GU Flashcards
What is BPH?
Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.
What are the typical LUTS that occur with prostate pathology?
There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:
Hesitancy – difficult starting and maintaining the flow of urine
Weak flow
Urgency – a sudden pressing urge to pass urine
Frequency – needing to pass urine often, usually with small amounts
Intermittency – flow that starts, stops and varies in rate
Straining to pass urine
Terminal dribbling – dribbling after finishing urination
Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night
Non-modifiable for BPH
patient’s age, genetics, and geography
Modifiable for BPH
hormones (testosterone, dihydrotestosterone, oestrogen), metabolic syndrome, diabetes, diet, physical activity, and inflammation.
What is used to assess the severity of LUTS in BPH?
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms.
What is the initial assessment of men presenting with LUTS ?
The initial assessment of men presenting with LUTS involves:
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
What is the PSA test?
The initial assessment of men presenting with LUTS involves:
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Common causes of a raised PSA
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
What should a benign prostate feel like?
A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
What does a cancerous prostate feel like?
A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
Management of BPH
Patients with mild and manageable symptoms may not require interventions.
The medical options are:
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
The general idea is that alpha-blockers are used to treat ________, and 5-alpha reductase inhibitors are used to treat ___________.
immediate symptoms ; enlargement of the prostate
How does 5-alpha reductase work?
5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.
The surgical options for BPH
Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
What is Transurethral Resection of the Prostate?
Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
Major complications of TURP
Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms
Transurethral electrovaporisation of the prostate (TEVAP / TUVP)
involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP
also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
Open prostatectomy
involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate. Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.
Differentials Dx of BPH
Urinary tract infection
Sexually transmitted infections
Prostatitis
Neurogenic bladder
Urinary tract stones
Complications of BPH
Acute urinary retention
Chronic retention
Urinary tract infection (due to incomplete emptying)
Haematuria
Bladder calculi
What is atrophic vaginitis?
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause.
Who is atrophic vaginitis common in?
often occurs in women who are post-menopausal women
What is the vaginal lining made of?
The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections.
What is the purpose of oestrogen for the vagina?
Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.
Presentation of atrophic vaginitis
Atrophic vaginitis presents in postmenopausal women with symptoms of:
Itching
Dryness
Dyspareunia (discomfort or pain during sex)
Bleeding due to localised inflammation
Presentation of atrophic vaginitis in older women
You should also consider atrophic vaginitis in older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse. Treatment with topical oestrogen where appropriate may improve the symptoms of these conditions.
It is worth asking about symptoms of vaginal dryness and discomfort, as women will often be reluctant to bring it up during a consultation. It is straightforward to treat and can make a big difference to their quality of life.
Examination of the labia and vagina in atrophic vaginitis
Pale mucosa
Thin skin
Reduced skin folds
Erythema and inflammation
Dryness
Sparse pubic hair
Management of atrophic vaginitis
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen can make a big difference in symptoms
Options for topical oestrgoen for atrophic vaginitis
Estriol cream, applied using an applicator (syringe) at bedtime
Estriol pessaries, inserted at bedtime
Estradiol tablets (Vagifem), once daily
Estradiol ring (Estring), replaced every three months
Contraindications for topical oestrogen in atrophic vaginitis
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.
What is an anal fissure?
An anal fissure (fissure in ano) is a longitudinal and superficial tear of the epithelium and dermis at the anal margin extending up into the anal canal but below the dentate line. Anatomically, anal fissures develop in the posterior aspect of the anal canal
Risk factors for anal fissures
post-partum women and the elderly Constipation
Low fibre diet
Inflammatory bowel disease (IBD)
Chronic diarrhoea
Pregnancy
Opioid analgesia: due to constipation
Aetiology of anal fissures
Anal fissures are a multifactorial condition with many risk factors (with constipation being the most common).
Pathophysiology that increases the risk of development of fissures include:
Mechanical/traumatic: due to the passage of a hard and bulky stool at the origin of an anodermal tear
Hypertonia of the internal anal sphincter: this is thought to reduce the blood supply to the anus and thus slows down the healing process
Ischaemia: hinders the healing of the fissure
Differentials for anal fissures
Thrombosed haemorrhoids: which present with anal pain and bright red rectal bleeding seen internally with a proctoscope
Inflammatory bowel disease: presents with more chronic symptoms and other extra-intestinal features such as episcleritis and erythema nodosum
Sarcoidosis
Malignancy: anal carcinoma presents with red flag symptoms (change in bowel movements, weight loss, family history) and may require an examination under anaesthesia with biopsy
Peri-anal abscess: presents with purulent discharge and anal pain. It appears as a pus-filled swelling rather than a tear in the skin.
