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1B Urology and Renal Medicine > Urinary Incontinence and BPH > Flashcards

Urinary Incontinence and BPH Flashcards

1
Q

how does the prostate develop?

A
  • The prostate 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.
  • Main influencing hormone is dihydrotestosterone
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2
Q

what is the arterial blood supply to the prostate?

A
  • Arises from branches of the inferior vesical artery
  • 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
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3
Q

what is the venous drainage of the prostate?

A
  • Via peri-prostatic venous plexus
  • The periprostatic venous plexus eventually drains into the internal iliac vein.
  • Lymph drainage: to the obturator nodes and then the internal iliac chain.
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4
Q

what is the anatomy of the prostate?

A

Zonal anatomy of prostate:

  • described using McNeal’s zones
  • Transition zone:
    • 10% of the glandular tissue of the prostate
    • Site of origin of benign prostatic hyperplasia
  • Central zone:
    • 25% of the glandular tissue of the prostate
  • Peripheral zone:
    • 65% of the glandular tissue of the prostate
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5
Q

what is the function of the prostate?

A

liquify ejaculate

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6
Q

what are lower urinary tract symptoms? (prostatism)

A

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

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7
Q

what is benign prostate enlargement

A

clinical finding of enlarged prostate

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8
Q

what is benign prostatic hyperplasia?

A

histological diagnosis

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9
Q

what is bladder outflow obstruction?

A

urodynamically proven obstruction to passage of urine

can be an effect of BPH

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10
Q

what is benign prostatic obstruction?

A

bladder outflow obstruction caused by benign prostatic enlargement

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11
Q

what is benign prostatic hypertrophy?

A

pathologically incorrect term

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12
Q

what is the pathophysiology of benign prostatic hyperplasia?

A
  • ↑ number of epithelial and stromal cells in the peri-urethral area of the prostate in response to androgens (testosterone) and growth factors
  • → ↑ urethral resistance → compensatory changes in bladder function
  • ↑ detrusor pressure required to maintain urinary flow
  • → ↓ urinary flow, urinary frequency, urgency and nocturia
  • The capsule transmits the ‘pressure’ of tissue expansion to the urethra and leads to an increase in urethral resistance
  • The size of the prostate ≠ the degree of obstruction
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13
Q

what is the histology of benign prostatic hyperplasia?

A
  • Smooth muscle represents a significant volume of the gland
  • Urethral resistance is can be increased by active and passive forces.
  • Active smooth muscle tone is regulated by the adrenergic nervous system
    • ⍺1A is the most abundant adrenoceptor subtype in the human prostate
  • LUTS in men with BPH are related to obstruction-induced changes in bladder function rather than to outflow obstruction directly.
    • ≅ ⅓ continue to have significant voiding dysfunction after surgical relief of obstruction.
  • Obstruction-induced changes are:
    • Detrusor instability/↓ compliance → frequency and urgency
    • ↓ detrusor contractility → further deterioration in the force of the urinary stream, hesitancy, intermittency, increased residual urine and sometimes detrusor failure
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14
Q

what are the symptoms of BPH?

A
  • Voiding: reduced flow, hesitancy, incomplete emptying, strangury
  • Storage: frequency (daytime and nocturia), urgency, incontinence
  • Others: visible haematuria, infection
  • NB important to ask about fluid intake
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15
Q

what is the examination for BPH?

A
  • General examination
  • Palpable bladder
  • Ballotable kidneys
  • Phimosis (narrowing foreskin)
  • Meatal stenosis (scaring opening of urethra/ gland penis)
  • Enlarged prostate on DRE, size, consistency, nodules, anal tone and sensation
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16
Q

what is the investigation for BPH?

A
  • Urine dipstick
  • Flow rate + PVR
  • IPSS Questionnaire
  • Bladder diary
  • USS KUB if impaired renal function, loin pain, haemturia, renal mass on examination
  • PSA, creatinine
  • Flexible cystoscopy in some circumstances- haematuria
  • TRUS prostate
  • Urodynamic studies- if mixed symptoms
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17
Q

what is the treatment for BPH?

A

watchful waiting

lifestyle changes

pharmacological treatment

surgery

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18
Q

what is the pharmacological treatment for BPH?

A
  • alpha-adrenergic antagonists
    • e.g. Tamsulosin, alfuzosin, doxazosin
    • reduction in symptoms of 30-40% and improvement in flow rates of 16-25%
    • can make them lightheaded and dry ejaculation
  • 5-alpha-reductase inhibitors
    • e.g. Finasteride, Dustasteride
    • to prevent disease progression, reducing the development of AUR/requirement for surgery
    • only useful with enlarged prostate over certain size
  • combination therapy
19
Q

what is the surgery options for BPH?

