Urinary Incontinence and Benign Prostatic Hyperplasia Flashcards
embryology of the prostate
between 10-16 weeks of gestation from epithelial buds which branch out from the posterior aspect of the urogenital sinus to invade the mesenchyme
main influencing hormone of the prostate
dihydrotestosterone
arterial blood supply of the prostate
branches of inferior vesical artery > prostatic artery > urethral + capsular groups of arteries > urethral group give rise to Flock’s + Badenoch’s arteries
venous drainage of the prostate
via peri-prostatic venous plexus > drains into internal iliac vein
lymph drainage of the prostate
to the obturator nodes and then the internal iliac chain
list the McNeal’s zones
transition
central
peripheral
transition zone
10% of the glandular tissue of the prostate
site of origin of benign prostate hyperplasia
peripheral zone
65% of the glandular tissue of the prostate
central zone
25% of the glandular tissue
benign prostatic hyperplasia
prostatism (lower urinary tract symptoms) benign prostatic enlargement benign prostatic hyperplasia bladder outflow obstruction benign prostatic obstruction benign prostatic hypertrophy
describe benign prostate hyperplasia
increase in number of epithelial and stromal cells in peri urethral area of the prostate in response to androgens (testosterone) and growth factors
bladder changes in BPH
decreased urinary flow
urinary frequency, urgency, nocturia
function of the prostate
liquefy ejaculate
pathophysiology of BPH
enlarged prostate > increased urethral resistance > compensatory changes in bladder fx
in regards to BPH, what change is required to maintain urinary flow?
increased detrusor pressure
the ______ transmits the ‘pressure’ of tissue expansion to the urethra
capsule
is the size of the prostate equal to the degree of the obstruction?
no
what is the most abundant adrenoreceptor subtype in the human prostate?
alpha1A
are lower urinary tract symptoms in men with BPH related to obstruction induced changes in bladder function or direct outflow obstruction?
obstruction induced changes in bladder function
list obstruction induced changes
detrusor instability/decreased compliance > frequency /urgency
decreased detrusor contractility > hesitancy, intermittency, increased residual urine, detrusor failure
symptoms of benign prostatic hyperplasia
voiding: reduced flow, hesitancy, incomplete emptying, strangury
storage: frequency (day/night), urgency, incontinence
other: infection, visible haematuria
examination for BPH includes?
general (ask about fluid intake) palpable bladder ballotable kidneys phimosis meatal stenosis enlarged prostate on DRE, size, consistency, nodules, anal tone, sensation
investigations for BPH includes?
urine dipstick flow rate + PVR IPSS questionnaire bladder diary PSA, creatinine flexible cytoscopy USS KUB TRUS prostate urodynamic studies
management of benign prostate hyperplasia
watchful waiting
lifestyle changes
pharmacological treatment
surgery
list pharmacological treatment options for BPH
alpha adrenergic antagonists
5-alpha reductase inhibitors
combination therapy
list examples of alpha adrenergic antagonists
tamsulosin
alfuzosin
doxazosin
list examples of 5-alpha reductase inhibitors
finasteride
dustasteride
alpha adrenergic antagonists are used to?
reduce symptoms
improve flow rate
5-alpha reductase inhibitors are used to?
prevent disease progression
reduce development of AUR/requirement for surgery
list surgical treatment options for BPH
TURP Rezum UroLIFT Millin's prostatectomy embolisation HoLEP
what is urine incontinence?
complaint of any involuntary loss of urine
list types of urine incontinence
stress incontinence urge incontinence mixed urinary incontinence continuous incontinence overflow incontinence nocturnal enuresis post-micturition dribble
what is stress incontinence?
the complaint of involuntary leakage on exertion /sneezing/coughing
what is urge incontinence?
the complaint of an involuntary leakage accompanied by or immediately preceded by urgency
what is mixed urinary incontinence?
the complaint of an involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing
what is continuous incontinence?
continuous leakage
what is overflow incontinence?
leakage associated with urinary retention
what is nocturnal enuresis?
the complaint of loss of urine occurring during sleep
what is micturition dribble?
the complain of an involuntary loss of urine immediately after passing urine
risk factors for urine incontinence
increasing age pregnancy and vaginal delivery obesity constipation drugs e.g. ACE inhibitors smoking family hx prolapse/hysterectomy/menopause
investigations for urine incontinence
urine dipstick flow rate + post-void/residual Bladder diary Pad tests Patient symptom scores/validated QoL questionnaire Urodynamic/video-urodynamic studies
stress urinary incontinence is more common in?
women of young to middle age
stress urinary incontinence is uncommon in?
men who have not had prostate surgery
list 5 causative theories of stress incontinence in women
urethral position theory intrinsic sphincter deficiency integral theory hammock theory trampoline theory
non-surgical treatments for stress urinary incontinence in men and women
supervised pelvic floor exercises
bladder re-training
lifestyle changes: weight loss, cessation of smoking, modification of high/low fluid intake
pharmacological treatment for stress urinary incontinence in women
oestrogen therapy is evidence of atrophy
oral medical therapy in rare cases
surgical treatments for stress urinary incontinence in women
occlusive e.g. bulking, compressive (AUS)
supportive (midurethral sling, colposuspension)
ileal conduit diversion
list 3 causative theories for stress incontinence in men
sphincter incompetence
reduction in urethral sphincter length
post-operative strictures
list structures that control continence
detrusor muscle internal sphincter ureterotrigonal muscles levator muscles rhabidosphincter (external sphincter)
pharmacological treatment for stress urinary incontinence in men
oral medical therapy in rare cases
surgical treatments for stress urinary incontinence in men
Occlusive e.g. bulking, compressive (AUS)
Supportive (suburethral sling)
Ileal conduit diversion
what is overactive bladder?
symptom syndrome: urinary frequency, urgency, nocturia with or without leak
prevalence of overactive bladder
16% in men and women
men have a higher prevalence in what type of overactive bladder?
OAB-dry
women have a higher prevalence in what type of overactive bladder?
OAB-wet
differential diagnosis for urge urinary incontinence
UTI DO Urethral syndrome Urethral divertivulum Interstitial cystitis Bladder cancer Large residual volume
management for urge urinary incontinence
lifestyle changes: decrease caffeine, smoking cessation, weight loss
bladder retraining
pelvic floor muscle exercise
pharmacotherapy
list examples of pharmacotherapy for urge urinary incontinence
anti-cholinergics e.g. e.g. solifenacin, tolterodine, trospium
beta-3-agonists e.g. betmiga
surgical treatment for urge urinary incontinence
Posterior tibial nerve stimulation (PTNS)
Intravesical injection of botulinum toxin A
Neuromodulation
Clam (augmentation) cystoplasty
Urinary diversion is an option if all else fails in very severe cases
