Prostate Disease and Urinary Obstruction Flashcards
What is the prevalence of benign prostatic hyperplasia in men?
50% of men at 60
90% of men at 85
How many people with BPH have symptoms, and what are these symptoms?
50% of men with BPH have moderate to severe LUTS
Voiding - obstructive
- hesitancy
- poor stream
- terminal dribbling
- incomplete emptying
Storage
- frequency
- nocturia
- urgency +/- urge incontinence
What might be found on examination of a person with diseases of the prostate?
Palpable bladder
External urethral meatal stricture, phimosis
Enlarged prostate on rectal exam, suspicious nodules or firmness
What investigations might be performed in suspected prostate disease?
MSSU
Flow rate study (Qmax <10mL/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 haematuriaUrodynamic studies in selected cases
TRUS-guided prostate biopsy if PSA raised or abnormal DRE
How are prostate symptoms scored?
International prostate symptom score sheet (IPSS)
- out of 35
- 0-7 = mild
- 8-19 = moderate
- 20+ = severe
How is uncomplicated prostate disease treated?
Watchful waiting
Medical therapy
Surgical intervention
medical therapy- alpha blockers, 5-alpha reductase inhibitors (finasteride/dutasteride), combination
surgical - TURP (gold standard, used when prostate <100cc), open retropubic or transvesical prostatectomy (prostate >100cc), endoscopic ablative (urolift)
What are some examples of alpha-blockers used to treat LUTS/BPO?
Non selective - phenoxybenzamine Selective short - prazosin, indoramin Selective long - alfuzosin, doxazosin, terazosin Highly selective (e.g. 1a) - tamsulosin
When is BPO considered complicated?
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
How is complicated BPO treated?
Medical therapy
Most patients will require surgery e.g. cystolitholapaxy, and TURP for patients with BPO and bladder stones
Alternative treatment options (e.g. unfit for surgery)
- long-term urethral or suprapubic catheterisation
- clean intermittent self-catheterisation
- may develop problems with difficult catheterisation, catheter trauma, blockages, frank haematuria or recurrent UTI
What are the most common prostate zones for benign prostatic hyperplasia, and prostate cancer?
BPH (fibromuscular and glandular hyperplasia) - transition zone
Cancer - peripheral zone
What are the possible areas of upper and lower urinary tract obstruction?
Upper
- pelviureteric junction
- ureter
- vesicoureteric junction
Lower (BOO)
- bladder neck
- prostate
- urethra
- urethral meatus
- foreskin e.g. phimosis
Who are most at risk of kidney stones?
M:F 3:1
Peak age at 30
Bimodal female peak - 35 and 55
50% recurrence within 10Y
What are some examples of causes of PUJ obstruction?
Intrinsic
- obstruction (physiological)
- stone
- tumour (TCC)
- blood clot
- fungal
Extrinsic
- obstruction (crossing vessel)
- lymph nodes
- abdominal mass
What are some examples of causes of ureter obstruction?
Intrinsic
- stone
- tumour
- scar tissue
- blood clot
- fungal
Extrinsic
- lymph nodes
- iatrogenic
- abdo/pelvic mass
What are some examples of causes of VUJ obstruction?
Intrinsic
- stone
- tumour (bladder/ureter)
Extrinsic
- cervical tumour
- prostate cancer
How does upper urinary tract blockage generally present?
Symptoms
- Pain
- Frank haematuria
- Symptoms of complications (e.g. infection, sepsis, renal failure)
Signs
- Palpable mass
- Microscopic haematuria
- signs of complications
How do kidney stones present?
Renal pain - fixed in loin Ureteric colic (radiating to groin) Dysuria/haematuria/testicular or vulval pain Urinary infection Loin tenderness Pyrexia
How does lower urinary tract obstruction present?
LUTS inc incontinence Acute urinary retention Chronic urinary retention Recurrent UTI and sepsis Frank haematuria Formation of bladder stones Renal failure
How do bladder stones present?
Suprapubic/groin/penile pain
Dysuria, frequency, haematuria
Urinary infection (persistent) Sudden interruption of urinary stream Usually secondary to outflow obstruction
What investigations might be done in urinary tract obstruction?
Blood tests - FBC, U&E, Creatinine Calcium, albumin, urate Parathormone Urine analysis and cultre 24hr urine collections
Radiology
- KUB xray - kidneys/ureter/bladder
- USS
- IVU (IV urogram)
- CT KUB
What are the different presentations of upper urinary tract obstruction in acute vs chronic?
Acute
- renal function could be normal
- pain?
Chronic
- renal function may be normal
- high pressure vs low pressure
What is the difference in presentation between low pressure and high pressure chronic upper urinary obstruction/retention?
High pressure
- painless
- incontinent
- raised cr
- bilateral hydro-nephrosis
Low pressure
- painless
- dry
- normal cr
- normal kidneys
What are the general treatments for urinary tract obstruction, whether upper or lower?
Resuscitation
- ABC
- IV access, bloods, ABG, urine and blood cultures, fluid balance
- IV fluids, broad-spectrum antibiotics if appropriate
- analgaesia
- HDU care +/- renal replacement therapy
How are upper obstructions treated?
Emergency treatment of obstruction (for unremitting pain or complications)
- percutaneous nephrostomy insertion OR
- retrograde stent insertion
Definitive treatment of obstruction
- stone - ureteroscopy and laser lithotripsy +/- basketing or ESWL
- ureteric tumour - radical nephro-ureterectomy
- PUJ obstruction - laparoscopic pyeloplasty
