Diseases of the Prostate Flashcards
What are the three McNeals zones of the prostate?
- Central zone - surrounds ejaculatory ducts
- Transitional zone: surrounds urethra
- Peripheral zone: main body of gland, located posteriorly
What does BPE stand for?
Benign prostatic enlargement
What does BPH stand for?
Benign prostatic hyperplasia
What does BPO stand for?
Benign prostatic obstruction
What does BOO stand for?
Bladder outflow obstruction
What does LUTS stand for?
Lower urinary tract symptoms
What are the three distinct pathologies of BPH?
Hald diagram:
- Lower urinary tract symptoms
- Bladder outflow obstruction
- Benign prostatic enlargement
Describe Benign Prostatic Hyperplasia
• 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)
What is the International Prostate Symptoms Score Sheet used for?
Screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of benign prostatic hyperplasia (BPH).
What is used to assess LUTS?
- Symptoms scoring systems (IPSS)
* Frequency volume charts
What are the two categories of LUTS?
Voiding (obstruction) and storage (irritative) symptoms
What are voiding (obstructive) symptoms of LUTS?
- Hesitancy
- Poor stream
- Terminal dribbling
- Incomplete emptying
What are the storage (irritative) symptoms of LUTS?
- Frequency
- Nocturia
- Urgency +/- urge incontinence
Describe potential findings on a physical examination of BPH
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
What investigations are carried out for BPH
• 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
What is PSA?
Prostate-Specific Antigen (produced by prostate gland) and can be measured using a blood test
What results of a flow rate study give pt 90% chance of having BOO?
Qmax (peak flow rate) < 10ml/s
What are the two types of BPO?
Uncomplicated and complicated
What is the treatment of uncomplicated BPO
• 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
What is the main treatment for LUTS due to BPO?
Alpha blockers
What are the actions of alpha blockers?
Smooth muscle of bladder neck relaxation and antagonise element of prostatic obstruction (sympathetics alpha-adrenergic nerves (alpha 1a))
What are the four different types of alpha blockers?
- 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
What is the action of enzyme 5a-reductase?
Convets testosterone to dihydrotestosterone
What are the two types of 5a-reductase inhibitors available?
- Finasteride (5AR Type II inhibitor)
* Dutasteride (5AR Type I and II inhibitor)
What are the actions of 5a-reductase inhibitors?
- 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
What is the medical therapy for reducing risk of BPE progression?
5ARIs and alpha blockers most effective
What is TURP surgery?
Transurethral resection of prostate:
• Gold standard
• Very effective in relieving symptoms and improves urodynamic parameters
What are possible complications of TURP?
Bleeding, infection, retrograde ejaculation, stress urinary incontinence, prostatic regrowth causing recurrent haematuria or BOO
What is an alternative ablative procedure to TURP?
Transurethral laser vaporisation
What are the complications of BOO
- 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
What is the treatment of complicated BOO?
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
What is the definition of acute urinary retention?
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
What are the risk factors for acute urinary retention?
BPO but can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems)
What is the treatment of acute urinary retention?
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)
What are the complications of catheterisation?
UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnormalities
What is the definition of chronic urinary retention?
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
What is the aetiology of chronic urinary retention?
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)
How does chronic urinary retention present?
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
What occurs in sever chronic urinary retention?
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)
What is the treatment of chronic urinary retention?
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
