritative) LUTS?
- Frequency
- Nocturia
- Urgency +/- urge incontinence
what may be done on physical examination?
Abdomen:
•? palpable bladder
Penis:
- ? external urethral meatal stricture
- ? phimosis
Digital rectal examination (DRE):
- assess prostate size
- ? suspicious nodules or firmness
Urinalysis:
- ? blood
- ? signs of UTI
what investigations can be carried out?
- 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 if haematuria
- Urodynamic studies in selected cases
- TRUS-guided prostate biopsy if PSA raised or abnormal DRE
what is this showing?
BPE
What are the differett ypes of BPO?
- Uncomplicated BPO
- Complicated BPO
what is the Treatment of 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 Main treatment for LUTS due to BPO?
Alpha blockers
how do alpha blockers work?
- Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by 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 different types of alpha blockers?
- non-selective (i.e. alpha 1 and 2): phenoxybenzamine
- selective short acting: prazosin, indoramin
- selective long acting: alfuzosin, doxazosin, terazosin
- highly selective (i.e. alpha-1a): tamsulosin
All a-blockers appear to be equally _______ but _________ in side effect profiles and pharmacodynamic properties
effective
differences
5a-reductase converts testosterone to what?
dihydrotestosterone
there are 5a-reductase inhibitors drugs avalible, what are they?
- Finasteride (5AR Type II inhibitor)
- Dutasteride (5AR Type I and II inhibitor)
what is the orle of 5ARIs?
- reduces prostate size and reduces risks of progression of BPE (but only if >25cc prostate)
- also reduces LUTS (but 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
what is the gold standard surgery?
Transurethral resection of prostate - TURP
Very effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 year)
what are the complications of TURP?
bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO
What are some alternative new endoscopic ablative procedures?
Transurethral laser vaporisation
Urolift
what are the complications of BOO (bladder outflow obstruction)?
- 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 is the treatment of complicated BOO?
Medical therapy
Most patients will require surgery - eg. cystolitholapaxy and TURP for patients with BPO and bladder stones
Some patients do not need any treatment (especially if residuals are relatively low, asymptomatic and no complications)
Alternative treatment options (e.g. patients unfit for surgery) :
- long term urethral or suprapubic catheterisation
- clean intermittent self-catheterisation
- may develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI
what is Acute urinary retention?
- Defined as ‘painful inability to void with a palpable and percussible bladder’
- Residuals vary from 500ml to >1 litre depending on time lag in seeking medical attention
what is the main risk factor for Acute urinary retention?
- Main risk factor is BPO but can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems)
- For those with BPO, can occur spontaneously (i.e. natural progression of BPO) or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)
what is the treatment for Acute urinary retention?
Immediate treatment is catheterisation (either urethral or suprapubic)
Treat underlying trigger if present
If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)
what re the complications of Acute urinary retention?
Complications : UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities
What is chronic urinary retention?
- Defined as ‘painless, palpable and percussible bladder after voiding’
- Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)
- Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding
- Overflow incontinence and renal failure occur at severe end of 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)
What causes chronic urinary retention?
Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)
do people with chronic urinary retention need treatment?
- Asymptomatic patients with low residuals do not necessarily need treatment
- Patients with symptoms or complications need treatment (but no role for medical therapy!)
what is the treatment of chronic urinary retention?
Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)
Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities
Manage with iv fluids (total input = 90% of output) and monitor closely; liaise with renal team
Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP
TURP in chronic retention has a less successful outcome than for acute retention; however, patients with high pressure chronic retention has better outcome with TURP than patients with low pressure chronic retention
whata re the complications of chronic urinary retention?
UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis
what are the types of urinary tract obstruction?
•Upper tract (i.e. supra-vesical)
- PUJ
- ureter
- VUJ
•Lower tract (i.e. bladder outflow obstruction)
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin (e.g. phimosis)
Causes of upper tract obstruction can be due to what 2 different ways?
intrinsic and extrinsic
Causes of upper tract obstruction can be due to what different anatomical sites?
Pelvi-ureteric junction (PUJ)
Ureter
Vesico-ureteric junction (VUJ)
Causes of upper tract obstruction can be due to what intrinsic causes in the Pelvi-ureteric junction (PUJ)?
- PUJ obstruction (physiological)
- Stone
- Ureteric tumour (TCC)
- Blood clot
- Fungal ball
Causes of upper tract obstruction can be due to what extrinsic causes in the Pelvi-ureteric junction (PUJ)?