Typical symptoms of anal fissures
Pain around the anus
Painful defecation (described as ‘feeling like passing broken glass’)
Rectal bleeding
Abdominal pain (rare)
Signs of anal fissures
Fissures can be palpable or visible around the anus
A tear can be seen on the posterior aspect
Ix for anal fissures
Stool sample
FBC + CRP
Faecal Calprotectin
Thyroid function tests
CT scan
Colonoscopy
Management of anal fissures
topical anaesthetic (lidocaine 5% ointment)
lactulose and other stool softeners
high fibre diet
adequate fluid intake
hygiene
Usually they heal after 2 weeks on their own.
Glyceryl trinitrate ointment
Topical CCB e.g. diltiazem
Botulinum toxin injections
Tx using glyceryl trinitrate ointment for anal fissures
acts on anal sphincter hypertonia and causes vasodilation of the surrounding blood vessels, which can help with healing.7 A key side effect to mention to the patient is headaches post-application.
Botox injections for anal fissures
If there is no improvement with a topical cream, the next stage would be examination under anaesthesia with botulinum toxin injections to the internal anal sphincter.6-8 Botulinum is injected into the internal anal sphincter, and this blocks the presynaptic reuptake of acetylcholine, which reduces the contraction of striated and smooth muscles of the anal canal.7
Surgical management for anal fissures
If the anal fissure does not heal or is reoccurring, surgery is advised. Surgery is recommended after six to eight weeks of medical treatment. Surgery is only the first line if the fissure has hyperalgesia or is infected.
Different surgical procedures are available:
Lateral internal sphincterotomy: partial resection of the internal anal sphincter to relieve hypertonia and allow healing of the fissure left in place (the side effect of incontinence is permanent and hence not a preferred procedure in females and should consider other surgical procedures).
Fissurectomy: an alternative involving resection of fibrous edges of the fissure. It can also be completed with anoplasty.
Complications for anal fissures
Faecal incontinence after surgery
Recurrence
What is urinary incontinence?
Urinary incontinence refers to the loss of control of urination. There are two types of urinary incontinence, urge incontinence and stress incontinence. Establishing the type of incontinence is essential, as this will determine the management.
What is urge incontinence?
Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. This can have a significant impact on their quality of life, and stop them doing work and leisure activities.
What is stress incontinence?
The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis.
Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.
What is mixed incontinence?
Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.
What is overflow incontinence?
Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.
Risk Factors for Urinary Incontinence
Increased age
Postmenopausal status
Increase BMI
Previous pregnancies and vaginal deliveries
Pelvic organ prolapse
Pelvic floor surgery
Neurological conditions, such as multiple sclerosis
Cognitive impairment and dementia
modifiable lifestyle factors that can contribute to symptoms of urinary incontinence
Caffeine consumption
Alcohol consumption
Medications
Body mass index (BMI)
Bimanual examination of pelvic muscle contractions
The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers. This can be graded using the modified Oxford grading system:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
Ix for urinary incontinence
Bladder diary
Urine dipstick testing
Post-void residual bladder volume
Urodynamic testing
Bladder diary
A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days.
Urine dipstick testing
Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology.
Post void residual bladder volume
Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.
Urodynamic testing
Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination. Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests.
What happens during urodynamic testing?
A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken:
Cystometry measures the detrusor muscle contraction and pressure
Uroflowmetry measures the flow rate
Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence.
Post-void residual bladder volume tests for incomplete emptying of the bladder
Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.
Management of Stress Incontinence
Avoiding caffeine, diuretics and overfilling of the bladder
Avoid excessive or restricted fluid intake
Weight loss (if appropriate)
Supervised pelvic floor exercises for at least three months before considering surgery
Surgery
Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
Pelvic floor exercises for stress incontinence
Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel. Pelvic floor exercises should be supervised by an appropriate professional, such as a specialist nurse or physiotherapist. Women should aim for at least eight contractions, three times daily.
Surgical Management of Stress Incontinence
Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape
Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support
What can be done if all else fails for stress incontinence management?
Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, specialist centres may offer an operation to create an artificial urinary sphincter. This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.
Management of Urge Incontinence
Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
Mirabegron is an alternative to anticholinergic medications
Invasive procedures where medical treatment fails
SE of anticholinergic medications
dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia, which can be very problematic in older, more frail patients.
Contradindication of Mirabegron
uncontrolled HTN ; Blood pressure needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke
Invasive options for overactive bladder that has failed to respond to retraining and medical management of Urge Incontinence
Botulinum toxin type A injection into the bladder wall
Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
