Bladder outlet obstruction

Question 1

Causes of lower urinary tract symptoms

Answer 1

nocturnal polyuria
chronic pelvic pain syndrome
neurogenic bladder dysfunction
UTI
foreign body
urethral stricture
bladder tumour
distal ureteric stone
benign prostatic obstruction
detrusor under-activity
overactive bladder/detrusor overactivity

Question 2

Bladder outlet obstruction definition

Answer 2

generic term for obstruction during voiding and is characterised by increasing detrusor pressure and reduced urine flow rate

Question 3

How is bladder outlet obstruction usually diagnosed?

Answer 3

studying synchronous values of flow rate and detrusor pressure
urodynamics
high pressure + low flow = bladder outlet obstruction

Question 4

What history questions need to be asked if suspecting bladder outlet obstruction?

Answer 4

number of voids per day/night
hesitancy (waiting for flow to start)
flow
post-void dribble (not normally associated with obstruction)
frequency
urgency/urge incontinence
visible haematuria
UTIs

Question 5

‘Voiding’ bladder outlet obstruction symptoms

Answer 5

weak/intermittent urinary stream
straining
hesitancy
terminal dribbling
incomplete emptying
(nocturia)

Question 6

‘Storage’ bladder outlet obstruction symptoms

Answer 6

urgency
frequency
incontinence
(nocturia)

Question 7

What are the 2 categories of symptoms in bladder outlet obstruction?

Answer 7

voiding
storage

Question 8

When should you be suspicious of bladder cancer with urinalysis?

Answer 8

+blood on >2 of 3 tests

Question 9

What is PSA a surrogate marker of?

Answer 9

marker of prostatic volume

Question 10

What PSA values would a small benign prostate and a bigger benign prostate have?

Answer 10

smaller = lower PSA
bigger = higher PSA

Question 11

What PSA predicts a higher risk of progression to cancer?

Answer 11

> 1.4

Question 12

What score can be used to assess prostate symptoms?

Answer 12

IPSS - international prostate symptom score

Question 13

What is the formal name for a bladder diary?

Answer 13

frequency volume chart

Question 14

Define nocturnal polyuria

Answer 14

> 30% of 24hr urine output at night
can be picked up with frequency volume chart

Question 15

Causes of nocturnal polyuria

Answer 15

inappropriate fluid intake
ADH sensitivity/production issues

Question 16

Management of nocturnal polyuria

Answer 16

lifestyle - fluid type/timing
diuretics late afternoon
vasopressin (beware in older patients)

Question 17

Community investigations for bladder outlet obstruction

Answer 17

flow rate
post void ultrasound scan

Question 18

What drugs can be used for bladder outlet obstruction due to enlarged prostate?

Answer 18

alpha blockers eg. tamsulosin
5-ARI eg. finasteride

Question 19

How do alpha blockers work on the prostate?

Answer 19

relax the smooth muscle of the bladder neck reducing obstruction
work quickly

Question 20

How do 5-alpha reductase inhibitors work on the prostate?

Answer 20

shrinks the prostate by blocking androgen conversion within the prostate
takes 6/12 to work
(once been on for 6/12 need to double PSA for corrected reading)

Question 21

Which patients with bladder outlet obstruction should be referred to urology?

Answer 21

might need surgery:
- failure of medical treatment (2 visits to review sx and management)
- severe lower urinary tract symptoms (IPSS>20)
- urinary retention (palpable bladder)
- recurrent UTI

might have cancer:
- elevated age-specific PSA
- persistent non-visible or any visible haematuria
- abnormal DRE suggestive of prostate cancer

Question 22

What surgical management is available for enlarged prostates causing bladder outlet obstruction?

Answer 22

TURP (gold standard)
HoLEP
REZUM
UROLIFT

Question 23

TURP surgery complications

Answer 23

retrograde ejaculation
erectile dysfunction

Question 24

HoLEP surgery complications

Answer 24

retrograde ejaculation
erectile dysfunction

Question 25

What is a benefit of Rezum/Urolift surgeries over the other options?

Answer 25

no erectile dysfunction

Question 26

What drug should be given if prostate is smaller but causing symptoms?

Answer 26

alpha blocker

Question 27

What drug should be given if prostate is bigger and causing symptoms?

Answer 27

5 ARI/combo