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.
The most common cause of them forming is due to bladder outlet obstruction*
*Benign prostatic hypertrophy, neurogenic bladder, urethral obstruction (commonest causes)
Describe the signs and symptoms of a patient with bladder caliculi?
May be asymptomatic
Pain in the suprapubic region or in men may radiate to 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)
Dysuria.
Hesistancy.
Haematuria.
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
Imaging:
Bladder US
Xray/CT KUB
How are bladder calculi managed?
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)
Describe the different types of bladder cancer and the risk factors for developing it?
Transitional cell carcinomas account for 90% of cases, most of the remainder are squamous cell carcinomas.
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.
Chronic inflammation from recurrent stones is associated with squamous cell ca.
Schistosomiasis is strongly associated with squamous cell carcinoma
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.
Describe how suspected bladder Ca is investigated and staged and graded?
Bedside:
Urinalysis
MCU (rule out infection)
Bloods:
FBC (anaemia)
U/E’s
CT/MRI imaging
Cystoscopy can be used to visualise suspicious legions and biopsy them
NICE recommends TURBT (trans urethral resection of bladder tumour) which can then be sent to histopathology
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
How is bladder cancer managed?
Low risk Ca: e.g G1pTa
-TURBT and surveilnace at 3 months with cystoscopy
High risk Ca: e.g G3pT2
- Cystectomy + ileal conduit*
- Radical radiotherapy is an alternative option.
Multifocal low risk Ca G1pTa:
-Intravesical chemotherapy Mitomycin. Weekly for 6 weeks.
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)
*ureters are connected to a section of the pre terminal ileum which is then used to make a bladder stoma.
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)
List the signs and symptoms of benign prostatic hyperplasia (BPH)?
Increased urinary frequency passing small amounts of urine. Nocturia.
Feeling of incomplete voiding of the bladder.
Urgency.
Hesitancy (takes a while to get going, may need to push or strain)
Poor stream/dribbling.
How should suspected BPH be investigated?
Bedisde:
- PR exam
- Urinalysis and MSU
Bloods:
- FBC, U/E’s and LFT’s
- PSA
Imaging:
- Post void bladder US
- Transrectal US +/- biopsy can be used to rule out Ca
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
Haematuria (microscopic or gross)
How can BPH be managed?
Assess impact on daily life options are:
- Watch and wait
- Medication*
- Transurethral resection of the prostate (relatively common complication is erectile dysfunction)
*Alpha blockers are used as they reduce the smooth muscle tone of both the bladder and prostate e.g:
1st line is tamsulosin alternatives include alfuzosin, doxazosin (less specific therefore greater anti adrenergic s/e’s)
Finasteride can also be used works by reducing testosterone conversion.
List the pathology (where it occurs) and natural history (proganosis etc) of adenocarcinoma of the prostate?
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.
80% men over age 80
