Diseases of Prostate and Urinary Tract Flashcards
What is an enlarged prostate?
> 30cc
BPH typically affects what?
Transition zone of the prostate
What proportion of the population suffers BPH in men?
50% at 60y
90% at 85y
How is BPH characterised?
Fibromuscular and glandular hyperplasia
How is LUTS assessed?
Symptom scoring - IPSS
Frequency volume chart
What are the main types of LUTS?
Storage
Voiding
How do voiding LUTS present?
Hesitancy
Poor Stream
Terminal dribbling
Incomplete emptying
How do storage LUTS present?
Frequency
Nocturia
Urgency +/- urge incontinence
What penis abnormalities can cause BOO?
External meatus stricture
Phimosis
What physical assessment is used for LUTS?
Abdominal exam
Penis exam
DRE
Urinalysis
What investigations are used in LUTS?
MSSU Flow rate study Post-void bladder residual USS U+E & PSA Renal tract USS (stone) Flexible cystoscopy Prostate biopsy (PSA↑)
What are the main types of benign prostatic obstruction?
Complicated
Uncomplicated
What is the treatment for an uncomplicated BPO?
non unless chronic retention, infections
Alpha blockers
5alpha reductase inhibitors
TURP
Prostatectomy
When are alpha blockers indicated?
Treatment for LUTS due to BPO
How do alpha blockers work?
Relax smooth muscle of bladder neck and prostate
What are the main types of alpha blockers?
Non-selective (1+2)
Selective short acting
Selective long acting
Highly selective
When are alpha blockers contraindicated?
Hypotension
Iris surgery
What are the side effects associated with alpha blockers?
Retrograde ejaculation
How do 5a-reductase inhibitors work?
Inhibit Test –> DHT
What are the two mainly used 5a-reductase inhibitors?
Finasteride (Type 2 only)
Dutasteride (Type 1+2)
What is the role of 5a-reductase inhibitors?
Reduce prostate size, slow progression
Reduce LUTS
Reduce prostatic bleeding
Reduce prostate cancer
What side effects are associated with 5a-reductase inhibitors?
Impaired sexual function
Breast growth
What complications are associated with TURP?
Bleeding Infection Retrograde ejaculation Stress urinary incontinence Prostatic growth
What complications are associated with BOO?
Progression of LUTS Acute/Chronic urinary retention Urinary incontinence UTI Bladder stone Renal failure
How is complicated BOO treated?
Mostly surgery
–> Cystolitholapaxy and TURP
Long term catheterisation
CISC
How is acute urinary retention defined?
Painful inability to void with palpable and percussable bladder
What residuals are seen in acute urinary retention?
0.5-1L
What are the main risk factors for acute urinary retention?
BPO UTI Urethral stricture Alcohol excess Acute surgical issues
What events can trigger acute urinary retention in patients with BPO?
(spontaneous) Constipation Alcohol excess Post-op Urological procedures
What is the immediate treatment for acute urinary retention?
Catheterisation
Treat underlying trigger
What complications are associated with acute urinary retention?
UTI Post-decompression haematuria Pathological diuresis Renal failure Electrolyte abnormalities
How should the immediate treatment be followed up in absence of renal failure?
Remove catheter
Start alpha blockers
Fail to void:
Re-catheterise and TURP
How is chronic urinary retention defined?
Painless
Palpable
Percussable bladder after voiding
What residual urine volumes are seen in chronic urinary retention?
0.4-2L
What is the cause of chronic urinary retention?
Detrusor under-activity
Longstanding BOO
How does chronic urinary retention typically present?
LUTS UTI Bladder stone Overflow incontinence (post-) Renal failure
When does overflow incontinence occur?
When pressure is in excess of 25cm water
Which chronic urinary retention patients are not in need of treatment?
Low residuals with no symptoms
What is the immediate treatment for chronic urinary retention?
Catheterisation
–> CISC
What complications are associated with chronic urinary retention?
UTI Post-decompression haematuria Pathological diuresis Electrolyte abnormalities Acute Tubular Necrosis
How does pathological diuresis present?
> 200ml/hr
postural hypertension
Weight loss
Electrolyte abnormalities
How does postural hypertension present?
> 20mmHg change in BP from lying to standing
How is pathological diuresis treated?
IV fluids and oral fluids
Where do obstructions typically occur in the upper urinary tract?
Pelvico-ureteric junction
Ureter
Vesico-ureteric junction
Where do obstructions typically occur in the lower urinary tract?
Bladder neck Prostate Urethra Urethral meatus Foreskin
What are the main types of upper tract obstruction?
Intrinsic
Extrinsic
What are the common causes of intrinsic PUJ obstruction?
Stone
Blood clot
Fungal ball
Ureteric tumour
What are the common causes of extrinsic PUJ obstruction?
Crossing of a vessel
Lymph node tumour
Abdominal tumour
What are the common causes of intrinsic ureter obstruction?
Stone Tumour Scar tissue Blood clot Fungal ball
What are the common causes of extrinsic ureter obstruction?
Lymph nodes
Iatrogenic
Abdominal/pelvic
What are the common causes of intrinsic VUJ obstruction?
Stone
Bladder tumour
Ureteric tumour
What are the common causes of extrinsic VUJ obstruction?
Cervical tumour
Prostate cancer
What are the symptoms of Upper tract obstruction?
Pain
Frank haematuria
Symptoms of sepsis/infection
Renal failure
What are the signs of Upper tract obstruction?
Palpable mass
Microscopic haematuria
How can renal function present in upper tract obstruction?
Acute - could be normal
Chronic (high pressure) probably wack
How should an upper tract obstruction be managed?
ABCs IV access, bloods, ABG Urine/blood cultures Floid balance monitoring Analgesia Antibiotics RRT if necessary
Percutaneous nephrostomy insertion
or
Retrograde stent insertion
How would a stone causing upper tract obstruction be managed?
Ureteroscopy and laser lithotripsy
How would a ureteric tumour causing upper tract obstruction be managed?
Radical nephro-ureterectomy
How would a PUJ obstruction causing upper tract obstruction be managed?
Laparoscopic pyeloplasty
What is the presentation of lower tract obstruction?
LUTS + incontinence Acute/chronic urinary retention Recurrent UTI Sepsis Frank haematuria Stones Renal failure
How is retention catheterised?
Immediate
14/16F
Measure residual
16F SPC if urethra impassable
How should a lower tract obstruction be managed?
ABCs IV access, bloods, ABG Urine/blood cultures Floid balance monitoring Analgesia Antibiotics RRT if necessary Bladder scan
Catheterisation
How should a BPE causing lower tract obstruction be managed?
TURP
How should a urethral stricture causing lower tract obstruction be managed?
Optical urethrotomy
How should a meatal stenosis causing lower tract obstruction be managed?
Meatal dilation
How should a phimosis causing lower tract obstruction be managed?
Circumcision
What is decompression haematuria?
Complication of relieving high pressure in bladder
Blood in urine, shearing of small vessels
What is post-obstructive diuresis?
> 200ml/hr
Osmotic diuresis
How is post-obstructive diuresis managed?
Normal saline input, preferably orally