- PUJ obstruction (crossing vessel)
- Lymph nodes (tumour)
- Abdominal mass (tumour)
Causes of upper tract obstruction can be due to what intrinsic causes in the ureter?
- Stone
- Ureteric tumour (TCC)
- Scar tissue
- Blood clot
- Fungal ball
Causes of upper tract obstruction can be due to what extrinsic causes in the ureter?
- Lymph nodes (tumour, retroperitoneal fibrosis)
- Iatrogenic
- Abdominal/pelvic mass (tumour, pregnant uterus)
Causes of upper tract obstruction can be due to what intrinsic causes in the Vesico-ureteric junction (VUJ)?
- Stone
- Bladder tumour
- Ureteric tumour
Causes of upper tract obstruction can be due to what extrinsic causes in the Vesico-ureteric junction (VUJ)?
Cervical tumour
Prostate cancer
what are the symptoms of upper urinary tract obstruction?
- Pain
- Frank haematuria
- Symptoms of complications
what are the signs of upper urinary tract obsturction?
- Palpable mass
- Microscopic haematuria
- Signs of complications
what are the complications of upper urinary tract obstruction?
- Infection and sepsis
- Renal failure
what is the difference between acute or chronic obstruction?
Acute:
- Renal function could be normal
- Pain ?
Chronic:
Renal function may be normal
High pressure vs Low Pressure
Partial or complete
Clinical case
Mr. Anderson is a 50 year old man who presents to A&E with Left sided loin pain. The pain is colicky and causes nausea and vomiting. He has no significant past medical history and is not on any medications
On examination, his temperature is 40°C, his pulse is 100 bpm, blood pressure is 90/60mm Hg, respiratory rate is 20 bpm and O2 saturation is 89% on air. He is extremely tender over the Left loin and flank areas
What is the most important step in his management?
What investigations would you organise?
what is the management of upper urinary tract obstruction?
Resuscitation:
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
Investigations (including imaging)
Emergency treatment of obstruction (for unremitting pain or complications):
- Percutaneous nephrostomy insertion OR
- Retrograde stent insertion
Definitive treatment of obstruction:
- Treat underlying cause
- e.g. stone – ureteroscopy and laser lithotripsy +/- basketing or ESWL
- e.g. ureteric tumour – radical nephro-ureterectomy
- e.g. PUJ obstruction – laparoscopic pyeloplasty
what is a Nephrostomy?
an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects. Its job is to temporarily drain the urine that is blocked
- Percutaneus puncture
- risk of bleeding and adjacent organs
- Usually under LA + sedation
- US or xray guidance
what is a Ureteric stent?
a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney
- Silicone
- Polyurethane
- Nickel titanium
what is the presentation of lower urinary tract obstruction?
- Lower urinary tract symptoms - including urinary incontinence
- Acute urinary retention
- Chronic urinary retention
- Recurrent urinary tract infection and sepsis
- Frank haematuria
- Formation of bladder stones
- Renal failure
if there is retention what do you do?
catheterisation
- Do it immediately
- Urethral catheter 14/16F
- Record residual
- 2 attempts (then introducer if GA experience)
- 16F SPC if urethra impassable
what resuscitation is down for lower urinary tract obstruction?
- ABCs
- IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
- IV fluids, broad-spectrum antibiotics (if appropriate)
- Analgesia
- HDU care +/- renal replacement therapy (if appropriate)
what ivestingations are done for lower urinary tract obstruction?
including imaging: Bladder scan, USS renal tract
what is the treatment for lower urinary tract obstruction?
- Emergency treatment of obstruction (for unremitting pain or complications) - Urethral catheterisation OR Suprapubic catheterisation
- Definitive treatment of obstruction - Treat underlying cause:
- e.g. BPE – TURP
- e.g. Urethral stricture – Optical urethrotomy
- e.g. Meatal stenosis – Meatal dilatation
- e.g. Phimosis – Circumcision
what does high pressure chronic retention cause?
painless
incontinent
raised cr
bilateral hydro-nephrosis
what does low pressure chronic retention cause?
painless
dry
normal cr
normal kidneys
what are complications of lower urinary tract obsturction?
• Decompression haematuria
- Shearing of small vessels due to differing compliance of tissue layers
- Usually self limiting
• Post obstructive diuresis
- Greater than 200ml/hr
- Osmotic diuresis 2y to urea; ADH; altered tubular function
–Can lead to life threatening sodium and water depletion
–Normal saline at input = output-30ml/hr
