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Urinary system > Benign diseases of the prostate and urinary tract obstruction > Flashcards

Benign diseases of the prostate and urinary tract obstruction Flashcards

1
Q

How big is the average prostate?

A

20cc (like a walnut)

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2
Q

Who first described the prostatic zones?

A

McNeal’s prostatic zones

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3
Q

Describe Benign prostatic hyperplasia

A

• Characterised by fibromuscular and glandular hyperplasia
• Predominantly affects transition zone
• 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 resulting in Bladder Outflow Obstruction (BOO)

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4
Q

What % of men at 60yo have benign prostatic hyperplasia?

A

50%

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5
Q

What % of men at 85yo have benign prostatic hyperplasia?

A

90%

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6
Q

Which zone of the prostate is predominantly affected in benign prostatic hyperplasia?

A

Transition zone

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7
Q

How is severity of prostate disease LUTS symptoms assessed?

A

International prostate symptom score sheet

Total score (out of 35) suggests severity of symptoms:
o Mild: 0-7
o Moderate: 8-19
o Severe: ≥ 20

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8
Q

How are lower urinary tract symptoms (LUTS) assessed?

A
  • Symptom scoring systems - IPSS

* Frequency volume charts

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9
Q

Describe the physical examination needed when investigating possible benign disease of the prostate

A

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

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10
Q

What investigations are used for benign diseases of the prostate?

A

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 or to visualise obstructions
Urodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE

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11
Q

How is uncomplicated BPO treated?

A 
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
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12
Q

What is the main treatment used for LUTS due to BPO?

A

Alpha blockers

  • 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
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13
Q

Why are 5a reductase inhibitors used for BPO?

A

5a-reductase converts testosterone to dihydrotestosterone

  • 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
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14
Q

What is TURP?

A

Trans-urethral resection of prostate

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15
Q

What is the gold standard surgical treatment of benign prostatic hyperplasia?

A

Trans-urethral resection of prostate/TURP

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16
Q

Describe efficacy of TURP 1 year after surgery

A

90%

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17
Q

What are some complications associated with TURP?

A 
o	Bleeding
o	Infection
o	Retrograde ejaculation
o	Stress urinary Incontinence
o	Prostatic regrowth causing recurrent haematuria or BOO
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18
Q

What are some alternative new endoscopic ablative techniques to TURP?

A

o Transurethral laser vaporisation

o Urolift

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19
Q

List some complications of benign prostatic obstruction (BPO)

A
  • 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
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20
Q

What are the alternative treatment options for complicated BPO?

A

– Long term urethral or suprapubic catheterisation
– Clean intermittent self-catheterisation
– May develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI

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21
Q

How is complicated BPO treated?

A

• 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)

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22
Q

Describe acute urinary retention

A
  • Defined as ‘an acute 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
23
Q

What are some risk factors for acute urinary retention?

A

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)

24
Q

How is acute urinary retention treated?

A

Immediate catheterisation

If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully)

If still fail to void, recatheterise and organise TURP (after 6 weeks)

25
Q

List some complications of catheterisation in acute urinary retention

A

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

26
Q

Describe chronic urinary retention

A
  • 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)
  • 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)
27
Q

How is chronic urinary retention treated?

A

Only really required if symptomatic or with complications!

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

28
Q

List some complications of catheterisation in chronic urinary retention

A

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

29
Q

Describe the features of pathological diuresis

A

Pathological diuresis features:

  • urine output >200ml/hr
  • postural hypotension (systolic differential >20mm Hg between lying and standing)
  • weight loss
  • electrolyte abnormalities
30
Q

Define postural hypotension

A

systolic differential >20mm Hg between lying and standing

31
Q

How is pathological diuresis following catheterisation in chronic urinary retention treated?

A
  • 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
32
Q

Patients with what type of urinary retention have better outcomes with TURP?

A

• 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

33
Q

Describe the symptoms and signs of upper urinary tract obstruction

A

Symptoms

  • Pain
  • Frank haematuria
  • Symptoms of complications

Signs

  • Palpable mass
  • Microscopic haematuria
  • Signs of complications
34
Q

What complications are associated with upper urinary tract obstructions?

A

• Complications

  • Infection and sepsis
  • Renal failure
35
Q

Describe resuscitation used in upper urinary tract obstruction

A
  • 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)
36
Q

List some emergency treatment for upper urinary tract obstruction for remitting pain or complications

A

– Percutaneous nephrostomy insertion

- Retrograde stent insertion

37
Q

How are stones in the upper urinary tract treated?

A

ureteroscopy and laser lithotripsy +/- basketing or ESWL

38
Q

How are ureteric tumours treated?

A

radical nephro-ureterectomy

39
Q

How are PUJ obstructions treated?

A

laparoscopic pyeloplasty

40
Q

How does lower urinary tract obstruction present?

A
  • LUTS e.g. urinary incontinence
  • Acute urinary retention
  • Chronic urinary retention
  • Recurrent urinary tract infection and sepsis
  • Frank haematuria
  • Formation of bladder stones
  • Renal failure
41
Q

Which size of urethral catheter is usually used in adults?

A

Urethral catheter - 14/16F size often used in adults

42
Q

What is used for catheterisation if urethra is impassable?

A

16F suprapubic catheter (SPC) if urethra impassable

43
Q

What is used to treat BPE if found to be causing lower urinary tract obstruction?

A

transurethral resection of prostate (TURP)

44
Q

What is used to treat urethral strictures if found to be causing lower urinary tract obstruction?

A

Optical urethrotomy

45
Q

What is used to treat mental stenosis if found to be causing lower urinary tract obstruction?

A

Meatal dilatation

46
Q

What is used to treat Phimosis if found to be causing lower urinary tract obstruction?

A

Circumcision

47
Q

List some potential causes of lower urinary tract obstruction

A

Phimosis
Meatal stenosis
Urethral strictures
Benign prostate enlargement

48
Q

List some potential causes of upper urinary tract obstruction

A

Ureteric stone
Ureteric tumour
PUJ obstruction

49
Q

Compare and contrast high pressure vs low pressure chronic retention

A 
High pressure 		             
•	Painless		
•	Incontinent			             
•	Raised creatinine		            
•	Bilateral hydronephrosis	
 Low pressure
•	Painless			         
•	Dry
•	Normal creatinine
•	Normal kidneys
50
Q

Describe decompression haematuria

A

– Shearing of small vessels due to differing compliance of tissue layers
– Usually self limiting

51
Q

Describe post-obstructive diuresis

A

– Greater than 150-200ml/hr
– 0.5-50%
– Osmotic diuresis secondary to urea; ADH; altered tubular function
– Can lead to life threatening sodium and water depletion
– Normal saline at input = output-30ml/hr

52
Q

What is the ‘gold standard’ investigation for renal colic?

a. Renal ultrasound scan
b. MRI of renal tract
c. IVU
d. CT-KUB
e. Plain KUB X-ray

53
Q

The following are common types of renal tract stones except:

a. Calcium phosphate
b. Calcium oxalate
c. Calcium bicarbonate
d. Uric acid (urate)
e. Magnesium ammonium phosphate (struvite)

A

c. Calcium bicarbonate

Urinary system (22 decks)

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