Diseases of the prostate and urinary tract obstruction Flashcards
What zone of the prostate does cancer usually form?
peripheral zone
What happens in BPH?
fibromuscular and glandular hyperplasia
What zone of the prostate does BPH usually occur?
transitional zone
What is the IPSS score and explain the components
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
The 2 ways to assess LUTS
symptom scoring system - IPSS
frequency volume charts
Voiding (obstructive) LUTS
poor stream
hesitancy
terminal dribbling
incomplete emptying
Storage (irritative) LUTS
frequency
nocturia
incontinence/urgency
4 physical examinations conducted on the patient with LUTS and what we look for
abdomen - palpable bladder - retention?
digital rectal examination
urinalysis - blood? infection?
penis - stricture?phimosis?
Investigations of LUTS
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)
Treatment for uncomplicated BPO
watchful waiting
medical - alpha blockers, 5 alpha reductase inhibitors or combination
surgery - TURP (<100cc) or open retropubic prostatectomy
endoscopic ablative procedures
What are alpha blockers most used for in terms of prostate and obstruction?
BPO LUTS
How do alpha blockers work?
smooth muscle of bladder neck and prostate innervated by sympathetic alpha adrenergic nerves so alpha blockers cause smooth muscle relaxation
Types of alpha blockers
non selective, long acting and short acting selective and highly selective
What does 5 alpha reductase do?
Enzyme which converts testosterone to DHT
5 actions of 5ARI
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
Complications of TURP
bleeding, infection, BOO, prostatic regrowth causing recurrent haematuria, stress urinary incontinence
Complications of BPO
progression of LUTS UTI acute/chronic urinary retention bladder stone overflow incontinence renal failure
Alternatives for treating complicated BPO
apart from medical and surgical procedures
long term catheter, CISC
Sites of upper tract obstruction
PUJ, VUJ and ureter
Sites of lower urinary tract BOO
bladder neck, prostate, urethra, urethral meatus and foreskin
Intrinsic causes of PUJ obstruction
PUJ obstruction, stone, TCC, blood clot, fungal ball
Extrinsic causes of PUJ obstruction
PUJ obstruction, LN and abdominal mass
Intrinsic causes of ureter obstruction
stone, TCC, scar tissue, blood clot, fungal ball
Extrinsic causes of ureteric obstruction
LN, iatrogenic, pelvic mass
Intrinsic causes of VUJ obstruction
stone, bladder tumour, ureteric tumour
Extrinsic causes of VUJ obstruction
cervical tumour, prostate cancer
Symptoms of upper tract obstruction
pain, frank haematuria, complications eg renal failure
Signs of upper tract obstruction
palpable mass, microscopic haematuria, complications
Complications of upper tract obstruction
infection & sepsis, renal failure
Management of upper tract obstruction
Resuscitation, ABC’s
IV access, bloods, ABG, blood and urine cultures, fluid monitoring, iv fluids, antibiotics, analgesia, HDU care+/- RRT
Emergency treatment of upper tract obstruction
percutaneous nephrostomy insertion
retrograde stent insertion
Definitive treatment of upper tract obstruction examples
stone - ureteroscope, laser lithotripsy, ESWL
tumour - radical nephron-ureterectomy
PUJ obstruction - laparascopic pyeloplasty
What is a nephrostomy?
percutaneous puncture allowing urine to drain
How is nephrostomy done and what are its complications
US or X-ray guided under LA+sedation
bleeding and adjacent organs
Material of most ureteric stents
silicone
Lower urinary tract obstruction symptoms
LUTS - including urinary incontinence acute or chronic urinary retention recurrent UTI Frank haematuria renal failure bladder stones
Immediate treatment for urinary retention
urethral catheter
if not possible after 2 attempts do a suprapubic catheter
Resuscitation management of lower urinary tract obstruction
ABC, IV access, bloods, ABG, urine and blood cultures, fluid monitoring, antibiotics, IV fluids, analgesia, HDU+/- RRT
Investigations of lower urinary tract obstruction
bladder scan and USS renal tract
Emergency treatment of LUT obstruction
urethral or sp catheter
Definitive treatment of LUT obstruction examples
BPE = TURP
urethral stricture = optical urethrotomy
meatal stenosis - meatal dilation
phimosis = circumcision
High pressure chronic retention symptoms
painless, incontinent, increased creatinine and bilateral hydronephrosis
Low pressure chronic retention symptoms
Painless, dry, normal creatinine and kidneys
2 main complications of treating chronic retention and LUT obstruction
decompression haematuria - sheer small vessels but usually self limiting
post obstructive diuresis - can be dangerous due to fluid and sodium loss so give saline
