BPH and Stones

Question 1

What are irritative LUTS that suggest bladder outlet obstruction?

Answer 1

nocturia
frequency
urgency

Question 2

What are obstructive LUTS that suggest bladder outlet obstruction?

Answer 2

straining
weak stream
intermittency of stream
straining

Question 3

What specific part of the prostate does BPH occur in?

Answer 3

transitional zone

Question 4

What happens to the detrussor muscle in BPH?

Answer 4

hypertrophy due to outflow obstruction

Question 5

What is the static component of LUTS and BPH?

Answer 5

progressive obstruction of urethra from enlarging stromal and glandular growth of periurethral glands

Question 6

What is the dynamic component of LUTS and BPH?

Answer 6

bladder neck, prostate and capsule have symp inn (as opposed to PS inn of bladder)
alpha adrenergic receptors present in high concentrations here
alpha 1 receptors = uroselective receptors - blocked by uroselective alpha blockers - relaxes resting tone in bladder neck

Question 7

What meds can be used to treat BPH?

Answer 7

alpha blockers
5alpha reductase inhibitors (prevent testosterone -> DHT - shrinks prostate, reduces PSA, and helps LUTS) - also reduce risk of urinary retention and surgery

Question 8

What are important values of serum PSA?

Answer 8

10 suspicious for prostate cancer

4-10 is grey zone - measure free:total PSA - <20% suspicious for cancer

Question 9

How can urinary flow rate recordings be interpreted?

Answer 9

> 15 normal
<10 suggest obstruction
10-15 require pressure flow urodynamic studies

Question 10

How can residual urine be interpreted?

Answer 10

normally <30 cc

varies day to day and not specific for BPH

Question 11

How can a pressure flow urodynamic study (UDS) be interpreted?

Answer 11

low voiding pressure and high flow rate - normal
low voiding pressure and low flow rate - weak detrussor
high voiding pressure and low flow rate - subvesical obstruction

Question 12

What can cystoscopy rule out?

Answer 12

urethral stricture disease
bladder neck sclerosis or contracture
bladder cancer
bladder trabeculation or muscle hypertrophy
bladder diverticulum
bladder stones

Question 13

What are the general screening recommendations for prostate cancer?

Answer 13

no screening men under 40
shared decision between patients and physician age 55-69
against screening men 70+ if life expectancy less than 10-15 years

Question 14

What are the screening recommendations for prostate cancer in high risk men?

Answer 14

under 55

AA or positive FH

Question 15

What is the next step in eval of a patient with total PSA >4 or free:total <20%?

Answer 15

Transrectal ultrasound guided biopsy (TRUS) - takes 6 random biopsy samples

Question 16

If the PSA is over 10, what additional study should be done to stage cancer?

Answer 16

bone scan

Question 17

What is the most common form of prostate cancer diagnosed currently?

Answer 17

T1c - abnormal PSA with no symptoms or abnormal DRE

Question 18

What are the signs and symptoms of a stone?

Answer 18

pain (abdominal, flank)
hematuria
infection
fever 
nausea and vomiting

Question 19

What are the different types of pain with stones and what causes each?

Answer 19

renal colic - stretching collecting system/ureter, waxes and wanes, obstruction, compression
non colicky pain - stretching of renal capsule

Question 20

What are the 3 physiological narrowing stones have to navigate through the ureter?

Answer 20

ureteropelvic junction
crossing of ureter over iliac vessels
ureterovesical junction

Question 21

Where do stones in different locations characteristically cause pain?

Answer 21

costovertebral angle pain radiating around flank toward abdomen = ureteropelvic stone
lower quadrant radiating to suprapubic = mid ureteral
radiating into bladder, vulva, scrotum = distal

Question 22

What kinds of infections are associated with stones?

Answer 22

obstructing - in setting of UTI is emergency!
magnesium ammonium phosphate = infection stone in alkaline medium
proteus, providencia, psuedomonas, klebsiella can split urea and make alkaline medium

Question 23

When is a fever a medical emergency with stones and what is the treatment?

Answer 23

with upper tract stone

drainage and antibiotics

Question 24

How is nausea and vomiting involved with stones?

Answer 24

paralytic ileus often present

requires IV fluids to restore volume and peristalsis

Question 25

What are conditions associated with stones?

Answer 25

RTA
FH
GI dx
recurrent UTIs

Question 26

How is sonography used in imaging for stones?

Answer 26

not very sensitive - only sees >5mm
can see hydro, but stones in ureter not diagnosed
stones of all composition seen as white spot

Question 27

What radiolucent stones are not seen on KUB?

Answer 27

uric acid
cystine
xanthine

Question 28

How is intravenous urography (IVU) used in stones?

Answer 28

in normal kidney
identifies obstruction
defines anatomy
radiolucent stones found by filling defect

Question 29

How is retrograde pyelography used in eval of stones?

Answer 29

in nonfunctioning kidney
uncertainty persists after films
use caution - ability to stent and decompress must be available when used

Question 30

How is percutaneous drainage and Antegrade nephrostogram (AGNG) used with stones?

Answer 30

with infection or sepsis with fever and elevated WBC and diagnosis by imaging
drainage from dilated collecting system
antegrade imaging of upper tract accomplished at same time even with obstruction and poorly functioning kidneys