Benign diseases of the Prostate and Urinary Tract Obstruction Flashcards

Question

why can TURP not be done for a prostate >100cc?

Answer 1

Too large for TURP – high risk of intra-operative or post-operative complications, including: - bleeding - fluid overload - hypothermia - TUR syndrome (triad of dilutional hyponatraemia, fluid overload and glycine toxicity) (only for monopolar TURP)

Answer 2

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

Answer 3

No role for medical therapy (except for acute urinary retention) Most patients will require surgery eg. cystolitholapaxy and TURP for patients with BPO and bladder stones Alternative treatment options (eg. 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

Answer 4

‘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

Answer 5

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)

Answer 6

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)

Answer 7

Immediate treatment is catheterisation (either urethral or suprapubic) 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)

Answer 8

UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities

Answer 9

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)

Answer 10

‘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)

Answer 11

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)

Answer 12

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)

Answer 13

Asymptomatic patients with low residuals do not necessarily need treatment Patients with symptoms or complications need treatment (but no role for medical therapy!)

Answer 14

Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)

Answer 15

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

Answer 16

urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities

Answer 17

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

Answer 18

b. refractory chronic urinary retention

Answer 19

e. cystoscopy under local anaesthetic

Answer 20

b. 4 weeks

Answer 21

d. 12 weeks

Answer 22

PUJ ureter VUJ

Answer 23

- bladder neck (i.e. primary bladder neck obstruction, in men only) - prostate (men only) - urethra (e.g. urethral stricture in men and women; pelvic mass causing extrinsic compression of urethra in women) - urethral meatus (i.e. meatal stenosis in men and women) - foreskin (e.g. phimosis in men only)

Answer 24

Pain Frank haematuria Symptoms of complications

Answer 25

Palpable mass Microscopic haematuria Signs of complications

Answer 26

Infection and sepsis Renal failure (only if bilateral obstruction, single kidney or concurrent systemic upset e.g. sepsis, dehydration, nephrotoxicity)

Answer 27

resuscitation

Answer 28

Abdominal/Renal tract ultrasound scan

Answer 29

If upper urinary tract is obstructed, USS will show: - Hydronephrosis - Hydroureter However, cause of obstruction may not be visualised (obscured by bowel gas)

Answer 30

An intravenous urogram (IVU) is a test that looks at the whole of your urinary system. It's sometimes called an intravenous pyelogram (IVP)

Answer 31

The advantage of non-contrast low-dose CT scan is its ability to measure the size and location of the calculus. This is important for an emergency physician who has to determine patient's disposition and access to further treatment. Patients with small stones (<6 mm) and pain resolution can be safely discharged home.

Answer 32

It looks at the kidneys, ureters and bladder

Answer 33

Nuclear isotope (Technetium-99) scan to determine: - Split renal function as a proportion of global renal function (e.g. 65% Right kidney; 35% Left; normal should be 50:50 split) - Severity of obstruction based on drainage through renal outflow tract (e.g. mild, moderate or severe) Not used in acute setting, nor for stones nor tumour Used for chronic unilateral upper urinary tract obstruction, esp. chronic PUJ obstruction

Answer 34

- For investigation of urinary tract stones and obstruction in emergency setting - Quick and lower radiation exposure (2-3 milliSieverts) - No risk of contrast nephrotoxicity - Can be used in renal failure - Lower sensitivity for assessing obstructing masses (except for stones) - Less useful if ureter and collecting system is undilated

Answer 35

Higher radiation exposure (15-20 milliSieverts) - Risk of contrast nephrotoxicity and contraindicated in renal failure - Higher sensitivity for obstructing masses (e.g. ureteric UCC/TCC, pelvic mass)

Answer 36

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

Answer 37

Lower urinary tract symptoms - voiding and storage, and urinary incontinence (overflow or urge) Acute urinary retention Chronic urinary retention Recurrent urinary tract infection and sepsis Frank haematuria Formation of bladder stones Renal failure (only for chronic high-pressure urinary retention) PV bleeding (for women)

Answer 38

Lower urinary tract symptoms - voiding and storage, and urinary incontinence (overflow or urge) Acute urinary retention Chronic urinary retention Recurrent urinary tract infection and sepsis Frank haematuria Formation of bladder stones Renal failure (only for chronic high-pressure urinary retention) PV bleeding (for women)

Answer 39

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; pelvic/transvaginal USS in women if pelvic mass suspected Flexible cystoscopy if haematuria Urodynamic studies in selected cases TRUS-guided prostate biopsy if PSA raised or abnormal DRE

Answer 40

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: Bladder scan, USS renal tract, etc.) 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

Answer 41

c. Calcium bicarbonate

Answer 42

Alpha blocker

Answer 43

Nephrostomy insertion This is an important lesson to learn. The patient is clearly unwell with obstructed infected kidney causing urosepsis. The mortality rate is very high. The most appropriate treatment option (apart from resuscitation, antibiotics, fluids, etc.) is immediate percutaneous nephrostomy insertion which will drain the kidney and relieve the infection. This is a life-saving intervention. For those who answered ESWL or Ureteroscopy and laser lithotripsy: These would be inappropriate because the patient is too unwell to go through these procedures. Also, these procedures will take time to undertake and time is a luxury we do not have when dealing with these critically ill patients. The only other alternative (which is deliberately not listed in the question) is cystoscopy and retrograde ureteric stent insertion which can also bypass the obstruction and drain the kidney and infection. In either cases (whether treated with nephrostomy or stent insertion), the stone is treated later on (usually weeks later) after the infection settles. This can be treated with ESWL or ureteroscopy and laser lithotripsy.