bladder outlet obstruction

Question 1

examples of causes for lower urinary tract symptoms in men (7)

Answer 1

1. benign prostate obstruction
2. distal uteric stone
3. bladder tumour
4. UTI
5. foreign body
6. overactive bladder/detrusor
7. detrusor underactivity

Question 2

what is bladder outlet obstruction

Answer 2

the generic term for obstruction during voiding, characterised by increasing detrusor pressure and reduced urine flow

high pressure + low flow = bladder outlet obstruction
(although some have low pressure and low flow)

Question 3

examples of voiding symptoms (5)

Answer 3

1. weak or intermittent urinary stream
2. straining
3. hesitancy
4. terminal dribbling
5. incomplete emptying

Question 4

examples of storage symptoms (4)

Answer 4

1. urgency
2. frequency
3. incontinence
4. nocturia

Question 5

what is PSA a surrogate marker of

Answer 5

prostatic volume i.e. larger prostate (benign or malignant) = higher PSA

Question 6

what does a higher PSA indicate in terms of outcomes of medical mgx

Answer 6

PSA >1.4 ng/mL can predict a higher risk of BPE progression but a better response to 5-alpha reductase inhibitors (5ARi) medication

Question 7

5-alpha reductase inhibitors MOA

Answer 7

inhibit the conversion of testosterone to its active form in the prostate (dihydrotestosterone)

Question 8

what scoring system is useful in prostate observation

Answer 8

International prostate symptom score (I-PSS)

Question 9

2 causes of nocturnal polyuria

Answer 9

1. inappropriate fluid intake
2. ADH sensitivity/production issues

Question 10

mgx for nocturnal polyuria

Answer 10

1. lifestyle -> fluid type/timing
2. diuretics in the late afternoon (pts go to be dehydration leadin got over produciton of ADH)
3. synthetic ADH -> careful for hyponatremia leading to neurological symptoms

Question 11

what does bladder outlet obstruction look like on flow rate graph (4)

Answer 11

1. slower reach of max flow rate
2. lower max flow rate
3. stops and starts
4. goes on for a long time

Question 12

what does urethral stricture look like on flow rate graph

Answer 12

normal upstroke but max flow is at <8 ml/sec, long flat top

Question 13

conservative treatment for bladder outlet obstruction

Answer 13

1. observation
2. fluid and lifestyle modifications (e.g. cutting tea and coffee)
3. phytotherapy

Question 14

what is phytotheraphy for bladder outlet obstruction

Answer 14

herbal medicine e.g. willow herb, saw palmetto, fruit, pumpkin seed

Question 15

pharma mgx for bladder outlet obstruction

Answer 15

1. alpha blockers
2. 5ARi e.g. finasteride
3. combination

Question 16

how do alpha blockers work in bladder outlet obstruction

Answer 16

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

Question 17

how do 5-ARi affect PSA results

Answer 17

drops PSA level -> need to double PSA levels after 5/12 taking these

Question 18

what pts should be referred to urology

Answer 18

1. might need surgery - failure of medical treatment, severe lower urinary symptoms, urinary retention, recurrent urinary tract infection
2. might have cancer - elevated age specific PSA, persistent haematuria, abnormal DRE

Question 19

what are the surgical options for prostate treatment (4)

Answer 19

1. TURP (transurethral resection of prostate) -> very durable operation
2. HoLEP -> removal of obstructing prostate tissue using laser, very durable operation, day case
3. rezum -> steam treatment to destroy prostate tissue (induces necrosis of prostatic tissue), day case an no erectile dysfuction
4. urolift - less invasive. local anesthetic, surgery what uses sutures to hold prostate sides apart

Question 20

complications of prostate surgery

Answer 20

1. retrograde ejactulation
2. erectile dysfunciton

Question 21

rough guide for bladder outlet obstruction mgx

Answer 21

small prostate - alpha blocker
large prostate - 5ARi or combo