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Year 2- Urinary > Benign Diseases of the Prostate and Urinary Tract Obstruction > Flashcards

Benign Diseases of the Prostate and Urinary Tract Obstruction Flashcards

1
Q

What is the average size of the prostate gland in men aged 25-30 years?

A

20 cubic cm

->increases in size with age

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2
Q

Name the four zones of the prostate.

A

Transitional zone
Central zone
Peripheral zone
Inferior fibromuscular stroma

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3
Q

Which zone of the prostate does benign prostatic hyperplasia usually affect?

A

Transitional zone

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4
Q

Why does benign prostatic hyperplasia cause symptoms?

A

Because the transitional zone surrounds the urethra and hyperplasia can cause obstruction to the bladder or urethra

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5
Q

Which prostatic zone do the majority of prostate cancers arise from?

A

Peripheral zone

->this is why they can be asymptomatic for so long as away from the ureter

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6
Q

BPE?

A

Benign prostate enlargement

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7
Q

BPH?

A

Benign prostate hyperplasia

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8
Q

BPO?

A

Benign prostatic obstruction

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9
Q

BOO?

A

Bladder outflow obstruction

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10
Q

LUTS?

A

Lower urinary tract symptoms

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11
Q

What is BPE characterised by?

->benign prostatic hyperplasia, imma use the abbreviations so you get them in your head but make sure you work out which one it is before answering the question

A

Fibromuscular and glandular hyperplasia

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12
Q

BPH is part of the aging process in men. What % of men at 60yrs have BPH?

A

50%

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13
Q

BPH is part of the aging process in men. What % of men at 85yrs have BPH?

A

90%

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14
Q

What % of men with BPH have moderate to severe LUTS?

A

50%

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15
Q

BPH is a progressive condition resulting in what?

A

BPO or BOO

(okay imma give you them again just to make sure- Benign prostatic obstruction and bladder outflow obstruction)

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16
Q

What can be sued for the assessment of LUTS?

A

Symptom scoring systems e.g. IPSS
Frequency volume charts

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17
Q

Are voiding symptoms obstructive or irritative?

A

Obstructive

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18
Q

Are storage symptoms obstructive or irritative?

A

Irritative

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19
Q

List some voiding symptoms which can relate to obstruction.

A

Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying

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20
Q

List some storage symptoms which can relate to irritation.

A

Frequency
Nocturia
Urgency +/- urge incontinence

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21
Q

IPSS score sheet = International Prostate Symptom Score which is put of 35.

What does an IPSS of 0-7 indicate?

A

Mild prostate symptoms

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22
Q

IPSS score sheet = International Prostate Symptom Score which is put of 35.

What does an IPSS of 8-19 indicate?

A

Moderate prostatic symptoms

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23
Q

IPSS score sheet = International Prostate Symptom Score which is put of 35.

What does an IPSS 20+ indicate?

A

Severe prostatic symptoms

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24
Q

For how long do patients complete a frequency volume chart?

A

Over three days

3-5 days makes in more representable however

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25
Q

Anyone presenting with lower urinary symptoms should have a physical examination.

What should be examined?

A

Abdomen
Penis
Digital rectal exam
Urinalysis

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26
Q

What is checked in an abdomen exam relating to prostate issues?

A

Palpable bladder is looked for

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27
Q

What would be looked for in an examination of the penis regarding prostate symptoms?

A

External urethral meatal stricture
Phimosis

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28
Q

Phimosis?

A

Condition of foreskin where the skin is tight and unable to retract back from behind the head of the penis

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29
Q

What are some of the investigations carried out in someone with BPH?

A

MSSU
Flow rate study
Post-bladder residual USS
Bloods

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30
Q

Which bloods are carried out in BPH?

A

PSA
Urea and creatinine if chronic retention

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31
Q

What investigation is carried out if renal failure or a bladder stone is suspected?

A

Renal tract ultrasound

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32
Q

What investigation may be carried out if thee is haematuria?

A

Flexible cystoscopy

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33
Q

If PSA is raised or there is abnormal rectal exam, what investigation may be carried out?

A

TRUS- guided prostate biopsy

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34
Q

In regards to flow rate studies, what findings are indicative of obstruction or underactivity of the bladder?

A

Prolonged flow with maximum flow rate

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35
Q

What is the treatment for uncomplicated BPO?

A

Mild symptoms don’t need anything- just watchful waiting

When treatment required, medical therapy can be used. 5 alpha reductase inhibitors, alpha blockers of a combination

Surgical intervention may be required

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36
Q

Give some examples of 5 alpha reductase inhibitors.

A

Finasteride
Dutasteride

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37
Q

In mild cases where treatment is required, which drug do you start with for BPO?

A

Start with alpha blockers and add on 5 alpha reductase inhibitors if required

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38
Q

When may the TURP procedure of open retropubic or transvesical proctectomy be carried out?

