Benign Diseases of the Prostate and Urinary Tract Obstruction Flashcards
What is the average size of the prostate gland in men aged 25-30 years?
20 cubic cm
->increases in size with age
Name the four zones of the prostate.
Transitional zone
Central zone
Peripheral zone
Inferior fibromuscular stroma
Which zone of the prostate does benign prostatic hyperplasia usually affect?
Transitional zone
Why does benign prostatic hyperplasia cause symptoms?
Because the transitional zone surrounds the urethra and hyperplasia can cause obstruction to the bladder or urethra
Which prostatic zone do the majority of prostate cancers arise from?
Peripheral zone
->this is why they can be asymptomatic for so long as away from the ureter
BPE?
Benign prostate enlargement
BPH?
Benign prostate hyperplasia
BPO?
Benign prostatic obstruction
BOO?
Bladder outflow obstruction
LUTS?
Lower urinary tract symptoms
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
Fibromuscular and glandular hyperplasia
BPH is part of the aging process in men. What % of men at 60yrs have BPH?
50%
BPH is part of the aging process in men. What % of men at 85yrs have BPH?
90%
What % of men with BPH have moderate to severe LUTS?
50%
BPH is a progressive condition resulting in what?
BPO or BOO
(okay imma give you them again just to make sure- Benign prostatic obstruction and bladder outflow obstruction)
What can be sued for the assessment of LUTS?
Symptom scoring systems e.g. IPSS
Frequency volume charts
Are voiding symptoms obstructive or irritative?
Obstructive
Are storage symptoms obstructive or irritative?
Irritative
List some voiding symptoms which can relate to obstruction.
Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying
List some storage symptoms which can relate to irritation.
Frequency
Nocturia
Urgency +/- urge incontinence
IPSS score sheet = International Prostate Symptom Score which is put of 35.
What does an IPSS of 0-7 indicate?
Mild prostate symptoms
IPSS score sheet = International Prostate Symptom Score which is put of 35.
What does an IPSS of 8-19 indicate?
Moderate prostatic symptoms
IPSS score sheet = International Prostate Symptom Score which is put of 35.
What does an IPSS 20+ indicate?
Severe prostatic symptoms
For how long do patients complete a frequency volume chart?
Over three days
3-5 days makes in more representable however
Anyone presenting with lower urinary symptoms should have a physical examination.
What should be examined?
Abdomen
Penis
Digital rectal exam
Urinalysis
What is checked in an abdomen exam relating to prostate issues?
Palpable bladder is looked for
What would be looked for in an examination of the penis regarding prostate symptoms?
External urethral meatal stricture
Phimosis
Phimosis?
Condition of foreskin where the skin is tight and unable to retract back from behind the head of the penis
What are some of the investigations carried out in someone with BPH?
MSSU
Flow rate study
Post-bladder residual USS
Bloods
Which bloods are carried out in BPH?
PSA
Urea and creatinine if chronic retention
What investigation is carried out if renal failure or a bladder stone is suspected?
Renal tract ultrasound
What investigation may be carried out if thee is haematuria?
Flexible cystoscopy
If PSA is raised or there is abnormal rectal exam, what investigation may be carried out?
TRUS- guided prostate biopsy
In regards to flow rate studies, what findings are indicative of obstruction or underactivity of the bladder?
Prolonged flow with maximum flow rate
What is the treatment for uncomplicated BPO?
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
Give some examples of 5 alpha reductase inhibitors.
Finasteride
Dutasteride
In mild cases where treatment is required, which drug do you start with for BPO?
Start with alpha blockers and add on 5 alpha reductase inhibitors if required
When may the TURP procedure of open retropubic or transvesical proctectomy be carried out?
If prostate > 100 cubic cm
What is the main treatment for LUTS due to BPO?
Alpha blockers
How do Alpha Blockers work?
Cause smooth muscle relaxation of the bladder neck and prostate
Give an example of a non-selective alpha blocker.
Phenoxybenzamine
Give an example of a selective short acting alpha blocker.
Prazosin, indoramin
Give an example of a selective long acting alpha blocker.
Alfuzosin
Doxazosin
Terazosin
Give an example of a highly selective alpha blocker.
Tamsulosin
What do 5 alpha reductase inhibitors do?
Converts testosterone to dihydrotestosterone
What are the two type of 5 alpha reductase inhibitors currently available?
Finasteride
Dutasteride
What is the role of 5-alpha reductase inhibitors?
Reduces prostate size
Reduces risks of progression (if <25cubic cm)
Reduces LUTS, although not as effective as alpha blockers)
Which type of drug is most effective against LUTS?
Alpha blockers
What medical treatment is most effective is reducing the risks of progression of BPE?
Combination therapy of Alpha Blockers and 5-alpha reductase inhibitors
What is the golden standard of surgical management in terms of BPE causing BOO?
TURP
Transurethral resection of prostate
What are some of the potential complications of TURP?
Bleeding, infection, retrograde ejaculation, prostatic regrowth causing recurrent haematuria or BOO
Prostate >100cc are too large for TURP as there are higher risks of what?
Bleeding
Fluid overload
Hypothermia
TUR syndrome
What are some of the complications of BPO?
Progression of LUTS
Acute/chronic urinary retention
Urinary incontinence
UTI
Bladder stone
Renal failure
What is the treatment for complicated BPO?
There is no role for medical therapy EXCEPT in patients with acute urinary retention
Most patients require surgery
What are some of the surgical treatments for patients with complicated BPO?
