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Renal/Urology > Lecture 18 + 19: Benign Diseases of the Urinary Tract > Flashcards

Lecture 18 + 19: Benign Diseases of the Urinary Tract Flashcards

1
Q

How big is the prostate?

A

About the size of a walnut

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2
Q

2/3rd of the prostate is ____. 1/3rd is ____

A

Glandular

Fibromuscular

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3
Q

What surrounds the prostate gland?

A

Thin fibrous capsule

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4
Q

What is the clinical histological division of the prostate (McNeal’s zones)?

A

Central zone
Transitional zone
Peripheral zone

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5
Q

Which of McNeal’s zones is the biggest?

A

Peripheral

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6
Q

What does the central zone surround?

A

Ejaculatory ducts

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7
Q

Where is the transitional zone?

A

It is central and surrounds the urethra

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8
Q

Which zone’s glands typically undergo hyperplasia in BPH?

A

Transitional zone

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9
Q

In which zone is prostate cancer most common?

A

Peripheral zone

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10
Q

Which zone is felt most on DRE?

A

Peripheral

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11
Q

What is the arterial supply to the prostate?

A 
Prostatic arteries
(mainly derived from internal iliacs)
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12
Q

What is the venous drainage of the prostate?

A

Prostatic venous plexus (drained by internal iliac veins)

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13
Q

What is BPH characterised by?

A

Fibromuscular and glandular hyperplasia

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14
Q

What % of men have BPH at age 60 and age 85?

A

60 - 50% men

85 - 90%

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15
Q

BPH is a progressive condition leading to what?

A

Bladder outflow obstruction

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16
Q

How is the severity of BPH scored?

A

International prostate symptom score

Mild 0-7, moderate 8-19, severe is 20+

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17
Q

How does BPH tend to present?

A

LUTS (lower urinary tract symptoms)

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18
Q

How are LUTS categorised?

A 
Voiding symptoms (obstructive) - weak/intermittent urinary flow, straining, hesitancy, terminal dribbling + incomplete emptying
Storage symptoms (irritative) - urgency, frequency, urgency incontinence, nocturia
Post-micturition - dribbling
Complications - UTI, retention, obstructive uropathy
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19
Q

What investigations may be useful in BPH?

A

Urinalysis
PSA
International Prostate Symptom Score
Frequency volume charts

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20
Q

What things should you look for on examination of someone with suspected BPH?

A

Abdomen - ?palpable bladder
Penis - ?external urethral meatal stricture, ?phimosis
DRE - assess prostate size, ?suspicious nodules/firmness
Urinalysis - ?blood, ?UTI

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21
Q

What other investigations might you consider in someone with BPH?

A 
MSSU
Flow rate study
Post-void bladder residual USS
PSA, urea/cr if chronic retention
Renal tract USS if renal failure/bladder stone suspected
Flexible cystoscopy if haematuria
Urodynamic studies in selected cases
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22
Q

What investigation should be done is PSA is raised or DRE is abnormal?

A

TRUS-guided prostate biopsy

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23
Q

What are management options for BPH?

A

Watchful waiting
Medications
Surgery

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24
Q

What medications can be used to treat BPH?

A

Alpha-1-antagonists
5 alpha-reductase inhibitors
Often used in combination

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25
Q

What surgery is used to treat BPH?

A

TURP - transurethral resection of prostate

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26
Q

Give e.g.s of alpha-1 antagonists

A

Tamsulosin, alfuzosin

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27
Q

How do alpha-1 antagonists work in treating BPH?

A

Decrease smooth muscle tone of bladder + prostate, thus antagonising the dynamic element to prostatic obstruction

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28
Q

What drugs are considered first line for BPH?

A

Alpha-1 antagonists

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29
Q

What AEs are associated with alpha-1 antagonists?

A

Dizziness, postural hypotension, dry mouth, depression

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30
Q

Give an e.g. of a 5-alpha reductase inhibitor

A

Finasteride

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31
Q

How do 5 alpha-reductase inhibitors work?

A

Block conversion of testosterone to dihydrotestosterone (which is known to induce BPH)

NB unlike alpha-1 antagonists they reduce prostate volume and decrease PSA but takes up to 6 months but doesn’t reduce LUTS as much as alpha-1 antagonists

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32
Q

What adverse effects are associated with 5 alpha-reductase inhibitors?

