Lecture 19 and 20 Benign Diseases of the Prostate and Urinary Tract Obstruction Flashcards
What are the zones of the prostate
Fibromuscular zone
Transitional zone
Peripheral zone
Central zone
What does BPE stand for
Benign Prostatic Enlargement
What does BPH stand for
Benign Prostatic Hyperplasia
What does BPO stand for
Benign Prostatic Obstruction
What does BOO stand for
Benign Outflow Obstruction
What 3 things overlap to form the Hard Diagram
LUTS
BOO
BPE
What is BPH characterised by
Fibromuscular and glandular hyperplasia
What zone does BPH normally effect
Transitional zone
How is LUTS assessed
International prostate Symptoms Score Sheet and Frequency volume charts
What is involved in a physical examination when assessing LUTS
- Abdomen
- ? palpable bladder
- Penis
- ? external urethral meatal stricture
- ? phimosis
- Digital rectal examination (DRE)
- assess prostate size
- ? suspicious nodules or firmness
- Urinalysis
- ? blood
- ? signs of UTI
What investigations are carried out when a patient presents with LUTS
- MSSU
- Flow rate study- If Qmax <10 ml/s : 90% chance of having BOO
- Post-void bladder residual USS
- Bloods :
- PSA
- urea and creatinine (if chronic retention)
- Renal tract USS if renal failure or bladder stone suspected
- Flexible cystoscopy if haematuria
- Urodynamic studies in selected cases
- TRUS-guided prostate biopsy if PSA raised or abnormal DRE (digital rectal exam)
What is the treatment for uncomplicated BPO
Watchful waiting
Alpha blockers
5 alpha reductase inhibitors (Finasteride or Dutasteride)
– TURP (prostate size <100cc)
– Open retropubic or transvesical prostatectomy (prostate size >100cc)
– Endoscopic ablative procedures
What is the mechanism of alpha blockers
- Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction
- Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
Name the types of alpha blockers
Non-selective- phenoxybenzamine
Selective short acting-prazosin, indoramin
Selective long acting- alfuzosin, doxazosin, terazosin
Highly selective- tamsulosin
What is the mechanism of 5a-reductase inhibitors
– Reduces prostate size and reduces risks of progression of BPE (but only if >25cc prostate)
– Also reduces LUTS (but not as effective as alpha blockers)
– Can also reduce prostatic vascularity and hence reduces haematuria due to prostatic bleeding
Name 5a reductase inhibitors
- Finasteride (5AR Type II inhibitor)
- Dutasteride (5AR Type I and II inhibitor)
What is the gold standard surgical technique for BPO
TURP- Transurethral resection of prostate
What are the complications of BPO
- Progression of LUTS
- Acute urinary retention
- Chronic urinary retention
- Urinary incontinence (overflow)
- UTI
- Bladder stone
- Renal failure from obstructed ureteric outflow due to high bladder pressure
Treatment for complicated BPO
o Cystolitholapaxy and TURP for patients with BPO and bladder
No treatment
o long term urethral or suprapubic catheterisation
o clean intermittent self-catheterisation
What is the main cause of chronic urinary retention
Detrusor underactivity
What is the primary and secondary cause for detrusor under activity
Primary- bladder failure
Secondary- longstanding BOO such as BPO or urethral stricture
Treatment for chronic urinary retention
Immediate catheterisation
Manage IV fluids
What are the complications of urinary retention
Post-decompression haematuria
Pathological diuresis
Electrolyte abnormalities- hyperkalaemia, hyponatraemia, metabolic acidosis
What are the types of urinary tract obstruction
Upper tract- PUJ, VUJ, ureter
Lower Tract- Bladder neck, prostate, urethra, urethral meatus, foreskin
Name intrinsic causes of PUJ obstruction
- Stone
- Ureteric tumour (TCC)
- Blood clot
- Fungal ball
Name Extrinsic causes of PUJ obstruction
- PUJ obstruction (crossing vessel)
- Lymph nodes (tumour)
- Abdominal mass (tumour)
Name intrinsic causes of ureter obstruction
- Stone
- Ureteric tumour (TCC)
- Scar tissue
- Blood clot
- Fungal ball
Name extrinsic causes of ureter obstruction
- Lymph nodes (tumour, retroperitoneal fibrosis)
- Iatrogenic
- Abdominal/pelvic mass (tumour, pregnant uterus)
Name intrinsic causes of VUJ obstruction
- Stone
- Bladder tumour
- Ureteric tumour
Name extrinsic causes of VUJ obstruction
- Cervical tumour
* Prostate cancer
What are the symptoms of upper tract obstruction
Loin pain
Frank haematuria
What are signs of upper tract obstruction
- Palpable mass
- Microscopic haematuria
- Signs of complications - infection, sepsis, RF
When someone has a urinary tract obstruction what is the management
• Immediate catheter
Pain management – NSAIDs/opiates
• ABCs
• IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
• IV fluids, broad-spectrum antibiotics (if appropriate)
• Emergency treatment
– Percutaneous nephrostomy insertion under LA OR
– Retrograde stent insertion
• Definite treatment
– Ureteroscopy
– Stone Fragmentation (laser)
– Ureteric tumour- radical nephro-ureterectomy
– PUJ obstruction- laparoscopic pyeloplasty
When someone has a urinary tract obstruction what is the investigations
- Urine dipstick
- U&Es
- FBC
- CT KUB
What are the symptoms of lower tract obstruction
- Lower urinary tract symptoms
- including urinary incontinence
- Acute urinary retention
- Chronic urinary retention
- Recurrent urinary tract infection and sepsis
- Frank haematuria
- Formation of bladder stones
- Renal failure
What are the symptoms of high pressure chronic urinary retention
- Painless
- Incontinent
- Raised creatinine
- Bilateral hydronephrosis
What are the symptoms of low pressure chronic retention
- Painless
- Dry
- Normal creatinine
- Normal kidneys
Why does decompression haematuria occur
– Shearing of small vessels due to differing compliance of tissue layers
– Usually self-limiting
Short-term urethral catheters (e.g. latex-based ones) should not be left in-situ for longer than
4 weeks
Long-term urethral catheters (e.g. silicone-based ones) should not be left in-situ for longer than:
12 weeks
What is the ‘gold standard’ investigation for renal colic
CT-KUB
What are common types of renal tract stones
Calcium phosphate
Calcium oxalate- most common
Uric acid (urate)
Magnesium ammonium phosphate (struvite)
