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Y2 - BRS - Uro > Urinary Incontinence and Benign Prostatic Hyperplasia > Flashcards

Urinary Incontinence and Benign Prostatic Hyperplasia Flashcards

1
Q

What is BPH?

A

Benign Prostatic Hyperplasia

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2
Q

How and when does the prostate develop in utero / gestation?

A

Develops between weeks 10-16 of gestation from epithelial buds which branch out from the posterior aspect of the urogenital sinus to invade the mesenchyme

Influenced by the hormone dihydrotestosterone, which is produced by epithelial cells

Stromal-epithelial interaction is important, dihydrotestosterone acts on mesenchymal androgen receptors

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3
Q

What is the arterial supply for the prostate?

A

Arises from branches of the inferior vesical artery

This provides the prostatic artery divides into urethral and capsular groups of arteries

Urethral group give rise to Flock’s and Badenoch’s arteries (both at 1 & 11 o’clock and Badenoch’s arteries approach it at 5 & 7 o’clock)

The capsular branches of th eprostatic artery run with the cavernosal nerves

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4
Q

What is the venous drainage of the prostate?

A

The venous drainage is via the peri-prostatic venous plexus

This also receives the deep dorsal vein of the penis and numerous vesical veins

The periprostatic venous plexus eventually drains into the internal iliac vein

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5
Q

What is the lymphatic drainage of the prostate?

A

Mainly to the obturator nodes and then the internal iliac chain

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6
Q

What is the zonal anatomy of the prostate?

A

They are also called McNeal’s zones

  1. Transition zone
    - 10% of the glandular tissue of the prostate
    - Site of origin of benign prostatic hyperplasia
  2. Central zone
    - 25% of the glandular tissue of the prostate
  3. Peripheral zone
    - 65% of the glandular tissue of the prostate
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7
Q

What is the role of the capsule?

A

The capsule transmits the ‘pressure’ of tissue expansion to the urethra and leads to an increase in urethral resistance

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8
Q

How is active smooth muscle tone regulated?

A

Active smooth muscle tone is regulated by the adrenergic nervous system
(alpha-1A) ⍺1A is the most abundant adrenoceptor subtype in the human prostate

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9
Q

What is the function of the prostate?

A

Liquify the ejaculation

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10
Q

What is Lower Urinary Tract Symptoms (LUTS)?

A

Non-specific term for symptoms which may be attributable to lower urinary tract dysfunction

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11
Q

What is meant by Benign Prostatic Enlargement (BPE)?

A

Clinical finding of enlarged prostate

i.e. during rectal examination - feel of an enlarged prostate

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12
Q

What is meant by Benign Prostatic Hyperplasia (BPH)?

A

Histological diagnosis - increase in number of cells

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13
Q

What is meant by Bladder Outflow Obstruction (BOO)?

A

Urodynamically (urodynamic = test for finding out how your bladder, sphincter, and urethra are working) proven obstruction to passage of urine
When this obstruction is caused by BPE, it is called BPO (benign prostatic obstruction)

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14
Q

What is meant by Benign Prostatic Obstruction (BPO)?

A

BOO caused be BPE

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15
Q

What is meant by Benign Prostatic Hypertrophy?

A

Pathologically incorrect - increase in cell size

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16
Q

What is the pathophysiology of BPH?

A

Increased number of epithelial and stromal cells in the peri-urethral area of the prostate in response to androgens (testosterone) and growth factors

Results in increased urethral resistance (as enlarged prostate puts pressure against the walls of the urethra) resulting in compensatory changes in bladder function

Can lead to reduced urinary flow, increased urinary frequency, urgency and nocturia

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17
Q

How does bladder function change in BPH to lead to reduced urinary flow, increased urinary frequency, urgency and nocturia?