A

Erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

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33
Q

What surgical intervention is recommended if the prostate is <100cc?

A

TURP

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34
Q

What surgical intervention is recommended if the prostate is >100cc?

A

Open retropubic/transvesicular prostatectomy

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35
Q

Apart from TURP/open/transvesicular surgery what other surgical options are there for BPH?

A

Endoscopic ablative procedures

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36
Q

The smooth muscle fo the bladder neck (internal urethral sphincter) and prostate is innervated by what nerves?

A

Sympathetic alpha-adrenergic nerves

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37
Q

Is it best to use alpha-1 antagonists, 5 alpha-reductase inhibitors or a combination of both?

A

Combination of both

38
Q

What are additional benefits of 5a-reductase inhibitors besides reducing prostate volume?

A

Reduces prostate vascularity –> reduced haematuria due to prostatic bleeding
Potential role in prostate cancer prevention

39
Q

What is the gold standard treatment for BPH?

40
Q

What are complications of TURP?

A 
Bleeding
Infection 
Retrograde ejaculation 
Stress urinary incontinence
Prostatic regrowth leading to recurrent haematuria or BOO
41
Q

What are alternative new endoscopic ablative procedures that can be used instead of TURP?

A

Transurethral laser vaporisation

42
Q

What are complications of benign prostatic obstruction?

A 
Progression of LUTS
Acute/chronic urinary retention
Urinary incontinence (overflow)
UTI
Bladder stone
Renal failure from obstructed ureteric outflow due to high bladder pressure
43
Q

What are treatment options for those with complicated BPO who are unfit for surgery?

A

Long term urethral/suprapubic catheterisation

CISC

44
Q

Define acute urinary retention

A

Painful inability to avoid with a palpable and percussible bladder

45
Q

What do the residuals in acute urinary retention vary from?

A

500ml to 1L

46
Q

What is the main risk factor for acute urinary retention?

47
Q

What are other aetiologies for acute urinary retention?

A 
UTI
Urethral stricture
Alcohol excess
Post-op causes
Acute surgical/medical problems
48
Q

How can acute urinary retention happen for those who have BPO?

A

Spontaneously i.e. natural progression of BPO

Triggered by unrelated event, e.g. constipation, alcohol excess, post-op causes, urological procedure

49
Q

What is the immediate treatment of urinary retention?

A

Catheterisation (urethral/suprapubic)

50
Q

What are complications of acute urinary retention?

A 
UTI
Post-decompressive haematuria
Pathological diuresis
Renal failure
Electrolyte abnormalities
51
Q

How do you manage acute urinary retention in someone with BPO as the underlying cause?

A

If no renal failure, start alpha blocker immediately, remove catheter in 2 days

If failure to void, recatheterize and organise TURP

52
Q

Define chronic urinary retention

A

Painless, palpable + percussible bladder after voiding

53
Q

What do the residuals in chronic urinary retention vary from?

A

400ml to >2L depending on stage of condition

54
Q

What is the main aetiological factor in chronic urinary retention?

A

Detrusor inactivity - can be primary (i.e. primary bladder failure) or secondary (e.g. due to longstanding BOO, e.g. BPO or urethral stricture)

55
Q

How does chronic urinary retention present?

A

LUTS or complications (e.g. UTI, stones, overflow incontinence, post-renal/obstructive renal failure)

56
Q

What patients with chronic urinary retention require treatment?

A

Those with symptoms/complications

57
Q

How is chronic urinary retention managed?

A

Immediately with catheterisation then CISC if appropriate

58
Q

What are complications of chronic urinary retention?

A

UTI
Post-decompressive haematuria
Pathological diuresis
Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)
Persistent renal dsyfunction due to acute tubular necrosis

59
Q

What are features of pathological diuresis?

A

Urine output >200ml/hr + postural hypotension (systolic >20mmHg between lying and standing), + wt loss + electrolyte abnormalities

60
Q

How is pathological diuresis managed?

A

IV fluids

Close monitoring

61
Q

What is the future management of chronic urinary retention?

A

Long term urethral/suprapubic catheter
CISC
TURP

62
Q

What are causes of urinary tract obstruction at the PUJ?

A 
Instrinsic - 
Physiological PUJ obstruction 
Stone
Ureteric tumour
Blood clot
Fungal ball

Extrinsic -
PUJ obstruction, e.g. crossing vessel
Tumour

63
Q

What are causes of obstruction of the ureter?

