PBL 34 Flashcards
1
Q
Post-renal causes of obstruction
A
- Obstruction of the urinary system (stones, tumours, blocked catheters)
- Blood clots in ureters or urethra
- Cancer of the prostate, cervix or colon
- Urethritis
- Urethral stricture
- BPH
- Prostate cancer
- UTI
- PUJO (excessive narrowing at the pelvi-ureteric junction)
- Vesicoureteric reflux (condition where urine flow is retrograde from the bladder back up to the kidneys)
2
Q
What is urethritis? Causes and symptoms?
A
- Inflammation of the urethra
- Causes: gonococcal (sexually transmitted) or non-gonococcal (bacterial pathogen-induced E.Coli)
- Signs and symptoms: dysuria
3
Q
What is a urethral stricture? Causes? Consequences? Management?
A
- Long term complication of urethritis, strictures are narrowing of the urethra through scar tissue formation
- Causes:
Can be iatrogenic - trauma of instrumentation = catheters or cystoscopes - Consequences:
Difficulty urinating - Management:
Simple dilatation or incision through scar tissue
4
Q
Symptoms of post-renal causes of obstruction
A
- Depends on cause, location and duration of obstruction
- Pain
- If kidney is distended –> renal colic can develop. This is an excruciating pain between ribs and hip of affected side which comes and goes ever few minutes. Pain may extend into testis or vaginal area. Nausea / vomiting
-
5
Q
Pathophysiology of prostate cancer
- Causes/mechanism
- Signs and symptoms
- Risk factors
- Screening/diagnostic testing
- Treatment
A
- Causes/mechanism
- >95% are adenocarcinomas as they arise from prostatic acinar or ductal epithelium
- Critical feature is absence of basal cell layer as the basement membrane is breached by malignant cells
- 75% of prostate cancer originates in peripheral zone (more aggressive). 20% from transitional zone. 5% from central zone
- Spreads through lymphatic system –> iliac nodes –> para-aortic lymph nodes
- Often early spreads to bones –> subsequent pathological fractures
- PTEN mutations
- P53 mutations
- Signs and symptoms
- Usually no symptoms until advanced stage
- Obstructive symptoms: poor stream, hesitancy, terminal dribbling, incomplete voiding and anuria
- Frequency
- Haematuria
- Blood in semen
- Bone pain
- Unexpected weight loss
- ED - Risk factors
- Age (>65 y/o)
- Ethnicity (Afro-caribbean > white > asian)
- Hereditary / Family Hx (BRCA 1/2 gene is associated)
- Obesity - Screening / diagnostic testing
- Digital rectal examination
- PSA (blood) test - but can be misleading (elevated due to BPH or prostatitis)
- Only way to diagnose is through trans-rectal prostate biopsy
- Gleason score, PSA level, and clinical stage predict prognosis! - Treatment
- Surgery - transurethral resection of prostate (TURP)
- Radiotherapy (suited for non-curable PCa = metastatic PCa)
- Hormonal therapy
- Chemotherapy
6
Q
What is the Gleason scoring system?
A
Most common way to grade prostate cancer
- Based on microscopic examination of tissues obtained from the biopsy
- The score is 1 - 5, the higher the number, the more aggressive the cancer is and more likely that it will spread
7
Q
Pathophysiology of bladder cancer
- Causes/mechanism
- Signs and symptoms
- Risk factors
- Diagnostic testing
- Treatment
A
- Causes/mechanism
- Changes to cells of the bladder, not always known why but often linked to exposure to certain chemicals
- TP53 mutation is common
- 95% are TCC
- 4% are SCC
- 1% small cell, sarcomatoid variants
- Non-muscle invasive (confined to mucosa or sub-mucosa & 80% 5yr survival rate) and muscle invasive (25% progress to muscle invasive) - Signs and symptoms
- Haematuria
- Dysuria
- Nocturia
- Incomplete voiding
- Frequency
- Anaemia
- Lower back pain on one side of body - Risk factors
- Smoking
- Exposure to chemicals - aromatic amines. They become concentrated in urine and cause cancer
- Age
- Occupation
- Long term exposure to some drugs especially CYCLOPHOSPHAMIDE (alkylating agent)
- Long term bladder stones
- Recurrent UTIs - Diagnostic testing
- Blood in urine and persistent symptoms of cystitis
- Cystoscopy and biopsy - Treatment
- Removal during cystoscopy
- Immunotherapy
- If the cancer has grown into the bladder wall, it cannot be completely removed during a cystoscopy, so a cystectomy is required. A stoma is required = ileal loop - to allow a method for urine draining
8
Q
Pathophysiology of benign prostate hyperplasia
- Causes/mechanism
- Signs/symptoms/complications
- Risk factors
- Diagnostic testing
- Treatment
A
- Causes/mechanism
- BPH is a non-cancerous increase in prostate size
- Involves hyperplasia of prostatic stromal and epithelial cells, resulting in large, discrete nodules in the transition zone of the prostate.
