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Year 3 Renal & Urology > Enlarged prostate > Flashcards

Enlarged prostate Flashcards

1
Q

What is benign prostatic hyperplasia?

A

AKA benign prostatic enlargement. Lower urinary tract symptoms caused by bladder outlet obstruction due to BPH

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2
Q

What is the aetiology of benign prostatic hyperplasia? (x3)

A
  • HORMONES: androgen changes (testosterone physiologically promotes prostate cell proliferation)
  • DIET: greater protein intake may be linked to BPH
  • AGE-RELATED fibrosis and weakening of muscular tissue in the prostate
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3
Q

What are risk factors for BPH? (x4)

A

Obesity, T2DM, erectile dysfunction, family history

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4
Q

What is the pathophysiology of benign prostatic hyperplasia? (x3)

A
  • STATIC COMPONENT: increase in benign prostatic tissue due to hyperplasia of the epithelial and stromal components, leading to narrowing of urethral lumen. Key characteristic is increased stromal:epithelial ratio
  • DYNAMIC COMPONENT: increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors
  • Bladder overactivity may also lead to bladder outlet obstruction
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5
Q

What is the epidemiology of BPH: Age? Common?

A

Increasing incidence with age. Affecting approximately 42% of men between 51 and 60.

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6
Q

What are the signs and symptoms of BPH? (x5)

A
  • STORAGE SYMPTOMS: frequency, urgency, nocturia
  • VOIDING SYMPTOMS: weak stream, hesitancy, intermittency, straining, incomplete emptying, and post-void dribbling
  • DRE: enlarged prostate that is symmetric and smooth (unilateral, firm or nodular raises suspicion for prostate cancer)
  • ABDOMINAL EXAMINATION: palpable bladder
  • UTI from incomplete voiding
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7
Q

What are the investigations for BPH? (x5)

A
  • Diagnosis is clinical
  • URINALYSIS: normal in uncomplicated BPH, pyuria (presence of pus) may indicate UTI, and haematuria may indicate cancer
  • PSA: presence of underlying prostate cancer or prostatitis. BPH also leads to raised PSA, but very high values tend to be more correlative to cancer
  • INTERNATIONAL PROSTATE SYMPTOM SCORE
  • GLOBAL BOTHER SCORE: measures degree of ‘bother’ in symptoms
  • RENAL USS/CT: indicated if patient has chronic retention, recurrent UTIs, renal sufficiency or stones: assess for hydronephrosis (kidneys become stretched from urinary retention), mass, urolithiasis (stones) and post-void residual (amount of urine left in the bladder post-urination)
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8
Q

What is the International Prostate Symptom score and how can it be interpreted?

A

7 questions with a Likert scale (0-5) covering both irritative and obstructive voiding symptoms. Mild score: 0-7, moderate score: 8-19, severe score 20-35.

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9
Q

How is BPH managed medically? (x1 and x3)

A
  • NON-BOTHERSOME SYMPTOMS: watchful waiting and counselling on fluid avoidance after dinner, bladder training etc.
  • BOTHERSOME SYMPTOMS:
  • Alpha-blocker (terazosin/doxazosin/alfuzosin/tamsulosin) to relax smooth muscle in prostate and bladder neck (but risk of hypotension and syncope)
  • 5-alpha-reductase inhibitor (finasteride/dutasteride) to reduce serum DHT and thus reducing prostate volume
  • Phosphodiesterase-5 (PDE-5) inhibitor (sildenafil/tadalafil/vardenafil) is a vasodilator (inhibitor of cGMP inhibitor) and can help with symptoms
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10
Q

What are the indications for surgical management of BPH? (x3)

A

Failure of medical management, renal complications, or urinary tract retention.

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11
Q

How is BPH surgically managed? (x1, x5 and x2)

A
  • PROSTATE VOLUME LESS THAN 30g: transurethral incision of the prostate (TUIP)
  • PROSTATE VOLUME 30-80g: minimally invasive therapies such as photo-selective vaporisation of the prostate (PVP), prostatic urethral lift (PUL), transurethral microwave therapy (TUMT) and water vapor thermal ablation therapy. OR moderately invasive therapy using TURP (transurethral resection of the prostate)
  • PROSTATE VOLUME MORE THAN 80g: open prostatectomy or laser enucleation (HoLEP or ThuLEP).
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12
Q

What is PVP?

