Urinary Incontinence and Benign Prostatic Hyperplasia

Question 1

What is BPH?

Answer 1

Benign Prostatic Hyperplasia

Question 2

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

Answer 2

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

Question 3

What is the arterial supply for the prostate?

Answer 3

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

Question 4

What is the venous drainage of the prostate?

Answer 4

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

Question 5

What is the lymphatic drainage of the prostate?

Answer 5

Mainly to the obturator nodes and then the internal iliac chain

Question 6

What is the zonal anatomy of the prostate?

Answer 6

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

Question 7

What is the role of the capsule?

Answer 7

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

Question 8

How is active smooth muscle tone regulated?

Answer 8

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

Question 9

What is the function of the prostate?

Answer 9

Liquify the ejaculation

Question 10

What is Lower Urinary Tract Symptoms (LUTS)?

Answer 10

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

Question 11

What is meant by Benign Prostatic Enlargement (BPE)?

Answer 11

Clinical finding of enlarged prostate

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

Question 12

What is meant by Benign Prostatic Hyperplasia (BPH)?

Answer 12

Histological diagnosis - increase in number of cells

Question 13

What is meant by Bladder Outflow Obstruction (BOO)?

Answer 13

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)

Question 14

What is meant by Benign Prostatic Obstruction (BPO)?

Answer 14

BOO caused be BPE

Question 15

What is meant by Benign Prostatic Hypertrophy?

Answer 15

Pathologically incorrect - increase in cell size

Question 16

What is the pathophysiology of BPH?

Answer 16

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

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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

Question 20

What is smooth muscle in BPH representative of?

Answer 20

Prostatic smooth muscle represents a significant volume of the gland

Question 21

How can urethral resistance be changed?

Answer 21

Urethral resistance can be increased by active and passive forces

Question 22

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

Answer 22

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

Question 23

What is LUTs related to in men with BPH?

Answer 23

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

Question 24

What are the obstruction induced changes in bladder function?

Answer 24

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

Question 25

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

Answer 25

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

Question 26

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

Answer 26

Fluid intake

Question 27

What are some examinations conducted for suspected BPH?

Answer 27

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

Question 28

What investogations are performed for suspected BPH?

Answer 28

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

Question 29

What is the conservative management for BPH?

Answer 29

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

Question 30

What are the medical / pharmacological management options for BPH?

Answer 30

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

Question 31

What are the surgical management options for BPH?

Answer 31

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

Question 32

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

Answer 32

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)

Question 33

What are the different types of urinary incontinence?

Answer 33

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)

Question 34

What are the causes of urinary incontinence?

Answer 34

``` 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 ```

Question 35

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

Answer 35

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

Question 36

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

Answer 36

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

Question 37

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

Answer 37

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

Question 38

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

Answer 38

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

Question 39

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

Answer 39

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

Question 40

What are the surgical options for SUI/SI?

Answer 40

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

Question 41

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

Answer 41

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

Question 42

What are the 5 structures that control continence in men?

Answer 42

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)

Question 43

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

Answer 43

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

Question 44

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

Answer 44

Oral medical therapy in rare cases | e.g. Duloxetine - not a good option long-term

Question 45

What are the surgical treatments for SUI /SI?

Answer 45

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

Question 46

What is urge urinary incontinence (UUI)?

Answer 46

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

Question 47

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

Answer 47

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

Question 48

What else could it be if its not UUI?

Answer 48

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

Question 49

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

Answer 49

Lifestyle changes - Decreasing caffeine intake - Stopping smoking - Losing weight if obese Bladder re-training Pelvic floor muscle exercises

Question 50

What are the medical / pharmacological treatments for UUI?

Answer 50

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

Question 51

What are the surgical treatments for UUI?

Answer 51

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