- Does not lead to or increase the risk of cancer
- Due to high levels of glandular cell proliferation
- Prostatic growth is under the influence of testosterone in its most potent form = DIHYDROTESTOSTERONE, which is produced largely by the testes
- Cause is unclear: likely due to increased cell proliferation and reduced cell death (apoptosis). These cellular processes are mediated by several factors such as androgens, oestrogens, and growth factors.
- As you increase in age, you get more aromatase and 5-alpha reductase. These enzymes convert androgens into oestrogen and DHT.
- As a result of the imbalance, uncontrolled proliferation occurs and nodules form in the transitional zone which sits around the urethra, causing compression over time and therefore bladder outflow obstruction
- Signs/symptoms/complications
- Occurs most in men over the age of 60
- Lower urinary tract symptoms due to compression of the urethra which causes bladder outflow obstruction = obstructive symptoms: poor stream, hesitancy, intermittent flow, incomplete voiding, terminal dribbling, overflow incontinence, episodes of near retention.
- The bladder must then undergo changes as it works harder to expel urine, giving storage symptoms: urgency, frequency, nocturia, and dysuria
- Risk factors
- Age 40 or older = age is the main risk factor
- Family history of BPH
- Medical conditions: obesity, heart and circulatory disease, type 2 diabetes, and ED
- Lack of physical exercise - Diagnostic testing
- Rectal examination
- Uroflowmetry
- Sometimes biopsy and MRI
- BPH should feel ENLARGED, SYMMETRICAL and SMOOTH & NOT PAINFUL TO TOUCH. Firm or hard areas may indicate prostate cancer - Treatment
- Alpha adrenergic blockers will relax certain muscles of the prostate and bladder, to improve the flow of urine
- Finasteride will block the effects of male hormones responsible for prostate growth
- TURP - can lead to complications such as retrograde ejaculation, ED, infections and permanent urinary incontinence.
- Treatment is not necessary unless BPH causes bothersome symptoms or complications such as UTI or kidney function, blood in urine, stones or retention
- Contraindications: OPIOIDS, ANTICHOLINERGIC DRUGS (anti-histamines and some anti-depressants), SYMPATHOMIMETICS
9
Q
Storage (filling) vs obstructive (voiding) symptoms (cause for each symptom)
A
Storage:
- Frequency (diabetes, polydipsia)
- Urgency (diabetes, pregnancy, prostate enlargement, diuretics, interstitial cystitis)
- Dysuria (cystitis, UTI, stones, fever)
- Nocturia (prostate infection, enlargement of prostate, bladder prolapse, diabetes, tumour of bladder/prostate/pelvic area, overactive bladder syndrome)
- Incontinence (pregnancy, Parkinson’s, MS, hysterectomy, prostate removal)
- Haematuria (UTI, stones, prostate/bladder cancer, BPH, sickle cell)
Obstructive:
- Poor stream (enlarged prostate, overactive bladder)
- Hesitancy (enlarged prostate, medications - anticholinergics, prostate infection, shy bladder syndrome)
- Terminal dribbling (weakness of pelvic floor, prostate surgery, constant cough, neurological damage)
- Anuria/oliguria (enlarged prostate, tumour compression of urinary flow, expanding haematoma, dehydration, shock)
- Incomplete voiding (BPH, prostatitis, prostatic cancer, damage to bladder/cauda equina/pelvic splanchnic nerve, STD, stones)
10
Q
Anatomy of the ureters: 4 regions? Blood supply? Innervation? Lymphatic drainage?
A
- Begin as funnel-shaped tubes at the renal pelvis
- Run retroperitoneally over the posterior abdominal wall in front of the iliac artery down to the pelvic brim
- As urine collects in the renal pelvis, the pelvis dilates.
- Action potentials in the pacemaker cells of the renal pelvis are set up, stimulating peristaltic contractions in the ureters that propel the urine
4 regions of the ureter:
- Renal pelvis
- Abdominal
- Pelvic
- Intramural
- Blood supply: (and corresponding veins)
1. Ureter-renal A
2. Lumbar segmental A
3. Gonadal A
4. Common iliac A
5. Internal iliac A
6. Superior vesical arteries - Innervation
T11-L2 and S2-S4
Supplied by the renal, aortic and hypogastric autonomic plexuses - Lymphatic drainage
Para-aortic lymph nodes
11
Q
What are the 4 parts of the bladder?
A
- Body
- Fundus
- Apex
- Neck
12
Q
How is the bladder able to expand with little increase in internal pressure?
A
Due to the rugae
13
Q
What is the trigone of the bladder? Why is it important?
A
Smooth triangular region at the base of the internal urinary bladder (between the bladder and urethra) formed by two ureteral orifices and the internal urethral orifice
- Effective connection between ureters and trigone are important for the proper function of the ureteral valve mechanism
14
Q
Epithelium type of the bladder?
A
Transitional (allows it to expand and shrink)
- Does NOT produce mucus
15
Q
What is the name of the bladder smooth muscle?
A
Detrusor
