Diseases of the Prostate Flashcards
What is the average size of the prostate gland in men aged 25-30 years?
20cc
What does the prostate do?
Secondary sexual organ
The function of the prostate is to secrete a slightly alkaline fluid, milky or white in appearance, that in humans usually constitutes roughly 30% of the volume of the semen along with spermatozoa and seminal vesicle fluid
Describe McNeal’s Prostatic Zones
The “zone” classification is more often used in pathology. The idea of “zones” was first proposed by McNeal in 1968. McNeal found that the relatively homogeneous cut surface of an adult prostate in no way resembled “lobes” and thus led to the description of “zones”.
The prostate gland has four distinct glandular regions, two of which arise from different segments of the prostatic urethra:
- Transition zone
- Central zone
- Peripheral zone
- Anterior fibromuscular stroma
What are the two important being prostatic disease terminologies for use with patients in general?
Bladder outflow obstruction (BOO)
Lower urinary tract symprtoms (LUTS)
When can you use the term benign prostatic hyperplasia (BPH)?
Histological diagnosis
What is benign prostatic obstruction (BPO)?
Used when you think the prostate is causing BOO
Describe the Hald Diagram
A ven diagram including:
- LUTS
- BOO
- BPE
Shows that benign prostate hyperplasia (BPH) was a syndrome of 3 overlapping, yet clinically distinct, entities
What is benign prostatic hyperplasia characterised by?
Fibromuscular and Glandular hyperplasia
Predominantly affects transition zone
How does Benign prostatic hyperplasia effect men?
Part of aging process
- 50% of men at 60 years
- 90% of men at 85 years
50% of men with BPH have moderate to severe LUTS
Progressive condition resulting in BOO
-Doesnt always cause BOO
What is the international prostate symptom score sheet (IPSS)?
Questionaire
- Patients score there different symptoms
- Saves a list of questions at consultation
- Focuses on symptoms (YOUR TREATING THE PATIENT NOT JUST PROSTATE HYPERPLASIA)
Score out of 35
- Mild = 0-7
- Moderate: 8-19
- Severe = >/=20
Can repeat to see if treatment is working
How do you assess LUTS?
Symptom scoring systems
- IPSS
- Can indicate wether bladder or below
Frequency volume charts
What LUTS symptoms indicate Voiding (obstructive) problem?
- Hesitancy
- Poor stream
- Terminal dribbling
- Incomplete emptying
What LUTS symptoms indicate Storage (Irritative) problem?
- Frequency
- Nocturia
- Urgency +/- urge incontinence
What is a frequency volume chart?
Record date and time of passing urine and the amount passed
Around 500ml normal in males
-Less in females
On physical examination why should you look for a palpable bladder?
If there is acute retention
Wont feel on chronic but may be percussive
What should you look for in physical examination of the penis?
External urethral meatal stricture
Phimosis
NOTE:
-Get patient to pull back foreskin so that you dont cause them undue discomfort
What should you be checking in a digital rectal examination?
Assess prostate size
-large or small
Assess feel
- Firm vs soft
- Nodular?
Should feel like your nose if normal
Assess anal tone
-Cauda equina problems
When should you do urinalysis in LUTS?
Always
- Blood?
- Signs of UTI
What is a MSSU?
Mid stream sample of urine
- Microscopy
- Culture
- Serology
What is a flow rate study?
Get patient to pee into special toilet
Measures how much urine is passing per unit time
- Look at Qmax
- Look at total time
If Qmax 90% chance of having BOO
Duration of micturition will also be increased in BOO
What is post- void bladder residual USS?
USS bladder after voiding to see how much residual fluid is there
What blood tests may you want to do and why?
PSA
- Prostate specific antigen
- Up in infection, catheter, prostate cancer and BPH
- Used to assess size of BPH
- Perfectly adequate to do in LUTS
Urea and Creatinine
- Look at renal function
- High pressure urinary retention?
When should you do a renal tract USS?
