The Bladder & Prostate Flashcards
What are the two main complications for bladder trauma?
Intraperitoneal bladder rupture
Extraperitoneal bladder rupture
How should intraperitoneal bladder rupture be managed?
Laparotomy & bladder suturing
How should extraperitoneal bladder rupture be managed?
Prolonged urethral/suprapubic catheterisation
What are the luminal causes of bladder outlet obstruction?
Bladder tumour
What are the mural causes of bladder outlet obstruction?
Urethral stricture (post-calculus/infection)
Congenital abnormalities
Neuropathic bladder
What are the extramural causes of bladder outlet obstruction?
BPH/prostatic carcinoma
Phimosis/paraphimosis
What are the sx of bladder outlet obstruction?
Suprapubic pain Hesitancy/diminished force of strength Terminal dribbling Overflow incontinence (retention, leakage) Signs of infection
What are the signs of bladder outlet obstruction?
Palpable full bladder
Loin tenderness/palpable hydronephrotic kidney
Enlarged prostate (on PR)
What investigations are appropriate in suspected bladder outlet obstruction?
Bloods (FBC, U&Es)
Urine dip & MCS
USS (?hydronephrosis)
CT/MRI
What are the management options for bladder outlet obstruction?
Catheterisation (suprapubic/urethral)
Treat underlying cause
What are the causes of bladder calculi?
Bladder outflow obstruction
Presence of FB
Passage of upper urinary tract stone
How do bladder calculi present?
Present w/ sx of UTI
-haematuria & pain occur at end of micturition
Pain felt at tip of penis
Perineal pain (if trigonitis)
Anuria/bladder distention (if obstruction)
What are the appropriate investigations for bladder calculi?
Investigate as for upper tract stone
Medical expulsive therapy
ESWL if stone is large
What is the main complication of a bladder calculus?
Predisposition to SCC
What is Benign Prostatic Hyperplasia?
Benign nodular/diffuse proliferation of glandular layers of prostate
-enlargement of inner transitional zone
How common is BPH?
70% of >70yrs
What are the sx of BPH?
Filling sx
Voiding sx
Sx due to complications
What are the filling sx of BPH?
Frequency (1st as nocturia)
Urgency +/- strangury
What are the voiding sx of BPH?
Hesitancy Poor/intermittent stream Post-void dribbling Strangury Retention w/ overflow incontinence/acute retention
What are the sx due to complications of BPH?
Haematuria (rupture of vv)
Sx of associated UTI
What investigations are appropriate in suspected BPH?
PR (palpable sulcus) Freq/volume chart Bloods (FBC, U&Es, PSA) Urinalysis/MCS Uroflowmetry Bladder USS (pre/post void) Transrectal USS +/- biopsy (?carcinoma)
What is Prostate Specific Antigen?
Prostate cancer marker
Concentrations <4.0ng/ml are normal
Describe uroflowmetry
Measures flow rate, requires >150ml be voided
-flow rate <12ml/sex suggests obstruction/weak contractility
What are the potential complications of BPH?
UTI Overflow incontinence Bladder calculi Bladder diverticulae Bilateral hydronephrosis & ESRD
What is the acute management of BPH?
Urethral catheter/suprapubic drainage
What are the conservative management options for BPH?
Avoid alcohol/caffeine Relax when voiding Void twice in a row to aid emptying Bladder retraining therapy Watchful waiting (if sx mild)
What are the medical management options for BPH?
alpha blockers (tamsulosin) 5-a reductase inhibitors finasteride)
What are the s/e of a-blockers?
Drowsiness
Dizziness
Depression
Hypotension
What are the s/e of 5a-reductase inhibitors?
Impotence
Reduce libido
Excreted in semen (use condoms)
What are the surgical management options for BPH?
Transurethral resection of BPH (TURP)
Holmium laser prostatectomy (HoLEP)
What are the risks of TURP?
Impotence (10%) Repeat procedure need (20% w/i 10yrs) Bleeding TURP syndrome -absorption of washout leading to hyponatremia & fits
Describe HoLEP
Endoscopic, used for large prostates
Urinary incontinence as main complication
What is the aetiology of prostate carcinoma?
2nd most common malignancy in males
Present in<80% of males >80
-only 4% die from it
Mostly adenocarcinomas (peripheral)
How do prostate carcinomas spread?
Local (seminal vesicles/bladder/rectum)
Lymphatic
Haematogenous (to bone)
How do prostate carcinomas present?
Asymptomatic, incidental finding
Filling/voiding/complication sx (as per BPH)
Wt loss/bone pain (metastatic disease)
Hard, craggy prostate
What investigations are appropriate in suspected prostate carcinoma?
PR (T-staging) PSA (rise >10ng/ml suggestive of tumour) Transrectal USS/biopsy (gleason grading) Bone XR Scan/contrast enhanced MRI
What factors may affect the PSA levels?
Mountain biking
Infection
Recent intercourse (48h)
Cystoscopy
What is the Gleason grade?
Two areas graded out of 5
>8 = high risk
<6 = low risk
What is D’Amico risk stratification?
Combines Gleason score w/ clinical stage & PSA to give more accurate prognostic score
What are the management options for localised prostate cancer (T1/T2)?
PATIENT CHOICE
- active surveillance (PSA/DRE)
- radiotherapy/brachytherapy (risk of impotence/incontinence)
- surgery (risk of impotence/incontinence)
What are the management options for advanced prostate cancer (T3/T4)?
Choice b/w radiotherapy & surgery
-no difference in outcomes
What are the management options for metastatic prostate cancer?
Hormonal therapy (GnRH agonists)
-palliative or as adjunct to curative disease
-1st stimulate then inhibit pituitary LH release, reduces testosterone production
Anti-androgens (cyproterone acetate)
-co-prescribed w/ hormonal therapy
-prevents early rise in testosterone
