The Bladder and Prostate Flashcards
Describe what bladder stones are made from and the commonest cause for them forming?
Bladder stones are formed from uric acid.
Causes:
- The most common cause of them forming is due to bladder outlet obstruction e.g. BPH, neurogenic bladder
- Foreign body e.g. prolonged catheterisation
- Stone from kidneys passing down
Describe the signs and symptoms of a patient with bladder caliculi?
May be asymptomatic
UTI symptoms: frequency, pain, haematuria
- Pain and haematuria occurs at the end of micturation as the bladder contracts
Pain in the suprapubic region or in men may radiate to the tip of the penis or scrotum it may be relieved by lying down.
Poyluria and nocturia. (not completely voiding bladder so you need to go more frequently)
Hesistancy.
What investigations should be done for a patient with suspected bladder calculi?
Similar investigations as for renal stones
Bedside:
Urinalysis (haematuria)
MSU (if infection likely)
DRE (looking for BPH)
Bloods:
FBC/U/E’s/LFT’s/bHCG
Imaging:
Bladder US
Xray/CT KUB
How are bladder calculi managed?
Name a long term risk of bladder calculi?
Often are caused by an element of bladder obstruction therefore unlike to pass naturally.
Often require cystolitholapaxy:
A cystocope is inserted through the urethra into the bladder. A laser/US devices is used to break up the stone and it is then washed out. (Under a GA)
> long term can predispose to SCC
Describe the different types of bladder cancer and the risk factors for developing it?
TRANSITIONAL CELL CARCINOMAS
- Account for 90% of cases
Risk Factors include:
Increasing age >60
Being male 3:1
Smoking (aromatic amines are renally excreted)
Occupational exposure to aromatic aminesin dyes, paints and solvents.
Phenacetin (ee) Smoking Analine Cyclophosphamide
SQUAMOUS CELL CARCINOMAS
Chronic inflammation from recurrent stones
Schistosomiasis
Long term catheters
Describe the signs and symptoms of transitional cell carcinoma?
Painless haematuria usually frank blood.
Painless haematuria should always be treated as malignancy of the urinary tract until proven otherwise.
In advanced disease patients may also have voiding symptoms.
Can also have recurrent UTI
Describe how suspected bladder Ca is investigated?
Bedside:
Urinalysis (Cancers can cause sterile pyruria)
MCU (rule out infection)
Bloods:
FBC (anaemia)
U/E’s
Gold standard: Cystoscopy, used to visualise suspicious legions and biopsy them.
Can then do CT/MRI imaging to assess spread
How is bladder cancer managed?
Low risk Ca: e.g G1pTa
-TURBT and surveilnace at 3 months with cystoscopy + intravesical chemo mitomycin C
High risk Ca: e.g G3pT2
- Cystectomy + urostomy.
- Radical radiotherapy is an alternative option.
Multifocal low risk Ca G1pTa:
- Intravesical chemotherapy Mitomycin. Weekly for 6 weeks.
- Follow up with cystoscopy
Invaded beyond the bladder:
-Pallitively
CIS: Different entity tend to be high grade but have not invaded BM and instead spread within the bladder.
-Treat with immunotherapy BCG (same as vaccine) intravesically (attracts TNF cytokines)
How should those with bladder Ca that has been treated be followed up?
Those with non invasive tumours should be followed up with cystoscopy every 3 months for minimum of a year, may be longer depending on the type.
After radical cystectomy patients should be monitored for:
- hydronephrosis, stones and cancer using imaging
- local and distant recurrence using CT
- GFR
- B12 and Folate levels annually (if terminal ileum has been used in a neobladder)
List the causes of bladder outlet obstruction?
Benign Prostatic Hyperplasia (most common)
Bladder Stones
Pelvic tumors (prostate, cervix, uterus, rectum)
Bladder cancer
Urethral stricture (previous inflammation which has left scar tissue)
Neuropathic bladder
Phimosis or parpaphimosis
List the signs and symptoms of benign prostatic hyperplasia (BPH)?
Filling symptoms (FUN): -Frequency, Urgency, Nocturia
Voiding symptoms:
- Hesitacy
- Poor stream
- Post void dripple
- Feeling of incomplete voiding of the bladder.
- Strangury
How should suspected BPH be investigated?
Bedisde:
- PR exam
- Urinalysis and MSU
Bloods:
- FBC, U/E’s and LFT’s
- PSA
- Uroflowmetry
- Ask patient to fill out a frequency volume charts
Imaging:
- Post void bladder US
- Transrectal US +/- biopsy can be used to rule out Ca (high sepsis rate so only do if ? cancer)
What are the complications of BPH?
Urinary retention (this may be precipitated by anticholinergic meds, TCA’s opiates)
Formation of bladder caliculi.
Recurrent UTI’s
Kidney damage from hydronephrosis
Haematuria (microscopic or gross)
How can BPH be managed?