A

Detrusor = smooth muscle wall of the bladder

The detrusor muscle remains relaxed to allow the bladder to store urine, and contracts during urination to release urine

The detrusor muscle pressure required to maintain urinary flow in the presence of urethral (outflow) resistance happens at the expense of normal bladder storage function

The urethral obstruction induces changes in the detrusor function - this causes the BPH related symptoms

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18
Q

What is the prostate capsule and how does it contribute to LUTS?

A

The capsule transmits the ‘pressure’ of tissue expansion to the urethra and leads to an increase in urethral resistance

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19
Q

Does the size of the prostate predict the degree of obstruction?

A

No, there is no correlation - other factors e.g. dynamic urethral resistance, the prostatic capsule, and anatomic pleomorphism, are more important in the production of clinical symptoms than the absolute size of the prostate

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20
Q

What is smooth muscle in BPH representative of?

A

Prostatic smooth muscle represents a significant volume of the gland

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21
Q

How can urethral resistance be changed?

A

Urethral resistance can be increased by active and passive forces

22
Q

What is the active smooth muscle tone in the prostate regulated by?

A

The adrenergic nervous system = alpha-1A is the most abundant adrenoreceptor in the prostate

23
Q

What is LUTs related to in men with BPH?

A

LUTS caused by obstruction induced changes in bladder function rather than the symptoms being caused directly by the outflow obstruction

This is shown because approx. 1/3 of men continue to have significant voiding (urinating) dysfunction even after surgical relief of obstruction

24
Q

What are the obstruction induced changes in bladder function?

A
  1. Changes that lead to detrusor instability or decreased compliance are clinically associated with symptoms of frequency and urgency
  2. Changes associated with decreased detrusor contractility are associated with further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine and sometimes detrusor failure
25
Q

What are the voiding (urinating) and storage symptoms of BPH clinically?

A

Overactive bladder and decreased stretchiness of the bladder = reduced ability of the bladder to contract and increase pressure leading to:
Voiding symptoms: reduced flow, hesitancy, incomplete emptying, strangury, intermittence
Storage syptoms: frequency (daytime and nocturia), urgency, incontinence
Other symptoms: visible haematuria, infection

26
Q

What is really important to ask about for lower urinary tract symptoms?

A

Fluid intake

27
Q

What are some examinations conducted for suspected BPH?

A 
General examination
Palpable bladder
Ballotable kidneys
Phimosis
Meatal stenosis
Enlarged prostate on DRE (digital rectal examination), size, consistency, nodules, anal tone and sensation
28
Q

What investogations are performed for suspected BPH?

A

Urine dipstick
Flow rate + PVR (postvoid residual) - asked to urinate and then use USS to see how much urine is still remaining in the bladder
IPSS questionnarie - designed specifically to ask about prostate enlargement
Bladder diary - intake, output, and frequency
USS KUB (ultrasound scan kidneys, ureters, bladder) if impaired renal function, loin pain, haemturia, renal mass on examination
PSA (prostate specific antigen test), creatinine
Flexible cystoscopy in some circumstances
TRUS (trasnrectal ultrasound scan) prostate
Urodynamic studies = test for finding out how your bladder, sphincter and urethra are working

29
Q

What is the conservative management for BPH?

A

Watchful waiting and lifestyle changes - targetted using their bladder diaries
e.g. less tea / coffee, not drinking later into the night

30
Q

What are the medical / pharmacological management options for BPH?

A

Pharmacological treatment:

  1. alpha-adrenergic antagonists = reduction in symptoms of 30-40% and improvement in flow rates of 16-25% by relaxing the bladder neck to allow for easier passage
    e.g. Tamsulosin, alfuzosin, doxazosin
    Side effects include: lightheadedness from lowered BP, retrogade (dry ejaculation)
  2. 5-alpha-reductase inhibitors = prevents disease progression, reducing the development of AUR (urinary retention) / requirement for surgery, can help shrink the prostate
    e.g. Finasteride, Dustasteride
    Usually used for super large prostates i.e. >30g
  3. Combination therapy
31
Q

What are the surgical management options for BPH?

