Urinary Incontinence and BPH Flashcards
At what point during gestation does the prostate develop?
Weeks 10-16
What hormone influences prostate development?
Dihydrotestosterone
From what artery does the arterial supply to the prostate arise from?
Inferior vesical artery
What is the name of the artery that supplies the prostate?
Prostatic artery
What does the prostatic artery divide into?
Urethral and capsular
What arteries does the urethral artery give rise to?
Flock’s and Badenoch’s arteries
Where are Flock’s arteries?
1 and 11 o clock
Where are Badenoch’s arteries?
5 and 7 o clock
What undertakes the venous drainage of the prostate?
Peri-prostatic venous plexus
What does the peri-prostatic venous plexus drain into?
Internal iliac vein
Describe the lymph drainage of the prostate
Firstly drains to the obturator nodes and then the internal iliac chain
What is the set of zones of the prostate known as? name them individually top
McNeal's zones: Transition zone Central zone Peripheral zone Anterior fibromuscular stroma
What is the function of the prostate?
To liquefy ejaculate
What does BPH stand for? What term for it would be pathologically incorrect?
Benign prostatic hyperplasia
You can’t call it hypertrophy
What condition may BPH develop into?
BPO= benign prostatic obstruction
How does BPH manifest?
Reduced urinary flow
Urinary frequency
Urgency
Nocturia
Describe the pathophysiology of BPH
Hihger number of epithelial and stromal cells in peri urethreal area of the prostate due to testosterone and grwoth factors
Higher urethral resistance
Compensatory changes in bladder function
Higher detrusor pressure needed to maintain urinary flow
What role does the capsule play in BPH?
It transmits the ‘pressure’ of tissue expansion to the urethra and leads to an increase in urethral resistance
How does the size of the prostate affect BPH?
As the size of the prostate increases so does the degree of obstruction
What type of tissue makes up most of the gland?
Smooth muscle
What forces increase urethral resistance?
Both active and passive
What is the most abundant adrenoceptor in the prostate?
⍺1A
What are lower urinary tract symptoms in men related to and how is this significant?
They are related to obstruction induced changes in bladder function rather than directly outflow obstruction
This means even after surgical relief for BPH symptoms persist in 1/3 of men
What are obstruction induced changes?
Detrusor instability
Reduced detrusor contractility
What symptoms associated with voiding may arise in BPH?
Reduced flow, hesitancy, incomplete emptying, strangury
What symptoms associated with storage may arise in BPH?
Higher frequency (daytime and nocturia), urgency, incontinence
What is t very important to ask about in BPH and why?
Fluid intake as it greatly affects lower urinary tract symptoms
What is examined in suspected BPH and what would results be?
General examination Palpable bladder Ballotable kidneys Phimosis- inability to retract foreskin Meatal stenosis- abnormal narrowing of the urethral opening
What investigations can be done in BPH?
Urine dipstick Flow rate + PVR IPSS Questionnaire Bladder diary PSA, creatinine Flexible cystoscopy in some circumstances TRUS prostate Urodynamic studies
What conservative management can be used for BPH?
Watchful waiting Lifestyle changes (look at bladder diary and suggest changes such as when to stop fluid intake in the evening, cut/reduce caffeine intake
What pharmacological treatment is used to treat BPH?
Alpha adrenergic antagonists
5 alpha reductase inhibitors
What surgical treatment is used to treat BPH?
Gold standard= trans urethral resection of the prostate (TURP)
Embolisation
Rezum- use of steam
What is urinary incontinence (UI)?
The complaint of any involuntary loss of urine
What is stress UI?
The complaint of involuntary leakage on exertion /sneezing/coughing
What is urge UI?
The complaint of an involuntary leakage accompanied by or immediately preceded by urgency
What is mixed UI?
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 post micturition dribble?
The complain of an involuntary loss of urine immediately after passing urine
What groups are more likely to suffer from UI?
Older people Pregnant and those who have had a vaginal delivery Obesity Constipation Drugs eg being on ACE inhibitors Smoking Family history
What investigations are done for UI?
Urine dipstick Flow rate and post-void residual Bladder diary Pad tests- the pads are weighed Patient symptom scores/validated QoL questionnaire Urodynamic/video-urodynamic studies
What groups is stress incontinence more common in?
Women of young to middle age
What groups is stress incontinence uncommon in?
Men who have not had prostate surgery
What are the 5 causative theories of stress incontinence in women?
Urethral causative theory Intrinsic sphincter deficiency Integral theory Hammock theory Trampoline theory
What are non surgical treatments for stress incontinence?
Lifestyle changes eg weight loss, cessation of smoking, modification of high/low fluid intake
Supervised pelvic floor exercises
Bladder re-training
What are pharmacological treatments for stress incontinence and when are they used?
Oestrogen therapy if there is evidence of atrophy
Oral medical therapy in rare cases
What are surgical treatments for stress incontinence?
Occlusive e.g. bulking, compressive (AUS), a material is inserted to cause a physical obstruction around the urethra or artificial sphincter holds in urine then they have to press a button to void
Supportive (mid-urethral sling, colposuspension)
Ileal conduit diversion
What are the 3 causative theories of stress incontinence in men?
Sphincter incompetence
Reduction in urethral sphincter length
Post-operative strictures
What 5 structures control continence?
Detrusor muscle Internal sphincter Ureterotrigonal muscles Levator muscles Rhabdosphincter (external sphincter muscle)
What are symptoms of overactive bladder (OAB)?
Urinary frequency
Urgency
Nocturia with or without leak
What are the names for oab with and without incontinence?
With= oab wet Without= oab dry
Which gender has a higher prevalence for oab wet vs dry?
Women have a higher prevalence for oab wet
Men have a higher prevalence for oab dry
What are differential diagnoses for oab?
UTI DO Urethral syndrome Urethral diverticulum Interstitial cystitis Bladder cancer Large residual volume
What lifestyle changes can be suggested for oab?
Decreasing caffeine intake
Stopping smoking
Losing weight if obese
What pharmacological treatment is used for oab?
Anti cholinergics
Beta 3 agonists
What surgical treatment can be used for oab?
Posterior tibial nerve stimulation (PTNS)
Intravesical injection of botulinum toxin A
Neuromodulation
Clam (augmentation) cystoplasty
Urinary diversion if severe