A
  • gold standard (TURP- transurethral resection)
  • Rezum
  • UroLIFT
  • Millin’s prostatectomy
  • Embolisation
  • HoLEP
20
Q

what is urinary incontinence?

A

involuntary loss of urine

21
Q

what is stress UI?

A

complaint of involuntary leakage on exertion/sneezing/coughing

22
Q

what is urge UI?

A

involuntary leakage accompanied by or immediately preceded by urgency

23
Q

what is mixed UI?

A

involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing

24
Q

what is continuous incontinence?

A

continuous leakage (sign of fistula)

25
Q

what is overflow incontinence?

A

leakage associated with urinary retention

26
Q

what is nocturnal enuresis?

A

loss of urine occuring during sleep

27
Q

what is post-micturition dribble?

A

involuntary loss of urine immediately after passing urine

28
Q

what are the risk factors for urine incontinence?

A
  1. increasing age
  2. pregnancy and vaginal delivery
  3. obesity
  4. constipation
  5. drugs (ACEi)
  6. smoking
  7. family history
  8. prolapse/hysterectomy/menopause
29
Q

what are the investigations for urine incontinence?

A
  • Urine dipstick
  • Flow rate and post-void residual
  • Bladder diary
  • Pad tests
  • Patient symptom scores/validated QoL questionnaire
  • Urodynamic/video-urodynamic studies
30
Q

who is stress UI more common in?

A

women of young to middle age

uncommon in men who have not had prostate surgery

31
Q

what is involved in female stress UI?

A
  • Pelvic floor
  • Urethral sphincter
  • Bladder function
  • Vagina and cervix
32
Q

what is the treatment for stress UI?

A

non-surgical

pharmacological treatment

surgery

33
Q

what is the non-surgical treatment for stress UI?

A
  • Lifestyle changes
    • weight loss
    • cessation of smoking
    • modification of high/low fluid intake
  • Supervised pelvic floor exercises
  • Bladder re-training
34
Q

what is the pharmacological treatment of stress UI?

A
  • Oestrogen therapy if there is evidence of atrophy (women only)
  • Oral medical therapy in rare cases
35
Q

what is the surgical treatment of stress UI?

A
  • Occlusive e.g. bulking, compressive (AUS)
  • Supportive (mid-urethral sling, colposuspension)
  • Ileal conduit diversion
36
Q

what are the causes of Stress UI in men?

A
  • Sphincter incompetence
  • Reduction in urethral sphincter length
  • Post-operative strictures
37
Q

what are the structures controlling continence in men?

A
  • Detrusor muscle
  • Internal sphincter
  • Ureterotrigonal muscles
  • Levator muscles
  • Rhabdosphincter (external sphincter muscle)
38
Q

what is the male urinary anatomy?

A
39
Q

what is the prevalence of urge urinary incontinence?

A
  • Prevalence 16% in men and women
    • Men higher urgency without leaking
    • Women higher urgency with leaking
40
Q

what are the differential diagnoses of urge UI?

A
  • UTI
  • DO
  • Urethral syndrome
  • Urethral divertivulum
  • Interstitial cystitis
  • Bladder cancer
  • Large residual volume
41
Q

what is the treatment for urge UI?

A

lifestyle changes

bladder re-training

pelvic floor muscle exercises

pharmacotheraphy

surgery

42
Q

what are the lifestyle changes of urge UI?

A

decreasing caffeine intake

stopping smoking

losing weight if obese

43
Q

what is the pharmacotherapy treatment for urge UI?

A
  • Efficacy is 50-75%
  • Anti-cholinergics e.g. solifenacin, tolterodine, trospium
  • Beta-3-agonists e.g. betmiga
44
Q

what are the options for surgery for urge UI?

A
  • Posterior tibial nerve stimulation (PTNS)
  • Intravesical injection of botulinum toxin A
    • efficacy is 36-89%, mean efficacy is 70%, upto a mean time of 6 months
  • Neuromodulation
    • 50% cure rate, 25% significant improvement of symptoms, 25% failure rate
  • Clam (augmentation) cystoplasty
    • 50% cure rate, 25% significant improvement of symptoms, 25% failure rate
  • Urinary diversion is an option if all else fails in very severe cases

1B Urology and Renal Medicine (6 decks)

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