A

TURP = trans-urethral resection of the prostate - cystoscope placed inside urethra and prostate tissue shaved away
Rezum = inject steam into the prostate
UroLIFT = pinning back the prostatic lobes
Millin’s prostatectomy = old surgical procedure where prostate is removed via bladder
Embolisation = coils into the vessels that provides blood supply to the prostate to shrink it
HoLEP = laser nucleation of the prostate

32
Q

What is urinary incontinence (UI) and what is its epidemiology?

A

UI = involuntary loss of urine

UI is a significant health problem worldwide associated with considerable social and economic impact on individuals and society

In women, prevalence 5-72% among community-dwelling women

It may be significantly under-reported as it is an embarrassing problem to many women

Women with stress incontinence (SI) are less likely to seek help than those with overactive bladder (OAB)

33
Q

What are the different types of urinary incontinence?

A

Urinary incontinence (UI) = any involuntary loss of urine

Stress (urinary) incontinence (SI) =
the complaint of involuntary leakage on exertion /sneezing/coughing

Urge (urinary) incontinence (sometimes reffered to as OAB - overactive bladder) = the complaint of an involuntary leakage accompanied by or immediately preceded by urgency

Mixed urinary incontinence =
the complaint of an involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing

Continuous incontinence = 
continuous leakage (could be suggestive of a fistula etc.)

Overflow incontinence =
leakage associated with urinary retention

Nocturnal enuresis =
the complaint of loss of urine occurring during sleep

Post-micturition dribble =
the complain of an involuntary loss of urine immediately after passing urine (usually in men, after full stream of urine, few drops come out at the end)

34
Q

What are the causes of urinary incontinence?

A 
Increasing age 
Pregnancy and vaginal delivery - due to effects on pelvic floor and pressures on the bladder 
Obesity
Constipation
Drugs e.g. ACEi
Smoking
Family History
Prolapse / hysterectomy / menopause
35
Q

What are the investigations done for urinary incontinence (UI)?

A

Urine dipstick = check for infection
Flow rate and PVR (postvoid residual) = useful for finding out if they are leaking due to overflow (too full) or if their bladder is really small
Bladder diary
Pad tests = patients wear pads, and weigh 24hrs worn of pads against a dry pad
Counting number of pads is useless due to frequency of changes
Patient symptom scores/validated QoL Questionnaire = how bothered the patient is by urinary incontinence
Urodynamic/video-urodynamic studies = mainstay of diagnosis of UI

36
Q

What is the defintion and epidemiology of stress (urinary) incontinence (SUI / SI)?

A

SUI / SI = involuntary loss of urine on effort or physical exertion or on coughing or sneezing
More common in women of young to middle age
Uncommon in men who have not had prostate surgery

37
Q

What are the 5 causative theories of SUI/SI in women?

A
  1. Urethral position theory
  2. Intrinsic sphincter deficiency
  3. Integral theory
  4. Hammock theory
  5. Trampoline Theory
38
Q

What are the conservative / non-surgical interventions for SUI/SI?

A

Lifestyle changes

  • Weight loss
  • Cessation of smoking
  • Modification of high/low fluid intake

Supervised pelvic floor exercises - patients that try to do them alone often don’t do them correctly

Bladder re-training

39
Q

What are the medical / pharmacological options for SUI/SI?

A

Oestrogen therapy - examine the perineum of a woman with UI, if there is evidence of atrophy i.e. signs of low oestrogen)
Important because there are oestrogen receptors in the urethra, urethral sphincter, pelvic floor, base of the bladder and vagina = important in maintanence of continence
So topical oestrogen usually prescribes, sometimes oral medication e.g. Duloxetine which helps to increase the closure pressure of the urethral sphinctel but many side effects to ineffective long-term treatment

Oral medical therapy in rare cases

40
Q

What are the surgical options for SUI/SI?