Cystolitholapxy
TURP
What are some alternative treatment options for complicated BPO if patient is unfit for surgery?
Long term urethral or suprapubic catheterisation
Intermittent self-catherisation
RECAP- define acute urinary retention
Painful inability to void with a palpable and percussible bladder
What is the main risk factor of acute urinary retention?
BPO
RECAP- what is the treatment for acute urinary retention?
Immediate catheterisation
RECAP- define chronic urinary retention
Painless, palpable and pecussable bladder after voiding
RECAP- what is the main cause of chronic urinary retention?
Detrusor muscle underactivity
How does chronic urinary retention present?
Often as LUTs or other complications e.g. bladder stones
What is the immediate treatment of chronic urinary retention?
Catheterisation
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
B- refractory chronic urinary retention
->because there’s no such thing apparently, just wanted to highlight the absolute indications for surgical intervention!!
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.
E- cystoscopy under local anaesthetic
Short-term urethral catheters should not be left in for longer than??
4 weeks
Long-term urethral catheters should not be left in for longer than??
12 weeks
Who will never get bladder neck obstruction?
Women
Only men get bladder neck obstruction
What are some of the causes of intrinsic obstruction at the pelvi-uretic junction AND the ureter?
Scar tissue
Stone
Uretic tumour
Blood clot
What are some of the causes of extrinsic obstruction at the pelvi-uretic junction?
Crossing vessels
Lymph nodes
Abdominal mass
What are some of the causes of intrinsic obstruction at the vesico-ureteric junction?
Stones
Bladder tumour
Ureteric tumour
Prostate cancer
In ureteric obstruction caused by extrinsic pathology, it is important to know that the cause might be iatrogenic.
What could this iatrogenic cause be?
Tying of ureter or accidentally coagulated during pelvic surgery
What are the symptoms of an upper urinary tract obstruction?
Pain
Frank haematuria
What are the signs of an upper urinary tract obstruction?
Palpable mass
Microscopic haematuria
What are the complications of an upper urinary tract obstruction?
Infection and sepsis
Renal failure if bilateral obstruction or patient has a single kidney
What type of imaging can be used in upper urinary tract obstruction?
Abdominal/renal tract ultrasound scan
If the upper urinary tract is obstructed, what will ultrasound show?
Hydronephrosis
Hydroureter
Hydronephrosis?
Dilatation of the collective system e.g. calyx, calyces, renal pelvis
->not a swollen kidney, swelling of this part of the kidney
Hydroureter?
Dilatated ureter
What is IVU?
Intravenous urogram
->contrast is injected and allows visualisation of whole urinary system
Now superseded by CT to look at stones etc
MAG-3 imaging can also be sued in imaging of the upper urinary tract for obstruction. What can it highlight?
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
When will MAG-3 renograms be used?
Chronic unilateral upper urinary tract obstruction
When will MAG-3 renograms NOT be used?
In the acute setting
For stones or tumours
What is CT-KUB?
Non contrast CT of the kidneys, ureter and bladder
When is CT-KUB used?
Investigation of urinary tract stones and obstruction in the emergency setting
What are the pros and cons of CT-KUB?
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
What are the pros and cons of CT-urograms?
Pros:
Higher sensitivity for obstructing masses
Cons:
Risk of contrast nephrotoxicity
Higher radiation exposure
Which renal imaging technique is contraindicated in renal failure?
CT-urogram
->CT-KUB is okay in renal failure
Which type of renal CT uses contrast?
CT-urogram
What are some of the emergency treatment for upper urinary tract obstruction?
Percutaneous nephrostomy insertion (drain in kidney)
Retrograde stent insertion
->most important thing to do is drain the kidney in an emergency situation
After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.
How would a stone be treated?
Uteroscopy and laser lithotripsy
After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.
How would an ureteric tumour?
Radical nephro-uterectomy
After the kidney is drained in emergency upper urinary tract obstructions, the actual obstruction can be treated.
How would a PUJ obstruction?
Laparoscopic pyeloplasty
List some of the possible presentations of a lower urinary tract obstruction.
LUTS
Acute/chronic urinary retention
Recurrent UTI’s and sepsis
Frank haematuria
Formation of bladder stones
PV bleeding in women
What should be checked in a physical examination if lower urinary tract obstruction was suggested?
Abdomen
Penis
Digital rectal examination
Per vaginal examination if bleeding
Urinalysis
What is the first step in management of upper AND lower urinary tract obstruction in the emergency setting?
Resuscitation
->mostly presents as emergencies in which patient is unconscious
What is the emergency treatment for a lower urinary tract obstruction?
Urethral catheterisation
Suprapubic catheterisation
After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.
What would be done in BPE?
TURP
After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.
What would be done in urethral stricture?
Optical urethrotomy
After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.
What would be done in meatal stenosis?
Meatal dilatation
After catheterisation, the management of an emergency lower urinary tract obstruction involves treating the underlying cause.
What would be done in phimosis?
Circumcision
What is the gold standard investigation for renal colic?
CT-KUB
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
Calcium bicarbonate
->component of bones and teeth but not renal stones
What would be the first line treatment for a 50yr man with moderate LUTS, slightly enlarged prostate (25cc) and poor urinary flow?
Alpha blockers
What would be the treatment for a 64yr man with 2nd episode of acute urinary retention. He is already on an alpha blocker.
TURP
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.
Nephrostomy insertion, assuming she has been resuscitated