Assess impact on daily life options are:
- Watch and wait
- Medication
- Surgery
Lifestyle: avoid alcohol or caffine, relaxation techniques, void twice in a row to help emptying
Medication:
- Alpha blockers e.g. tamsulosin, doxasosin
- Finasteride
Surgery:
- Transurethral resection of the prostate
- HoLEP - used for very large prostates
If old and don’t want surgery - can learn to intermittent catheterise
Which area of the prostate is most likely to be affected in prostate cancer and what is the prognosis?
Adenocarcinoma of the prostate usually occurs in the posterior glandular outer portion of the prostate.
It is a very common cancer in elderly gentleman. As it is very slow growing most patients die of other causes although it does have metastatic potential.
What are the signs and symptoms of adenocarcinoma of the prostate?
Mostly asyptomatic
Progressive lower urinary tract obstruction. (Filling or voiding)
May have:
- Weight loss or bone pain suggests mets
- Signs and symptoms of anaemia.
- Haematuria if invades into ureter
- Haematospermia
- AKI if obstructs ureters
How is prostate cancer treated?
Depends on staging
If low risk monitor with serial PSA tests
If intermediate/high risk local disease:
-Hormone therapy and radical radiotherapy
OR
-Radical prostatectomy (risks of incontinence / impotence)
If metastatc disease:
- GnRH agonist goserelin (doesn’t cure just managed symptoms)
Describe the basis of hormone therapy used for prostate Ca?
Also known as androgen deprivation treatment.
Refers to treatments that act by reducing the effects of testosterone and other androgens, thus inhibiting the progression of prostate cancer.
The main treatments used are LHRH agonists and anti-androgens
Discuss the diagnosis of bladder infection aka (UTI) outlining the importance of significant bacteruria and white cells in the urine?
Symptoms of UTI:
Polyuria
Dysuria
Urgency
+/-
Haematuria
Loin Pain
Confusion
A urinary tract infection is defined as the presence of bacturia >100,000 organisms/ml.
Presence of white cells in urine indicates you should treat for bacterial infection.
What is the management for bladder infection?
Remove any catheters which may be indwelling.
For a simple UTI in a women a 3 day course of Trimethoprim or Nitrofurantoin.
If there is a relapse a 5-10 day course should be given with a different agent ideally recommended by the lab following a MSU
A 7 day course should be given as standard for men
What are the signs and symptoms of bladder trauma?
Obviously history of some trauma may be blunt.
May be in hypovolaemic shock!
Symptoms:
Suprapubic pain and tenderness
Difficulty or inability to void
Frank haematuria (may be microscopic)
Signs:
- Guarding/percussion tenderness
- Absent bowel sounds
- Bruising in suprapubic region.
- Swelling of the scrotum/perineum/abdomen/thighs may occur.
How should bladder injury be investigated in traumatic and surgical complication circumstances?
Cystography should be used to assess the extent of a traumatic bladder injury.
Cystoscopy can be used to assess a bladder injury following a surgical complication
How should bladder injury be managed?
If a minor injury: catheterise, bed rest and obs.
If intraperitoneal bladder rupture (very serious high risk of sepsis).
Managed with resus and emergency laparotomy
How is bladder cancer graded and stages?
Staging: Ta doesn't invade BM T1 invades BM T2 invades muscle T3 invades fat and perivesicular tissue T4 invade adjacent tissues and organs.
Grade
G1: well differentiated
G3: poorly differentiated
Describe the clinical features of bladder outlet obstruction
Suprapublic pain (acute) Chronic: hesitancy, diminished force, terminal dribbling, overflow incontinence, infection
How would you investigate bladder outlet obstruction?
- PR/ PSA
- Urine dip/MCS
- USS to see if hydronephrosis, distended bladder
- Bloods: FBC, U+E
- Serum Ca,P, Mg if suspecting stones or CT
How do these prostate medications work:
1) Tamsulosin
2) Finasteride
3) Goserelin
1) alpha blocker: reduce the smooth muscle tone of both the bladder and prostate
2) reducing testosterone conversion, slowing prostate enlargement
3) GnRH agonist, inhibits LH therefor reducing testosterone production. Cancer cells need testosterone to grow
Name the side effects of these BPH treatments:
1) Finasteride
2) TURP
1) Impotence, reduced libido
2) impotence (10%), retrograde ejaculation, incontinence (1%)
How would you investigate suspected prostate cancer?
- PR (should feel rock hard, nodulated and symmetricak)
- PSA
- Transrectal biopsy needed for gleason grading
- Can MRI before biopsy (do in derby)
- If evidence of mets or PSA extremely high then bone scan
Why is PSA not a reliable prostate cancer screening method
High sensitivity but poor specificity
- can be affected by recent intercourse, mountain biking, infection, cystoscopy
What is the Gleason grade?
For prostate cancer. During biopsy they take out two areas of tissue and grade them both out of 5.
6 = low risk
>8 = high risk
