Bladder Outflow Obstruction

Question 1

Causes of BOO (5)

Answer 1

BPH

urethral stricture

prostate ca.

stones

neurological disease affecting lower urinary tract-parasympathetic, S2/3/4

Question 2

Causes of urethral strictures (3)

Answer 2

infections

trauma

iatrogenic

Question 3

Ix and Rx of urethral strictures (2)

Answer 3

urine flow rate shows characteristic plateau w. prolonged voiding cycle.

endoscopic urethrotomy

Question 4

McNeal’s zones of the prostate (3)

Answer 4

around urethra: transitional zone-only 20% of ca.

central zone

peripheral zone: 70% of ca.

BPH occurs mainly in central and peripheral zones=>still risk of ca. after surgery for BPH

Question 5

Presentation of BPH (4)

Answer 5

hesitancy

poor flow

nocturia

frequency

Question 6

Features of AUR (7)

Answer 6

onset over hrs

painful

tender, tense bladder

no nocturnal/overflow incontinence

no impaired renal function

no post catheter diuresis/haematuria

residue <1L

Question 7

Features of CUR (8)

Answer 7

onset over days-weeks

painless

flabby, non-tender bladder

nocturnal incontinence and marked overflow incontinence

renal impairment common but now always present

post obstructive diuresis. can> dehydration and low Na and HCO3

post catheter haematuria common

residue >1/5-2L

Question 8

Causes of retention in men (7)

Answer 8

BPH-most common

prostate ca.

prostatitis

meatal stenosis

phimosis

paraphimosis

penile constricting bands

Question 9

Causes of prostatitis (3)

Answer 9

strep faecalis

E.coli

chlamydia

Question 10

Features of prostatitis (5)

Answer 10

urinary retention

pain

haematospermia

UTIs

swollen, boggy prostate

Question 11

Ix for prostatitis

Answer 11

urine sample

Question 12

Rx of prostatitis

Answer 12

analgesia+ciprofloxacin/levofloxacin

Question 13

Causes of urinary retention in women (3)

Answer 13

prolapse

gynae mass

retroverted gravid uterus

Question 14

Causes of urinary retention in both men and women (13)

Answer 14

cystoscopy

drugs-anticholinergics, antispasmodics, antihistamines

peri-aortitis>retroperitoneal fibrosis

bladder calculi

bladder ca.

foecal impaction/constipation

neurological-sacral problems e.g. cauda equina, check perineal sensation

GI/retroperitoneal malignancy

urethral strictures

foreign body

trauma

clot retention

infection

Question 15

Ix for BOO (8)

Answer 15

DRE

urine dip

PSA

Urodynamic flow: non invasive, 25ml/s normal, <10ml/s significant

USS of urinary tract

full urodynamic studies:

• pressure transducer in bladder
• differentiates between, high pressure-low flow, detrusor dysfunction and atonic bladder

voiding diary/frequency-volume chart

IPSS-dictates Rx:

• 0-7=mild
• 8-19=moderate
• 20-35=severe

Question 16

conservative Mx for BOO (4)

Answer 16

if mild:

• advice on fluid intake
• reduce caffeine and alcohol
• continence products
• bladder retraining

Question 17

Medical Mx of BOO+mechanisms, SEs and when to review (8)

Answer 17

dynamic problem-contraction of smooth muscle in prostate/bladder neck:

• alpha blocker e.g. tamsulosin, alfuzosin, doxazosin
• relax smooth muscle in bladder neck
• SEs: post-hypo, RETROGRADE EJACULATION, lethargy, GI disturbance, nasal congestion
• review at 4-6wks

static problem-prostatic enlargement:

• 5-ARIs: finesteride, dutasteride
• inhibit conversion of testosterone>DHT
• takes 3mo to start working.
• indicated if prostate>30cc or high risk of progression
• SEs: decreased libido, erectile dysfunction, increased scalp hair.
• excreted into semen so warn to use condoms
• review at 3-6 mo

Question 18

Surgical Mx of BOO (3)

Answer 18

TURP:

• peripheral zone still left
• post-op: no driving or sex for 2wks, may have some haematuria
• SEs: incontinence, retrograde ejaculation, impotence, UTIs, failure to void
• TUR syndrome: de-ionised fluid used in irrigation enters circulation>hyponatraemia+seizures+fluid overload

TUVaporisationP:

• electrical current ablates prostate
• lower cost, can be used w. anticoagulants, fewer SEs, shorter recovery time

Laser surgery

Question 19

LT Mx of AUR (4)

Answer 19

start alpha blocker

trial w/o catheter

if this fails:

• long term catheter
• prostatic surgery

Question 20

LT Mx of CUR (3)

Answer 20

Prostate surgery

LT catheter

monitor electrolytes imbalances esp. hyponatraemia