BLADDER OUTFLOW OBSTRUCTION Flashcards
What percentage of men in their fifties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?
30%
What percentage of men in their eighties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?
50%
What’s the difference between BPE, BPH and BOO?
BPE - Benign Prostatic Enlargement - this is a clinical finding of which BPH is a leading cause
BPH - Benign Prostatic Hyperplasia - this is a histological diagnosis characterised by an increase in the number of cells
BOO - Bladder Outflow Obstruction - This is a clinical finding which does not take cause into account
How do we divide up the male lower urinary tract symptoms (LUTS)?
Storage symptoms
Voiding symptoms
What are the male lower urinary tract symptoms (LUTS) associated with storage problems?
Frequency
Nocturia
Urgency
Urgency incontinence
What are the male lower urinary tract symptoms (LUTS) associated with voiding problems?
Weak urinary stream
Prolonged voiding
Abdominal straining
Hesitancy
Intermittency
Incomplete bladder emptying
Terminal and post-void dribbling
What is the different diagnosis for male lower urinary tract symptoms (LUTS)?
BPH
Bladder cancer
Prostate cancer
UTI
Overactive bladder syndrome (OAB)
Urethral strictures
Neurological disease
What investigations would you do in a man who presents with LUTS?
Validated symptom score such as International Prostate Symptom Score (IPSS) - used to assess response to treatment
Urine analysis - blood, infection or diabetes
PSA when appropriate
Urodynamic studies
Detrusor pressure
Why do we perform a DRE (digital rectal examination) of men with LUTS?
To make a rough estimate of prostate size
To detect locally invasive prostate cancer
What is the normal upper limit of PSA for someone in their 40s above which we would worry about prostate cancer? 50s? 60s? 70s?
40s: Less than 2.5
50s: Less than 3.5
60s: Less than 4.5
70s: Less than 6.5
In a urodynamic study, what is the normal maximum flow rate?
About 25 ml per second
In a urodynamic study, what would be considered a significantly reduced flow rate?
Less 10 ml per second
How do we measure detrusor pressure in patients with LUTS? Why is this useful?
Measure intravesical pressure and rectal pressure
Detrusor pressure then calculated by subtracting rectal pressure from intravesical pressure.
Helps to distinguish between high-pressure low-flow obstructed systems, detrusor dysfunction or atonic bladder as the cause of LUTS
What are the indications for urological referral and intervention in someone presenting with LUTS?
Acute urinary retention
Obstructive nephropathy
Large post-void residual volume causing UTIs
Bladder stones
Failure of medical treatment to help with LUTS
What are the four categories of management options available for treatment of bladder outflow obstruction?
Conservative
Medical
Surgical
Catheter
What are the details of conservative management of bladder outflow obstruction?
Advice on fluid intake
Reduction in caffeine and alcohol ingestion
Bladder retraining
Continence products
What are the first line medical management options for bladder outflow obstruction?
Alpha blockers
5-alpha reductase inhibitors
What are the two physiological elements involvement in bladder outflow obstruction due to BPE?
Static element - mechanical obstruction due to enlargement
Dynamic element - increased tone of prostate smooth muscle
How do alpha blockers work to reduce LUTS caused by BPE?
Relax prostatic smooth muscle
Name 5 alpha blockers used in the treatment of bladder outflow obstruction.
Terazosin
Doxazosin
Tamsulosin
Alfuzosin
Silodosin
What are the side effects of alpha blockers used in the treatment of bladder outflow obstruction?
Postural hypotension
Lethargy
Gastrointestinal disturbance
Nasal congestion
Ejaculatory dysfunction
How do 5-alpha reductase inhibitors work to reduce LUTS caused by BPE?
Reduce size by inhibiting conversion of testosterone into its active metabolite dihydrotestosterone.
What is the minimum prostate size and PSA level beyond which 5-alpha reductase inhibitors are recommended as first line treatment for BPE even without moderate symptoms?
30 cc (about the size of a ping pong ball)
PSA more than 1.4 ng/ml
Name 2 5-alpha reductase inhibitors used in the treatment of bladder outflow obstruction.
Finasteride
Dutasteride
In which patients do we recommend combination therapy of an alpha blocker and a 5-alpha reductase inhibitor?
Severe symptoms
Risk factors for progression
What are the risk factors for progressive BPH?
Age over 70 with LUTS
Moderate to severe symptoms ie IPSS of more than 7
PSA or more than 1.4 ng/ml
Prostate volume over 30 cc
Maximum flow rate of less than 12 ml/second
What is the most popular and widely available herbal medication used in the treatment of symptomatic BPH?
Saw Palmetto, extracted from berries of the American dwarf palm
In which patients with LUTS would we use anticholinergics as opposed to alpha blockers or 5-alpha reductase inhibitors?
Those with overactive bladder syndrome
What are the surgical management options for bladder outflow obstruction?
Transurethral resection of the prostate (TURP)
Laser surgery
What percentage of men will receive good symptomatic relief from transurethral resection of the prostate (TURP)?
90% - gold standard
How is transurethral resection of the prostate (TURP) performed?
Electrocautery through endoscopic instruments introduced via the urethra. Tissue is resected in small chips until obstruction is removed.
After transurethral resection of the prostate (TURP), how long must patients be catheterised for?
2-3 days
What are the complications of transurethral resection of the prostate (TURP)?
UTI 2%
Blood transfusion 6%
Retrograde ejaculation 70%
TUR syndrome 2%
Impotence 8%
Incontinence 1%
Failure to void 5%
What are the two types of laser surgery used in treatment of bladder outflow obstruction?
Holmium laser enucleation of the prostate
Laser ablation of the prostate
What are the complications of acute urinary retention?
Hydronephrosis
Chronic retention
Obstructive nephropathy
Bladder stones
What are the other non-malignant causes of bladder outflow obstruction?
Urethral strictures
Bladder neck dysfunction
What is the classic sign of urethral stricture seen on investigation of LUTS?
Flow rate shows a plateau with a prolonged voiding cycle
How do we treat short urethral strictures?
Endoscopic urethrotomy
In which group of men is bladder neck dysfunction typically seen as the cause of LUTS?
Younger men
How do we treat bladder neck dysfunction?
Alpha blockers
Surgical bladder neck incision
What are the complications of surgical bladder neck incision?
Retrograde ejaculation so this will affect fertility