A

If prostate > 100 cubic cm

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39
Q

What is the main treatment for LUTS due to BPO?

A

Alpha blockers

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40
Q

How do Alpha Blockers work?

A

Cause smooth muscle relaxation of the bladder neck and prostate

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41
Q

Give an example of a non-selective alpha blocker.

A

Phenoxybenzamine

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42
Q

Give an example of a selective short acting alpha blocker.

A

Prazosin, indoramin

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43
Q

Give an example of a selective long acting alpha blocker.

A

Alfuzosin
Doxazosin
Terazosin

44
Q

Give an example of a highly selective alpha blocker.

A

Tamsulosin

45
Q

What do 5 alpha reductase inhibitors do?

A

Converts testosterone to dihydrotestosterone

46
Q

What are the two type of 5 alpha reductase inhibitors currently available?

A

Finasteride
Dutasteride

47
Q

What is the role of 5-alpha reductase inhibitors?

A

Reduces prostate size
Reduces risks of progression (if <25cubic cm)
Reduces LUTS, although not as effective as alpha blockers)

48
Q

Which type of drug is most effective against LUTS?

A

Alpha blockers

49
Q

What medical treatment is most effective is reducing the risks of progression of BPE?

A

Combination therapy of Alpha Blockers and 5-alpha reductase inhibitors

50
Q

What is the golden standard of surgical management in terms of BPE causing BOO?

A

TURP

Transurethral resection of prostate

51
Q

What are some of the potential complications of TURP?

A

Bleeding, infection, retrograde ejaculation, prostatic regrowth causing recurrent haematuria or BOO

52
Q

Prostate >100cc are too large for TURP as there are higher risks of what?

A

Bleeding
Fluid overload
Hypothermia
TUR syndrome

53
Q

What are some of the complications of BPO?

A

Progression of LUTS
Acute/chronic urinary retention
Urinary incontinence
UTI
Bladder stone
Renal failure

54
Q

What is the treatment for complicated BPO?

A

There is no role for medical therapy EXCEPT in patients with acute urinary retention

Most patients require surgery

55
Q

What are some of the surgical treatments for patients with complicated BPO?

A

Cystolitholapxy
TURP

56
Q

What are some alternative treatment options for complicated BPO if patient is unfit for surgery?

A

Long term urethral or suprapubic catheterisation
Intermittent self-catherisation

57
Q

RECAP- define acute urinary retention

A

Painful inability to void with a palpable and percussible bladder

58
Q

What is the main risk factor of acute urinary retention?

A

BPO

59
Q

RECAP- what is the treatment for acute urinary retention?

A

Immediate catheterisation

60
Q

RECAP- define chronic urinary retention

A

Painless, palpable and pecussable bladder after voiding

61
Q

RECAP- what is the main cause of chronic urinary retention?

A

Detrusor muscle underactivity

62
Q

How does chronic urinary retention present?

A

Often as LUTs or other complications e.g. bladder stones

63
Q

What is the immediate treatment of chronic urinary retention?

A

Catheterisation

64
Q

The following are an absolute indications for surgical intervention in patients with BPO EXCEPT:

a. refractory acute urinary retention
b. refractory chronic urinary retention
c. renal failure
d. recurrent UTI
e. failure of medical therapy to control symptoms

A

B- refractory chronic urinary retention

->because there’s no such thing apparently, just wanted to highlight the absolute indications for surgical intervention!!

65
Q

The following are common causes of acute urinary retention in men EXCEPT:
a. spinal cord compression
b. UTI
c. constipation
d. pain from laparotomy wound
e. cystoscopy under local anaesthetic

->think about nerve supplies, muscles having to strain etc.

A

E- cystoscopy under local anaesthetic

66
Q

Short-term urethral catheters should not be left in for longer than??

A

4 weeks

67
Q

Long-term urethral catheters should not be left in for longer than??

A

12 weeks

68
Q

Who will never get bladder neck obstruction?

A

Women
Only men get bladder neck obstruction

69
Q

What are some of the causes of intrinsic obstruction at the pelvi-uretic junction AND the ureter?

A

Scar tissue
Stone
Uretic tumour
Blood clot

70
Q

What are some of the causes of extrinsic obstruction at the pelvi-uretic junction?

A

Crossing vessels
Lymph nodes
Abdominal mass

71
Q

What are some of the causes of intrinsic obstruction at the vesico-ureteric junction?

A

Stones
Bladder tumour
Ureteric tumour
Prostate cancer

72
Q

In ureteric obstruction caused by extrinsic pathology, it is important to know that the cause might be iatrogenic.
What could this iatrogenic cause be?

A

Tying of ureter or accidentally coagulated during pelvic surgery

73
Q

What are the symptoms of an upper urinary tract obstruction?

