Bladder Outflow Obstruction

Question 1

What are the causes of bladder outflow obstruction?

Answer 1

Benign prostatic hyperplasia, urethral stricture, prostate cancer, bladder stones, extrinsic (cystocolele, pelvic non-urinary cancer), drugs (anti-cholinergics, nasal decongestants)

Question 2

What are the three components of Hald’s rings?

Answer 2

Lower urinary tract symptoms (LUTS), bladder outflow obstruction, benign prostatic hyperplasia

Question 3

Why do patients present to their GP?

Answer 3

Bothersome symptoms, risk of acute retention, possibility of prostate cancer = must establish reason as may impact choice of treatment

Question 4

What are the two main groups of lower urinary tract symptoms?

Answer 4

Storage = when bladder is filling with urine
Voiding = when patient is trying to pass urine

Question 5

What are some symptoms associated with storage?

Answer 5

Frequency, urgency, nocturia

Question 6

What are some symptoms associated with voiding?

Answer 6

Hesitancy, poor flow, intermittent flow, sensation of incomplete emptying, post-micturition dribbling

Question 7

What specific symptoms should you ask about?

Answer 7

Bedwetting = high pressure chronic retention

Back pain/neurological symptoms = sciatica, lower limb weakness or sensory symptoms

Question 8

What are some red flags symptoms?

Answer 8

Haematuria, suprapubic pain, recurrent UTIs = suspect bladder cancer if present

Question 9

What aspects of a patient’s symptoms should you ask about?

Answer 9

Duration, extent, impact/troublesome nature

Question 10

What lifestyle aspects should you ask about?

Answer 10

Fluid intake and changes tried by patient

Question 11

What are some features of the patient’s past medical and drug histories?

Answer 11

Drugs = trial in primary care and outcome, sympathomimetic and anti-cholinergic effects
PMH = urethral injury/instrumentation, pelvic surgery, neurological disorders

Question 12

What are the standardised questionnaires for assessing severity?

Answer 12

IPSS, AUA, Bristol male LUTS

Question 13

What is the IPSS?

Answer 13

Derived from AUA and is most commonly used = can’t be used to establish diagnosis of benign prostatic hyperplasia

Question 14

What does the IPSS consist of?

Answer 14

7 questions (scored 0-5) based on extent of symptoms and 1 question about quality of life

Question 15

How is the IPSS scored?

Answer 15

Mild LUTS = 0-7
Moderate = 8-19
Severe = 20-35
Quality of life = 0-6

Question 16

What are some features of the examination?

Answer 16

Palpable bladder, ballotable kidneys, anal tone and sensation, external genitalia and meatus, prostate (size, consistency, nodules)

Question 17

What examination should be done on a younger patient?

Answer 17

Focused neurological examination

Question 18

What features of renal failure and neurological disorders may be present on examination?

Answer 18

Renal failure = fluid overload, uraemic

Neurological = tremor, gait

Question 19

What investigations can be done?

Answer 19

Frequency-volume chart = polyuria and nocturia

Urinalysis, serum creatine, PSA (after counselling)

Question 20

How does flow investigation results aid diagnosis?

Answer 20

Qmax <10ml/s = 90% likelihood of obstruction
Qmax 10-15ml/s = 60% likelihood of obstruction
Qmax >15ml/s = 30% likelihood (flow maintained by high pressure system)

Question 21

When would you do a renal USS?

Answer 21

Impaired renal function (creatine >130 =hydonephrosis in 33%) = loin pain, haematuria, renal mass on exam

Question 22

When would you do cytoscopy?

Answer 22

Previous urological surgery, haematuria, profound symptoms, pain, recurrent UTIs

Question 23

When would you do a trans-rectal US (TRUS)?

Answer 23

Elevated PSA, abnormal rectal examination, surgical treatment planning = TRUS volume >100ml is significant

Question 24

What conservative treatment options are there?

Answer 24

Watchful waiting, lifestyle modification

Question 25

What are some surgical treatments?

Answer 25

Transurethral resection of prostate

Holmium laser enucleation of prostate

Question 26

What are some pharmacological treatment options?

Answer 26

Alpha blockers = Tamsulosin (acts on smooth muscle)
5 alpha reductase inhibitors = inhibit testosterone conversion to dihydrotestosterone
Anti-cholinergics and beta agonsit = inhibits bladder smooth muscle contraction