A

Occlusive e.g. bulking - collagen around urethra to cause physical obstruction, compressive (AUS)
Artificial urinary sphincter - part of the device goes around the urethra to place pressure on it - button needs to be pressed to get rid of the pressure so they can pass urine

Supportive e.g. mid-urethral sling - prevents too much movement of the urethra and supports urethral sphincter, colposuspension - support the bladder

Ileal conduit diversion - suitable for someone who has been thorugh the other options but still continues to have significant leakage

41
Q

What are the 3 causative theories of SUI/SI in men?

A

SUI/SI normally occurs in men who have had prostatectomies for prostate cancer or benign prostate sugery - removal of prostate = damage to internal sphincter, external sphincter or nerve damage

  1. Sphincter incompetence - weakness in external urethral sphincter
  2. Reduction in urethral sphincter length = less efficient in contracting
  3. Post-operative strictures - in the area of the urethral sphincter
42
Q

What are the 5 structures that control continence in men?

A

5 structures control continence:

  1. Detrusor muscle
  2. Internal sphincter (in the bladder neck)
  3. Ureterotrigonal muscles
  4. Levator muscles = pelvic floor
  5. Rhabdosphincter (external sphincter muscle)
43
Q

What are the non-surgical / conservative treatments for SUI/SI?

A 
Lifestyle changes 
weight loss
cessation of smoking
modification of high/low fluid intake
Supervised pelvic floor exercises
Bladder re-training
44
Q

What are the medical / pharmacological treatments for SUI/SI?

A

Oral medical therapy in rare cases

e.g. Duloxetine - not a good option long-term

45
Q

What are the surgical treatments for SUI /SI?

A

Occlusive e.g. bulking, compressive (AUS)
Supportive (suburethral sling)
Ileal conduit diversion

46
Q

What is urge urinary incontinence (UUI)?

A

Pathophysiology of overactive bladder (OAB) is not well understood
OAB is a symptom syndrome: urinary frequency, urgency, nocturia with or without leak
OAB prevalence (NOBLE study) 16% in men and women

47
Q

How do men and women differ in terms of urgency and leaking?

A

But men have a higher prevalence of OAB-dry (13.4%) cf. 7.6% in women - i.e. urgency without leaking
Women have a higher prevalence of OAB-wet (9.3% vs 2.6% in men - i.e. urgency with leaking

48
Q

What else could it be if its not UUI?

A 
Differential diagnosis =
UTI
DO = detrusor overactivity
Urethral syndrome
Urethral divertivulum
Interstitial cystitis
Bladder cancer
Large residual volume
49
Q

What are the conservative / non-surgical treatments for UUI?

A

Lifestyle changes

  • Decreasing caffeine intake
  • Stopping smoking
  • Losing weight if obese

Bladder re-training
Pelvic floor muscle exercises

50
Q

What are the medical / pharmacological treatments for UUI?

A

Efficacy is 50-75%

Anti-cholinergics e.g. solifenacin, tolterodine, trospium
- Side effects = dry mouth, blurry vision (temporary), constipation

Beta-3-agonists e.g. betmiga
- Side effect of raising BP, prolong QT interval

51
Q

What are the surgical treatments for UUI?

A

Posterior Tibial Nerve Stimulation (PTNS) = aeedle placed next to the PTNs to provide electrical stimulation once a week for 12 weeks
Efficacy = helps 40% of patients
Relatively low risk

Intravesical injection of botulinum toxin A
= botox treatment in bladder = under local anaesthetic = repeated every 6-9 months
Efficacy = 36-89%, mean efficacy is 70%, upto a mean time of 6 months

Neuromodulation = into S3 foramina = can be switched on and off to modulate bladder and sphincter
Efficacy = 50% cure rate, 25% significant improvement of symptoms, 25% failure rate

Clam (augmentation) cystoplasty - open up bladder and place some bowel in the middle to interrupt the contractions of the bladder
Efficacy = 50% cure rate, 25% significant improvement of symptoms, 25% failure rate
Long term risks / side effects

Urinary diversion is an option if all else fails in very severe cases

Y2 - BRS - Uro (8 decks)

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