Jan16 M2-LUTS Flashcards
what type of cells in the pelvis
transitional
two ways to control continence and how controlled
bladder neck (internal sphincter): by ANS external sphincter, skeletal muscle
normal things bladder should do to store urine (2) (when don’t want to pee)
low detrusor pressure (SS activity to relax the SM) + PSS inhibition
what affects bladder compliance (common ones)
neurological problem, diabetes (neuropathy), fibrosis , prolonged obstruction
what can cause obstruction
enlarged prostate for a long time (high R downstream)
external sphincter what type of control and what nerve
somatic. pudendal nerve
2 types of fibers in the external sphincter (or distal or rhabdo sphincter) + fct
slow-twitch: (type I) maintain skm resting tone
fast-twitch: (type IIa) rapid response to sudden rises in intra-abd coughing
why females more prone to incontinence (3)
- post menopause atrophy in submucosa (harder to fight P)
- shorter urethra (less downstream P)
- misalignement from anatomical changes (bladder prolapse, cystocele)
CNS actions when you want to pee (what part of the brain starts it all and what it acts on)
- pontine micturition center. inhibits guarding relaxation
- sacral micturition center (S2 to S4)
2 brain centers for micturition: 3 things they do
- relax skm of external sphincter
- rise in detrusor P
- open bladder neck (ANS)
two types of LUTS
irritative and obstructive
irritative LUTS
dysuria incontinence urgency frequency hematuria nocturia
obstructive LUTS
frequency hesitancy intermittency incomplete emptying weak stream retention straining terminal dribbling
intermittency def
must force abd muscles but intermittently bc get tired
straining def
have to force
terminal dribbling def
urine falls slowly in drops of a thin stream
main reason for obstruction
prostate enlargement
main risk factors for LUTS
age, obesity, diabetes, ETOH intake, phys activity
main meds that affect voiding
anticholinergics: relax bladder SM
CCB: relax bladder SM
alpha blockers: decrease outlet resistance
alpha agonist: increase outlet R
3 other meds that relax the bladder and increase outlet resistance
- narcotis
- antipsychotics
- antihistamines
overactive bladder def and caues
SS too weak. fail to act as a low P storage
causes: neurogenic or myopathic
LUTS in overactive bladder
urgency, frequency, incontinence maybe
management of overactive bladder
- anticholinergic
- catheterization
- cystostomy, surgical bladder augmentation
4 voiding dysfunctions ex
- overactive bladder
- obstruction (BPH)
- urinary incontinence
- urinary retention
retention causes
- bladder prob (neuro, pharmaco, myopathic)
- outlet prob (prostate obstruction, stricture, neck contracture, neuro (sphincter))
incontinence causes
- bladder prob (neuro, myopathic, retention with overflow incontinence)
- outlet prob (sphincter prob, stress incontinence = anato)
BPH def
benign prostatic hyperplasia
hyperplasia of what cells in BPH
glandular tissue (epithelial cells) prostate stroma (SM)
how prostate develops
testosterone (T) converted to dihydrotestosterone (DHT) by 5-alpha reductase. DHT is a more potent androgen, acts for prostate dev
how BPH leads to LUTS (2)
- pressure on urethra from prostate bulk
- higher SM tone in prostate and urethra
how detrusor reacts to BPH over time
becomes hypertrophic
4 prostate zones
transitional, central, peripheral, fibromuscular stroma
prostate zones with BPH and with cancer
BPH in transitional
peripheral: cancer
rectal exam to check what and why
for prostate CANCER (peripheral zone in front of the rectum)
2 scores to evaluate for LUTS
IPSS score (international prostate symptom score) AUA (Am Urol ASsoc Symptom score)
most common cause of LUTS
UTI
ddx for LUTS and how to differentiate
UTI, neuro, BPH, cancer, stricture, diabetic neuropathy, etc. LAB TESTS + history
PSA meaning and shows what (test)
blood prostate specific antigen. shows prostate enlargement or cancer or infection
high sensitivity testing for prostate cancer
DRE AND PSA
complications of BPH
UTI, overflow incontinence, urinary retention, renal fialure
hematuria workup and how to check for the cause
- imaging of upper urinary tract
- cystoscopy for lower urinary tract
BPH and PSA
PSA high
principle in diagnosing BPH and how to do it
by elimination. rule out renal failure by physical exam. DRE to rule out cancer. (stones, other cancer)
labs to do in LUTS
UA, urine culture, PSA, uroflow scan
BPH = dx by exclusion. what to rule out b4 BPH
UTI, prostate infection, cancer, prostate cancer, neuro voiding problem
non-pharma vs pharma options in BPH
non-pharma: timed voiding, double voiding
pharma: alpha blockers, 5 alpha reductase inhibitors, anticholinergics
alpha blockers act on what
alpha-1 adrenergic receptors in prostatic SM and in the bladder neck
alpha receptors type in the prostate, bladder, vasculature and CNS
prostate: alpha 1a
bladder: alpha 1d
vasculature: alpha 1a and alpha 1b
CNS: alpha 1b
2 drugs (alpha 1 a blockers)
tamsulosin
silodosin
2 5-alpha-reductase inhibitors and what type
finasteride (type2)
dutasteride (type 1 and 2 inhibitor)
surgeries in BPH + most common
TURP (most common), TUIP (incision rather than resection)
criteria for referring LUTS to a urologist
- intense symptoms
- young patients
- meds side effects too bad
- BPH complications
- complex presentation