A

Transurethral procedure involving firing of laser at a wavelength absorbed by Hb. This results in tissue vaporisation and an underlying layer of coagulation to prevent bleeding.

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13
Q

What is PUL?

A

Increases patency (openness) of the urethra by suturing the prostate tissue away from the urethra (performed transurethrally)

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14
Q

What is water vapor thermal ablation therapy?

A

Utilised convectively delivered thermal energy to target ablation of prostatic tissue.

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15
Q

What is HoLEP?

A

Holmium laser enucleation of the prostate: transurethral laser used to remove prostate, then cut into fragments and removed.

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16
Q

What is ThuLEP?

A

Thilium laser enucleation of the prostate: transurethral laser used to remove prostate, then cut into fragments and removed.

17
Q

How is open prostatectomy performed?

A

Incision made in lower abdomen, and occasionally in perineum.

18
Q

What are the complications of BPH? (x6)

A
  • Prostate cancer
  • UTI
  • Renal insufficiency from congestion
  • Stones secondary to urinary stasis
  • Erectile dysfunction from medical therapy (alpha blockers or 5-alpha-reductase inhibitors)
  • Acute urinary retention
19
Q

What is the prognosis of BPH?

A

Clinical progression occurs in 20% of patients.

20
Q

What is prostate cancer?

A

Tumour of glandular tissue of prostate.

21
Q

What is the aetiology/risk factors of prostate cancer?

A

Unknown. Factors include high-fat diet, black ethnicity, and family history.

22
Q

What is the pathophysiology of prostate cancer?

A

Prostatic intra-epithelial neoplasia (PIN) which can invade seminal vesicles and bladder neck. Subsequent spread can be to the peri-neural spaces, lymphatics and blood vessels. The most frequent metastases occurs via haematogenous routes to bone, then lung, liver, pleura and adrenals.

23
Q

What is the epidemiology of prostate cancer: Common? Age? Ethnicity?

A

2nd leading cause of mortality in male cancers. Median age at diagnosis is 66. Highest incidence in black men.

24
Q

What are the signs and symptoms of prostate cancer? (x5)

A
  • Nocturia, urinary frequency, hesitancy, and dysuria associated with obstruction. Haematuria not common
  • DRE: asymmetrical and nodular
  • Weight loss and lethargy
  • Bone pain
  • Palpable lymph nodes
25
Q

What are the blood investigations for prostate cancer? (x5)

A
  • PSA: high, but also raised in prostatitis and BPH
  • Testosterone: baseline test for patients in whom androgen deprivation is considered
  • LFTs: baseline test for patients in whom androgen deprivation is considered, due to risk of hepatitis
  • FBC: baseline test for patients in whom androgen deprivation is considered, due to risk of anaemia
  • Renal function: baseline and abnormalities indicate locally advanced disease with tumour causing obstruction
26
Q

What are the other investigations for prostate cancer? (x3)

A
  • BIOPSY: transrectal ultrasound (TRUS)-guided needle biopsy identifies PIN and malignant cells
  • Bone scan if PSA higher than 20 mcg/L, with X-rays
  • CT/MRI: staging
27
Q

What is TURP?

A

Resection of the prostate in BPH where the prostate is visualised through the urethra and tissue removed by electrocautery or sharp dissection.

28
Q

What are the indications for TURP?

A

Failed medical treatment for BPH, renal complications of BPH, or urinary tract retention from BPH. Prostate volume between 30 and 80g.

29
Q

What are the acute complications of TURP? (x3)

A
  • BLEEDING
  • Clot retention (clot blocks urethra and causes urinary retention)
  • Post-TURP syndrome (hyponatraemia and water intoxication caused by an overload of fluid absorption from washing out the open prostatic sinusoids during the procedure. Causes CNS and CVS disturbances)
30
Q

What are the chronic complications of TURP? (x3)

A
  • Urinary incontinence (most commonly stress incontinence)
  • Retrograde ejaculation is common, due to injury of the prostatic urethra i.e., ejaculate is directed into bladder
  • 14% become impotent

Year 3 Renal & Urology (10 decks)

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