If renal failure or bladder stone suspected
- Upper urinary tract more
- Not needed for LUTS
In larger patient can be hard to see so may want to replace USS with Computerised Tomography of the abdomen and pelvis
When may you do a felxible cystoscopy?
What is it?
If haematuria
A cystoscopy is a procedure that looks at the bladder and other parts of the urinary system. It involves inserting a special tube, called a cystoscope, into the urethra and then passing it through to the bladder. There are two types of cystoscope: rigid and flexible.
Flexible more for examination, straight more for surgery
In selected cases what study may you want to carry out?
Urodynamic testing or Urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests can help explain symptoms such as: incontinence. frequent urination. sudden, strong urges to urinate but nothing comes out.
When may you want to carry out a TRUS-guided prostate biopsy?
If PSA raised or abnormal DRE
How is BPO divided?
Uncomplicated
-Guys who come along with classic symptoms
Complicated
- Retention (palpable bladder)
- UTI
- PSA elevated for age
- Haematuria
- Elevated uria/ creatinine
how do you treat Uncomplicated BPO?
30% will stay same
30% will get better
30% will get worse
-Watchful waiting is therefore an option
Medical therapy
- Alpha blockers
- 5 alpha rectucatse inhibitors
- Combination
Surgical intervention
- TURP (prostate size 100cc)
- Endoscopic ablative procedures
Name the two 5 alpha reductase inhibitors
Finasteride
Dutasteride
What are alpha blockers?
Main treatment for LUTS due to BPO
Smooth muscle of bladder neck (intrinsic urethral sphincter) and prostate innervated by sympathetic alpha agrenergic nerves (mostly alpha-1a subtype)
Alpha blockers cause smooth muscle relaxation and antagonise the dynamic element to BPO
Give some types of alpha blockers
Non-selective (i.e. alpha 1 and 2): phenoxybenzamine
Selective short acting: prazosin, indoramin
Selective long lasting: ALFUZOSIN, doxazosin, terazosin
Highly selective (i.e. alpha-1a): TAMSULOSIN
What side effect should you be aware of in alpha blockers?
Relaxes intrinstic urethral sphincter -> retrograde ejaculation
Sperm enters bladder and pee out during next micturition
Cannot pregnate
-Must make patients aware
What is the role of 5a- reductase inhibitors?
Reduces prostate size and REDUCES RISK OF PROGRESSION of BPE (only if >25cc)
Also reduces LUTS (not as effective as alpha blockers)
Combination therapy with alpha blockers most effective in reducing risk of progression of BPE
Can also reduce vascularity and hence reduces haematuria due to prostatic bleeding
Potential role in prostate cancer prevention
-BUT increases risk of aggressive prostate cancer in 10-15 years -> may want to think twice in younger patients
What is TURP?
Trans-Urethral Resection of Prostate
Remains GOLD STANDARD
V. effective in relieving symptoms and improves urodynamic parameters (90% efficacy at 1 year)
What are the complications of TURP?
- Bleeding
- Infection
- Retrograde ejaculation
- Stress urinary incontinence
- Prostatic regrowth causing recurrent haematuria or BOO
What new alternative endoscopic ablative procedures are available for prostate resection?
Transurethral laser vaporisation
-Urolift
NOT as effective as TURP
What are the complications of BPO?
Progression of LUTS
Acute urinary retention
Chronic urinary retention
Urinary incontinence (overflow)
UTI
Bladder stone
Renal failure from obstructed ureteric outflow due to high bladder pressure
How do you treat complicated BPO?
Medical therapy
Most patients will require surgery
-e.g. cystolitholapaxy and TURP for patients with BPO and bladder stones
Some patients do not need any treatment (especially if residuals are relatively low, asymptomatic and no complications
What alternative treatment options are available for complicated BPO (e.g. patients unfit for surgery)?
Long term urethral or suprapubic catheterisation
Clean intermittent self-catheterisation
May develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI
