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09. HPB (870) > Male voiding LUTS + EAU > Flashcards

Male voiding LUTS + EAU Flashcards

1
Q

What is the percentage of men above 65 years with LUTS?

A

30%

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2
Q

How many men with LUTS will undergo prostate surgery?

A

around 20%

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3
Q

Basic clinical evaluation for LUTS:

A 
History
Assesment of symptoms (ex IPSS)
Frequency Volume Charts (ex tidsmiktion)
Digital Rectal Examination
Urinalysis
Blood Tests
-creatinine/eGFR
-PSA
Flow rate
Post void residue
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4
Q

When it comes to the size of the prostate, how sensitive is Digital Rectal examination?

A

It can discriminate between prostate volume > or < 50mL

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5
Q

What is a Mildly symptomatic IPSS-score?

A

1-7

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6
Q

What is a Moderately symptomatic IPSS-score?

A

8-19

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7
Q

What is a Severly symptomatic IPSS-score?

A

20-35

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8
Q

Predict prostate size with a PSA of >1,5 ng/mL:

A

> 30 ng/mL

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9
Q

When should you measure PSA in a patient with LUTS?

A

If a diagnosis of prostate cancer will change the management

If it assists in the treatment and/or decision making process

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10
Q

Does DRE underestimate or overestimate prostate volume?

A

underestimates

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11
Q

Why should PVR (post-void residual) be assesed at first clinical visit for a patient with LUTS?

A

High baseline PVR is predictive for future symptom progression

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12
Q

What information should be included in a bladder diarie?

A 
Voiding frequency
Voiding volume
Fluid intake
Use of pads
Activities
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13
Q

What additional tests can be considered when evaluating LUTS?

A 
Pressure flow studies
Endoscopy
Upper urinary tract US scan
Transrectal ultrasound
Bladder wall thickness
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14
Q

Lifestyle advice for LUTS:

A

reduction of fluid intake (not below 1500ml)
moderation of caffeine and alcohol intake
urethral milking to avoid post micturition dribbling
Distraction techniques- breathing exercises, mental tricks
Bladder re-training (to around 400 mls)

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15
Q

How quickly does Alpha 1 adrenoreceptors give effect?

A

1-2 weeks

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16
Q

What is the effect of Alpha 1 adrenoreceptors on LUTS?

A

improves symptoms /flow

you can expect an improvement in Qmax by 15-30%

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17
Q

What are the most common side-effects of Alpha 1 adrenoreceptors?

A

Asthenia
Dizziness (orthostatic)
Hypotention

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18
Q

What Alpha 1 adrenoreceptor is more likely to cause floppy iris syndrome?

A

Tamsulosin

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19
Q

What are the effects of 5 Alpha reductase inhibitors?

A

Improves symptoms/flow
Reduce prostate volume
Reduce longer-term risk of AUR and surgery

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20
Q

How quickly does 5 Alpha reductase inhibitors give effect?

A

6-12 months

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21
Q

How much does 5 Alpha reductase reduce the volume of the prostate?

A

by 15-25%

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22
Q

How much does 5 Alpha reductase reduce PSA?

A

50% by 6 months

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23
Q

How big is the risk reduction for surgery because of BPH with 5 Alpha reductase?

A

55%

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24
Q

How big is the risk reduction for surgery because of AUR with 5 Alpha reductase?

A

57%

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25
Q

What is the patophysiology behind Antimuscarin drugs?

A

Main neurotransmitter in the bladder (acetylcholine) stimulates muscarinic receptors of detrusor smooth muscle cells

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26
Q

What type of Muscarin receptor subtype is present in the bladder?

A

M2 (80%) and M3 (20%) in the detrusor

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27
Q

What is the effect of antimuscarin drugs?

A

Reduction in:

  • voiding frequency
  • nocturia
  • urge incontinence
  • IPSS
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28
Q

What size prostate does antimuscarine drugs have the greatest effect on?

A

small prostates

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29
Q

What are the most common side effects of antimuscarine drugs?

A

Dry mouth (<16%)
Constipation (<4%)
Dizziness (<5%)

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30
Q

What LUTS symptom can become worse from antimuscarine treatment?

A

BOO (PVR can increase, no increase rate of AUR)

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31
Q

What should be included in the follow-up of patients on antimuscarine treatment?

A

PVR

IPSS

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32
Q

What type of drug i Mirabegron?

A

An antimuscarine, selective Beta3 receptor agonist

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33
Q

What is the mechanism of Mirabegron?

A

Mirabegron mediates relaxation of the detrusor muscle during the storage phase of the micturition cycle, thus incereasing bladder storage capacity

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34
Q

What is the drug containing Mirabegron called?

A

Betmiga

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35
Q

What are the contraindications for Mirabegron?

A

Not well controlled hypertention

has higher incidence of CV events

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36
Q

What is the mechanism of PDE-5 inhibitors?

A

NO stimulates synthesis of cyclic GMP which reduces smooth muscle tone of detrusor, prostate and urethra
PDE-5 inhibitors prevent hydrolysis of cyclic GMP

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37
Q

What is the effect on LUTS by PDE-5 inhibitors?

A

Less storage and voiding symptoms

Significant QoL improvement

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38
Q

What is the improvement on IPSS by PDE-5 inhibitors?

A

17-37%

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39
Q

What are the contraindications for PDE-5 inhibitors?

A

Nitrates
guanylatcyklas-stimulators

kraftigt nedsatt leverfunktion, hypotension (blodtryck < 90/50 mmHg), nyligen genomgången stroke eller hjärtinfarkt samt känd hereditär degenerativ näthinnesjukdom

40
Q

What kind of drug is Desmopressin?

And how does it work?

A

A vasopressin analogue
It binds to V2-receptors in the renal collecting duct
Increases the water re-absorbtion

41
Q

What are the practical considerations when prescribing Desmopressin?

A

1x1 before sleep
dose titration 0,1 mg –>0,4 mg
regular check of sodium concentration

42
Q

When should you use a combination of α-blocker and

a 5α-reductase inhibitor?

A

Men with moderate-to-severe LUTS

and risk of disease progression (prostate volume >40mL)

43
Q

When should you use a combination of α-blocker and a muscarinic receptor antagonist?

A

Men with moderate-to-severe LUTS if relief of storage symptoms has been insufficient with monotherapy with either drug

44
Q

What is a reason to be careful when prescribing a combination of α-blocker and a muscarinic receptor antagonist?

A

Post-void residual volume > 150 mL

45
Q

What are the indications for BPO surgery?

A

Bothersome LUTS refractory to medical treatment (relative indication)

Recurrent/refractory urinary retention
Overflow incontinence
Recurrent UTI’s
Bladder stones of diverticula
Treatment resisten macroscopic haematuria due to BPH/BPE
Dilatation of upper urinary tract due to BPO

46
Q

If considering surgery for LUTS what should be completed before?

A

Use a bladder diary for at least 3 days
Use a validated symptom score questionnaire (IPSS)

Physical examination including digital rectal examination
Uroflowmetry
Prostate imaging

47
Q

How effective is an open prostatectomy?

A

63-86% reduction of LUTS

60-87% improvement of IPSS

48
Q

What is the blood transfusion rate after an open prostatectomy?

A

7-10%

49
Q

What are the complications after an open prostatectomy?

A

Bleeding (need for transfusion 7-10%)
Urinary incontinence ≤ 10%
Bladder neck stenosis/ urethral stricture ≈5%

50
Q

What is the re-operation rate for TurP?

A

2,6-7,4%

51
Q

In men with moderate-to-severe LUTS, when is the prostate size an indication for open surgery?

A

> 80 mL

52
Q

What is TUR-syndrome?

A

Absorbtion of fluids used to irrigate the bladder causing a disturbed electrolyte balance mostly hyponatraemia. Symptoms and electrolyte imbalance depends on what fluid is used.

53
Q

What are the benefits of monopolar TurP vs bipolar TurP?

A

Similar surgical result
Lower TUR-syndrome and clot-retention
Shorter irrigation and catheter time

54
Q

In men with moderate-to-severe LUTS, when is the prostate size an indication for TurP?

A

30-80 mL prostate

55
Q

In men with moderate-to-severe LUTS, when is the prostate size an indication for transurethral incision?

A

< 30 mL prostate without middle lobe

56
Q

What technique can be used instead of TurP for transurethral resection of the prostate?

A

HoLEP(holmium laser) and 532nm (greenlight) laser vaporisation
Thulium Laser vaporisation (ThuVaRP)
Diodelaser (DiLRP) (not enough science yet but seems good at least short-term)

57
Q

Which patients should ideally be considered for 532nm laser treatment for LUTS?

A

Patients with anticoagulant treatment or high cardiovascular risk

58
Q

When is Thulium laser vaporisation (ThuVaRP) an alternative to TurP and HoLEP?

A

Men with moderate-to-severe LUTS and small- or medium-sized prostates

59
Q

What is the weakness with HoLEP (holmium laser) and 532 nm (greenlight) laser vaporisation

A

Increased risk of need for retreatment 19-25%

60
Q

When is greenlight (532nm laser) a safe and effective treatment?

A

In small-medium prostates

61
Q

Techniques for less invasive treatment options for LUTS?

A

Mechanical Device:
PUL -prostatic urethral lift
TIND -temporary implantable nitinol device

Rezum (water vapor thermal therapy)
Aquaablation

62
Q

What are the benefits of Less invasive treatment options for LUTS?

A

Outpatient procedure
Local anaesthesia
Minimal adverse events
Better ejaculatory function

63
Q

How do you divide lower urinary tract symptoms?

A

Storage
Voiding
Post-micturition symptoms

64
Q

Define acute retention of urine:

A

Painful, palpable or percussible bladder when the patient is unable to pass any urine

65
Q

Define chronic retention of urine:

A

Non-painful bladder, wich remains palpable or percussible after the patient has passed urine.
The patient may also be incontinent

66
Q

What characterises bladder outlet obstruction?

A

Increasing detrusor pressure and reduce urine flew rate

67
Q

What is benign prostatic obstruction?

A

A form of BOO (bladder outlet obstruction) where the cause of outlet obstruction is known to be BPE (Benign prostatic enlargement)

68
Q

What is Detrusor overactivity (DO)?

A

A urodynamic observation chareacterised by involuntary detrusor contratctions during the filling phase which may be spntaneous or provoked

69
Q

IPSS: Asymptomatic?

A

0

70
Q

IPSS: Mildly symptomatic?

A

1-7

71
Q

IPSS: Moderately symptomatic?

A

8-19

72
Q

IPSS: Severely symptomatic?

A

20-35

73
Q

Give an example of a questionnaire that is suitable to evaluate nocturia and OAB?

A

ICIQ-MLUTS

The international consultation on Incontinence Questionnaire

74
Q

When should Frequency volume charts and bladder diaries primarily be used?

A

Nocturia

75
Q

For what period of time should the patient record their bladder diary?

A

At least 3 Days.

76
Q

In male patients with LUTS what should the physical examination primarily focus on?

A

Suprapubic area, the external genitalia, the perineum and lower limbs.
Urethral discharge, meatal stenosis, phimosis and penile cancer must be excluded

77
Q

How sensitive is DRE (digital rectal examination) when it comes to estimate prostate volume?

A

DRE can discriminate between volumes > or < 50 mL

78
Q

If a patient has LUTS, should PSA be measured?

A

Yes If a diagnosis of prostatecancer will change management

or if it will assist in the treatment and/or decision making process

79
Q

Is PSA useful in predicting prostate volume?

A

Yes, PSA > 1,5 predict a prostate volume of > 30 mL

80
Q

What predictions can be made from baseline PSA value?

A

Risk of acute urinary retention (AUR) and BPE- related surgery

81
Q

When evaluating a patient for LUTS, what labratory tests should be performed?

A

Krea and/or GFR

Urinalysis (dipstick or sediment)

82
Q

What role in LUTS does measurements of PVR (post-void residual) have?

A

Monitoring Changes over time may allow for identification of patients at risk of AUR (acute urinary retention)

83
Q

What volume is needed for diagnostic accuracy of uroflowmetry?

A

> 150 mL

84
Q

When should uroflowmetry be used?

A

Prior to Medical or invasive treatment.

Not necessarily in the initial evaluation av LUTS.

85
Q

What is measured with uroflowmetry?

A

Qmax and flow pattern

86
Q

When should men with LUTS be examined with ultrasound?

A

Large PVR (post void residual)
haematuria
history of urolithiasis

87
Q

When should TRUS be performed on men with LUTS?

A

When considering surgical treatment and prior to treatment with 5-ARIs

88
Q

When should urethrocystoscopy be performed on men with LUTS?

A

If there is a history of haematuria, urethral stricture or bladder cancer

89
Q

What is DUA?

A

Detrusor underactivity

decreased detrusor pressure during voiding

90
Q

How many men with LUTS suffer from DUA?

A

11-40%

91
Q

What is PFS?

A

Pressure flow studies

92
Q

When performing a TRUS you can assess IPP.

What is it and what information can be gained from the knowledge?

A

Intravesical Prostatic Protrusion
correlates well with BPO (presence and severety).
Can predict the outcome of a trial without catheter after AUR

93
Q

FVC?

A

Frequency volume chart

94
Q

What are the strongest predictive factors when it comes to failed WW for LUTS?

A

Increasing symptoms and PVR volumes

95
Q

Which Lifestyle advice should be given to men with LUTS and WW?

A
  • reduction of fluid intake
  • moderation of caffeine and alcohol
  • use of relaxed and double voiding techniques
  • urethral milking (prevents post-micturial dribbling)
  • distraction techniques
  • bladder retraining
  • Review of medication for fewer urinary effects
  • treatment for constipation
  • assistance if there is an impairment that limits the patient
96
Q

ewWhat is the treatment failure for WW in five years?

A

21%

71% of patients are clinically stable

09. HPB (870) (8 decks)

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