A 
Intrinsic - 
Stone
Ureteric tumour (TCC)
Scar tissue
Blood clot
Fungal ball
Extrinsic - 
LNs 
Iatrogenic
Pregnancy 
Tumour
64
Q

What are causes of obstruction at the VUJ?

A

Intrinsic -
Stone
Bladder/ureteric tumour

Extrinsic
Cervical tumour
Prostate cancer

65
Q

What are symptoms/signs of upper urinary tract obstruction?

A

Pain
Haematuria
Palpable mass

66
Q

What are complications of urinary tract obstruction?

A

Infection, sepsis

Renal failure

67
Q

In men what does acute urinary retention most commonly occur secondary to?

A

BPH (enlarged prostate presses on urethra, which makes bladder wall thicker + less able to empty)

68
Q

What other things apart from BPH can cause acute urinary retention?

A

Urethral obstructions - strictures, calculi, cystocele, constipation, masses
Rarer causes incl. neurological causes

69
Q

What medications can cause acute urinary retention and how do they do this?

A 
Affects nerve signals to the bladder - 
Anticholingerics
TCAs
Antihistamines
Opioids
Benzos
70
Q

When does acute urinary retention often occur?

A

Post-op

Postpartum in women

71
Q

How do patients in acute urinary retention typically present?

A

Inability to pass urine
Lower ab discomfort
Considerable pain/distress

72
Q

What is a big difference in the presentation of acute vs chronic urinary retention?

A

Chronic usually painless

73
Q

What signs are typical of acute urinary retention?

A

Palpable distended bladder

Lower ab tenderness

74
Q

All women and men in urinary retention should have what examinations?

A

Both - DRE, neurological - assess for causes

Women - pelvic

75
Q

What investigations should be done in acute urinary retention?

A

Urinalysis + culture
Serum UE, Cr to check for kidney injury
FBC, CRP to check for infection

76
Q

What investigation should be done to confirm a diagnosis of acute urinary retention?

A

Bladder USS

Volume >300cc confirms diagnosis

77
Q

What is the management of acute urinary retention?

A

Catheterisation

78
Q

How should the patient in acute urinary retention be assessed after they are catheterised?

A

Measure volume of urine produced after 15m
<200 = not in acute urinary retention
>400cc = leave catheter in lace

79
Q

If there is no obvious cause for acute urinary retention what should happen next?

A

Send to urologist to assess for of anatomical and urological causes

80
Q

What are the two types of chronic urinary retention?

A

High pressure: impaired renal function + bilateral hydronephrosis, typically due to bladder outflow obstruction
Low pressure: no hydronephrosis, normal renal function

81
Q

What commonly occurs after catheterisation for chronic urinary retention?

A 
Decompression haematuria (due to rapid decrease in pressure in bladder --> shearing of small vessels)
It does not req. treatment usually
82
Q

What emergency treatments may be needed for upper urinary tract obstruction leading to retention?

A

Percutaneous nephrostomy insertion

Retrograde stent insertion

83
Q

What does a nephrostomy involve?

A

Percutaneous puncture under LA + sedation
US/X-Ray guidance

It temporarily collects urine while the urinary tract is blocked

84
Q

What kind of ureteric stents can be inserted?

A

Silicone
Polyurethane
Nickle titanium

85
Q

How is lower tract obstruction leading to urinary retention managed?

A

Urethral catheterisation or suprapubic catheterisation

86
Q

What is involved in ‘resus’ when a patient is in acute urinary retention?

A 
ABC
IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
IV fluids, antibiotics
Analgesia
HDU care +/- renal replacement therapy
87
Q

What things may cause lower urinary tract obstruction and how would you treat them?

A

BPH - TURP
Urethral stricture - optical urethrotomy
Meatal stenosis - meatal dilatation
Phimiosis - circumcision

88
Q

How does high pressure chronic urinary retention present?

A

Painless
Incontinent
Raised Cr
Bilateral hydronephrosis

89
Q

How does low pressure chronic urinary retention present?

A

Painless
Dry
Normal Cr and kidneys

90
Q

Define post-obstructive diuresis

A

Prolonged urine production >= 200ml for at least 2h immediately following the relief of urinary retention or similar obstructive uropathy

Renal/Urology (29 decks)

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