A

Pain
Frank haematuria

74
Q

What are the signs of an upper urinary tract obstruction?

A

Palpable mass
Microscopic haematuria

75
Q

What are the complications of an upper urinary tract obstruction?

A

Infection and sepsis
Renal failure if bilateral obstruction or patient has a single kidney

76
Q

What type of imaging can be used in upper urinary tract obstruction?

A

Abdominal/renal tract ultrasound scan

77
Q

If the upper urinary tract is obstructed, what will ultrasound show?

A

Hydronephrosis
Hydroureter

78
Q

Hydronephrosis?

A

Dilatation of the collective system e.g. calyx, calyces, renal pelvis

->not a swollen kidney, swelling of this part of the kidney

79
Q

Hydroureter?

A

Dilatated ureter

80
Q

What is IVU?

A

Intravenous urogram

->contrast is injected and allows visualisation of whole urinary system
Now superseded by CT to look at stones etc

81
Q

MAG-3 imaging can also be sued in imaging of the upper urinary tract for obstruction. What can it highlight?

A

Split renal function as shows % of isotope used in each kidney, should be 50:50 but in cases where one kidney works harder, shows this
Also shows severity of obtrusive through the tract

82
Q

When will MAG-3 renograms be used?

A

Chronic unilateral upper urinary tract obstruction

83
Q

When will MAG-3 renograms NOT be used?

A

In the acute setting
For stones or tumours

84
Q

What is CT-KUB?

A

Non contrast CT of the kidneys, ureter and bladder

85
Q

When is CT-KUB used?

A

Investigation of urinary tract stones and obstruction in the emergency setting

86
Q

What are the pros and cons of CT-KUB?

A

Pros:
Quick
Lower radiation exposure
No risk of contrast nephrotoxicity

Cons:
Lower sensitivity for assessing obstructing masses (apart from stones)
Less useful if ureter and collecting system is undilated

87
Q

What are the pros and cons of CT-urograms?

A

Pros:
Higher sensitivity for obstructing masses

Cons:
Risk of contrast nephrotoxicity
Higher radiation exposure

88
Q

Which renal imaging technique is contraindicated in renal failure?

A

CT-urogram

->CT-KUB is okay in renal failure

89
Q

Which type of renal CT uses contrast?

A

CT-urogram

90
Q

What are some of the emergency treatment for upper urinary tract obstruction?

A

Percutaneous nephrostomy insertion (drain in kidney)
Retrograde stent insertion

->most important thing to do is drain the kidney in an emergency situation

91
Q

After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.

How would a stone be treated?

A

Uteroscopy and laser lithotripsy

92
Q

After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.

How would an ureteric tumour?

A

Radical nephro-uterectomy

93
Q

After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.

How would a PUJ obstruction?

A

Laparoscopic pyeloplasty

94
Q

List some of the possible presentations of a lower urinary tract obstruction.

A

LUTS
Acute/chronic urinary retention
Recurrent UTI’s and sepsis
Frank haematuria
Formation of bladder stones
PV bleeding in women

95
Q

What should be checked in a physical examination if lower urinary tract obstruction was suggested?

A

Abdomen
Penis
Digital rectal examination
Per vaginal examination if bleeding
Urinalysis

96
Q

What is the first step in management of upper AND lower urinary tract obstruction in the emergency setting?

A

Resuscitation

->mostly presents as emergencies in which patient is unconscious

97
Q

What is the emergency treatment for a lower urinary tract obstruction?

A

Urethral catheterisation
Suprapubic catheterisation

98
Q

After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.

What would be done in BPE?

A

TURP

99
Q

After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.

What would be done in urethral stricture?

A

Optical urethrotomy

100
Q

After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.

What would be done in meatal stenosis?

A

Meatal dilatation

101
Q

After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.

What would be done in phimosis?

A

Circumcision

102
Q

What is the gold standard investigation for renal colic?

A

CT-KUB

103
Q

The following are common types of renal stones EXCEPT:

a. calcium phosphate
b. calcium oxalate
c. calcium bicarbonate
d. uric acid (urate)
e. magnesium ammonium phosphate

A

Calcium bicarbonate

->component of bones and teeth but not renal stones

104
Q

What would be the first line treatment for a 50yr man with moderate LUTS, slightly enlarged prostate (25cc) and poor urinary flow?

A

Alpha blockers

105
Q

What would be the treatment for a 64yr man with 2nd episode of acute urinary retention. He is already on an alpha blocker.

A

TURP

106
Q

What would be the treatment: 35yr old with temperature of 40 degrees, right loin and flank pain, CT-KUB shows 10mm stone at upper right ureter causing sever hydronephrosis.

A

Nephrostomy insertion, assuming she has been resuscitated

107
Q
A

Year 2- Urinary (22 decks)

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