Diseases of the prostate and urinary tract obstruction

Question 1

What zone of the prostate does cancer usually form?

Answer 1

peripheral zone

Question 2

What happens in BPH?

Answer 2

fibromuscular and glandular hyperplasia

Question 3

What zone of the prostate does BPH usually occur?

Answer 3

transitional zone

Question 4

What is the IPSS score and explain the components

Answer 4

international prostate symptoms score out of 35
includes things like urgency, frequency, nocturia, weak stream etc
0-7 = mild, 8-19=moderate and over 20 is severe

Question 5

The 2 ways to assess LUTS

Answer 5

symptom scoring system - IPSS

frequency volume charts

Question 6

Voiding (obstructive) LUTS

Answer 6

poor stream
hesitancy
terminal dribbling
incomplete emptying

Question 7

Storage (irritative) LUTS

Answer 7

frequency
nocturia
incontinence/urgency

Question 8

4 physical examinations conducted on the patient with LUTS and what we look for

Answer 8

abdomen - palpable bladder - retention?
digital rectal examination
urinalysis - blood? infection?
penis - stricture?phimosis?

Question 9

Investigations of LUTS

Answer 9

flexible cystoscopy if haematuria 
MSSU 
flow rate study 
post void bladder residual USS 
bloods eg PSA, urea and creatinine 
renal tract USS 
urodynamic studies 
TRUS guided prostate biopsy (raised PSA/abnormal DRE)

Question 10

Treatment for uncomplicated BPO

Answer 10

watchful waiting
medical - alpha blockers, 5 alpha reductase inhibitors or combination
surgery - TURP (<100cc) or open retropubic prostatectomy
endoscopic ablative procedures

Question 11

What are alpha blockers most used for in terms of prostate and obstruction?

Answer 11

BPO LUTS

Question 12

How do alpha blockers work?

Answer 12

smooth muscle of bladder neck and prostate innervated by sympathetic alpha adrenergic nerves so alpha blockers cause smooth muscle relaxation

Question 13

Types of alpha blockers

Answer 13

non selective, long acting and short acting selective and highly selective

Question 14

What does 5 alpha reductase do?

Answer 14

Enzyme which converts testosterone to DHT

Question 15

5 actions of 5ARI

Answer 15

reduce prostate size and reduce risk of progression
Reduce LUTS
reduce risk of medium and low grade cancers
reduce vascularity and hence haematuria
best taken in combo with alpha blockers

Question 16

Complications of TURP

Answer 16

bleeding, infection, BOO, prostatic regrowth causing recurrent haematuria, stress urinary incontinence

Question 17

Complications of BPO

Answer 17

progression of LUTS 
UTI 
acute/chronic urinary retention 
bladder stone 
overflow incontinence 
renal failure

Question 18

Alternatives for treating complicated BPO

Answer 18

apart from medical and surgical procedures

long term catheter, CISC

Question 19

Sites of upper tract obstruction

Answer 19

PUJ, VUJ and ureter

Question 20

Sites of lower urinary tract BOO

Answer 20

bladder neck, prostate, urethra, urethral meatus and foreskin

Question 21

Intrinsic causes of PUJ obstruction

Answer 21

PUJ obstruction, stone, TCC, blood clot, fungal ball

Question 22

Extrinsic causes of PUJ obstruction

Answer 22

PUJ obstruction, LN and abdominal mass

Question 23

Intrinsic causes of ureter obstruction

Answer 23

stone, TCC, scar tissue, blood clot, fungal ball

Question 24

Extrinsic causes of ureteric obstruction

Answer 24

LN, iatrogenic, pelvic mass

Question 25

Intrinsic causes of VUJ obstruction

Answer 25

stone, bladder tumour, ureteric tumour

Question 26

Extrinsic causes of VUJ obstruction

Answer 26

cervical tumour, prostate cancer

Question 27

Symptoms of upper tract obstruction

Answer 27

pain, frank haematuria, complications eg renal failure

Question 28

Signs of upper tract obstruction

Answer 28

palpable mass, microscopic haematuria, complications

Question 29

Complications of upper tract obstruction

Answer 29

infection & sepsis, renal failure

Question 30

Management of upper tract obstruction

Answer 30

Resuscitation, ABC's | IV access, bloods, ABG, blood and urine cultures, fluid monitoring, iv fluids, antibiotics, analgesia, HDU care+/- RRT

Question 31

Emergency treatment of upper tract obstruction

Answer 31

percutaneous nephrostomy insertion | retrograde stent insertion

Question 32

Definitive treatment of upper tract obstruction examples

Answer 32

stone - ureteroscope, laser lithotripsy, ESWL tumour - radical nephron-ureterectomy PUJ obstruction - laparascopic pyeloplasty

Question 33

What is a nephrostomy?

Answer 33

percutaneous puncture allowing urine to drain

Question 34

How is nephrostomy done and what are its complications

Answer 34

US or X-ray guided under LA+sedation | bleeding and adjacent organs

Question 35

Material of most ureteric stents

Answer 35

silicone

Question 36

Lower urinary tract obstruction symptoms

Answer 36

``` LUTS - including urinary incontinence acute or chronic urinary retention recurrent UTI Frank haematuria renal failure bladder stones ```

Question 37

Immediate treatment for urinary retention

Answer 37

urethral catheter | if not possible after 2 attempts do a suprapubic catheter

Question 38

Resuscitation management of lower urinary tract obstruction

Answer 38

ABC, IV access, bloods, ABG, urine and blood cultures, fluid monitoring, antibiotics, IV fluids, analgesia, HDU+/- RRT

Question 39

Investigations of lower urinary tract obstruction

Answer 39

bladder scan and USS renal tract

Question 40

Emergency treatment of LUT obstruction

Answer 40

urethral or sp catheter

Question 41

Definitive treatment of LUT obstruction examples

Answer 41

BPE = TURP urethral stricture = optical urethrotomy meatal stenosis - meatal dilation phimosis = circumcision

Question 42

High pressure chronic retention symptoms

Answer 42

painless, incontinent, increased creatinine and bilateral hydronephrosis

Question 43

Low pressure chronic retention symptoms

Answer 43

Painless, dry, normal creatinine and kidneys

Question 44

2 main complications of treating chronic retention and LUT obstruction

Answer 44

decompression haematuria - sheer small vessels but usually self limiting post obstructive diuresis - can be dangerous due to fluid and sodium loss so give saline