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Urinary System > Diseases of the Prostate > Flashcards

Diseases of the Prostate Flashcards

1
Q

What are the three McNeals zones of the prostate?

A
  • Central zone - surrounds ejaculatory ducts
  • Transitional zone: surrounds urethra
  • Peripheral zone: main body of gland, located posteriorly
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2
Q

What does BPE stand for?

A

Benign prostatic enlargement

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3
Q

What does BPH stand for?

A

Benign prostatic hyperplasia

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4
Q

What does BPO stand for?

A

Benign prostatic obstruction

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5
Q

What does BOO stand for?

A

Bladder outflow obstruction

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6
Q

What does LUTS stand for?

A

Lower urinary tract symptoms

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7
Q

What are the three distinct pathologies of BPH?

A

Hald diagram:

  1. Lower urinary tract symptoms
  2. Bladder outflow obstruction
  3. Benign prostatic enlargement
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8
Q

Describe Benign Prostatic Hyperplasia

A 
• Characterised by fibromuscular and glandular hyperplasia
• Predominantly affects transition zone
• Part of aging process in men :
	-  50% of men at 60 years
	-  90% of men at 85 years
  • 50% of men with BPH have moderate to severe LUTS
  • Progressive condition MAY result Bladder Outflow Obstruction (BOO)
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9
Q

What is the International Prostate Symptoms Score Sheet used for?

A

Screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of benign prostatic hyperplasia (BPH).

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10
Q

What is used to assess LUTS?

A
  • Symptoms scoring systems (IPSS)

* Frequency volume charts

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11
Q

What are the two categories of LUTS?

A

Voiding (obstruction) and storage (irritative) symptoms

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12
Q

What are voiding (obstructive) symptoms of LUTS?

A
  • Hesitancy
  • Poor stream
  • Terminal dribbling
  • Incomplete emptying
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13
Q

What are the storage (irritative) symptoms of LUTS?

A
  • Frequency
  • Nocturia
  • Urgency +/- urge incontinence
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14
Q

Describe potential findings on a physical examination of BPH

A

Abdomen:
• Palpable bladder

Penis:
• External urethral mental stricture
• Phimosis (disease of foreskin, cannot be pulled back)

Digital rectal examination (DRE)
• Assess prostate size
• Suspicious nodule or firmness

Urinalysis
• Blood
• Signs of UTI

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15
Q

What investigations are carried out for BPH

A 
• MSSU
• Flow rate study
• Post-void bladder residual USS 
• Bloods : 
 - PSA 
 - Urea and creatinine (if chronic retention)
  • Renal tract USS if renal failure or bladder stone suspected
  • Flexible cystoscopy if haematuria
  • Urodynamic studies
  • TRUS-guided prostate biopsy if PSA raised or abnormal DRE
  • Flow rate study
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16
Q

What is PSA?

A

Prostate-Specific Antigen (produced by prostate gland) and can be measured using a blood test

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17
Q

What results of a flow rate study give pt 90% chance of having BOO?

A

Qmax (peak flow rate) < 10ml/s

18
Q

What are the two types of BPO?

A

Uncomplicated and complicated

19
Q

What is the treatment of uncomplicated BPO

A

• Waiting, as could resolve

Medical therapy;
• Alpha blockers
• 5 alpha reductase inhibitors
• Combination

Surgical intervention:
• TURP (prostate size < 100cc)
• Open retropubic or transvesical prostatectomy (prostate size >100cc)
• Endoscopic ablative procedures

20
Q

What is the main treatment for LUTS due to BPO?

A

Alpha blockers

21
Q

What are the actions of alpha blockers?

A

Smooth muscle of bladder neck relaxation and antagonise element of prostatic obstruction (sympathetics alpha-adrenergic nerves (alpha 1a))

22
Q

What are the four different types of alpha blockers?

A
  • Non-selective (i.e. alpha 1 and 2): phenoxybenzamine
  • Selective short acting: prazosin, indoramin
  • Selective long acting: alfuzosin, doxazosin, terazosin
  • Highly selective (i.e. alpha-1a): tamsulosin
23
Q

What is the action of enzyme 5a-reductase?

A

Convets testosterone to dihydrotestosterone

24
Q

What are the two types of 5a-reductase inhibitors available?

A
  • Finasteride (5AR Type II inhibitor)

* Dutasteride (5AR Type I and II inhibitor)

25
Q

What are the actions of 5a-reductase inhibitors?

A
  • Reduces prostate size and reduces risk of BPE progression
  • Reduces LUTS
  • Reduce prostatic vascularity and therefore reduces haemapuria due to pros. bleeding
  • Potential prostate cancer prevention
26
Q

What is the medical therapy for reducing risk of BPE progression?

A

5ARIs and alpha blockers most effective

27
Q

What is TURP surgery?

A

Transurethral resection of prostate:
• Gold standard
• Very effective in relieving symptoms and improves urodynamic parameters

28
Q

What are possible complications of TURP?

A

Bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO

29
Q

What is an alternative ablative procedure to TURP?

A

Transurethral laser vaporisation

30
Q

What are the complications of BOO

A
  • 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
31
Q

What is the treatment of complicated BOO?

A

Medical therapy:
• Cystolitholapaxy and TURP for BPO and bladder stones
• May not need any

Alternative (if not fit 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

32
Q

What is the definition of acute urinary retention?

A

Painful inability to void with a palpable and percussible bladder

Residuals vary from 500ml to >1 litre depending on time lag in seeking medical attention

33
Q

What are the risk factors for acute urinary retention?

A

BPO but can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems)

34
Q

What is the treatment of acute urinary retention?

A

For those with BPO, can occur spontaneously or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)

Immediate treatment is catheterisation (either urethral or suprapubic)

Treat underlying trigger if present

If no renal failure, start alpha blocker immediately and remove catheter in 2 days; if fail to void, recatheterise and organise TURP (after 6 weeks)

35
Q

What are the complications of catheterisation?

A

UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities

36
Q

What is the definition of chronic urinary retention?

A

Painless, palpable and percussible bladder after voiding

Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition

37
Q

What is the aetiology of chronic urinary retention?

A

Detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

38
Q

How does chronic urinary retention present?

A

Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

Asymptomatic patients with low residuals do not necessarily need treatment

Pathological diuresis features: urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities

39
Q

What occurs in sever chronic urinary retention?

A

Overflow incontinence and renal failure, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or high pressure chronic urinary retention)

40
Q

What is the treatment of chronic urinary retention?

A

Immediate treatment is catheterisation

Manage with IV fluids and monitor closely

Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP

Urinary System (31 decks)

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