Urinary Incontinence and BPH

Question 1

how does the prostate develop?

Answer 1

• 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

Question 2

what is the arterial blood supply to the prostate?

Answer 2

• 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

Question 3

what is the venous drainage of the prostate?

Answer 3

• 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.

Question 4

what is the anatomy of the prostate?

Answer 4

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

Question 5

what is the function of the prostate?

Answer 5

liquify ejaculate

Question 6

what are lower urinary tract symptoms? (prostatism)

Answer 6

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

Question 7

what is benign prostate enlargement

Answer 7

clinical finding of enlarged prostate

Question 8

what is benign prostatic hyperplasia?

Answer 8

histological diagnosis

Question 9

what is bladder outflow obstruction?

Answer 9

urodynamically proven obstruction to passage of urine

can be an effect of BPH

Question 10

what is benign prostatic obstruction?

Answer 10

bladder outflow obstruction caused by benign prostatic enlargement

Question 11

what is benign prostatic hypertrophy?

Answer 11

pathologically incorrect term

Question 12

what is the pathophysiology of benign prostatic hyperplasia?

Answer 12

• ↑ 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

Question 13

what is the histology of benign prostatic hyperplasia?

Answer 13

• 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

Question 14

what are the symptoms of BPH?

Answer 14

• 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

Question 15

what is the examination for BPH?

Answer 15

• 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

Question 16

what is the investigation for BPH?

Answer 16

• 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

Question 17

what is the treatment for BPH?

Answer 17

watchful waiting

lifestyle changes

pharmacological treatment

surgery

Question 18

what is the pharmacological treatment for BPH?

Answer 18

• 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

Question 19

what is the surgery options for BPH?

Answer 19

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

Question 20

what is urinary incontinence?

Answer 20

involuntary loss of urine

Question 21

what is stress UI?

Answer 21

complaint of involuntary leakage on exertion/sneezing/coughing

Question 22

what is urge UI?

Answer 22

involuntary leakage accompanied by or immediately preceded by urgency

Question 23

what is mixed UI?

Answer 23

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

Question 24

what is continuous incontinence?

Answer 24

continuous leakage (sign of fistula)

Question 25

what is overflow incontinence?

Answer 25

leakage associated with urinary retention

Question 26

what is nocturnal enuresis?

Answer 26

loss of urine occuring during sleep

Question 27

what is post-micturition dribble?

Answer 27

involuntary loss of urine immediately after passing urine

Question 28

what are the risk factors for urine incontinence?

Answer 28

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

Question 29

what are the investigations for urine incontinence?

Answer 29

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

Question 30

who is stress UI more common in?

Answer 30

women of young to middle age uncommon in men who have not had prostate surgery

Question 31

what is involved in female stress UI?

Answer 31

* Pelvic floor * Urethral sphincter * Bladder function * Vagina and cervix

Question 32

what is the treatment for stress UI?

Answer 32

non-surgical pharmacological treatment surgery

Question 33

what is the non-surgical treatment for stress UI?

Answer 33

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

Question 34

what is the pharmacological treatment of stress UI?

Answer 34

* Oestrogen therapy if there is evidence of atrophy (women only) * Oral medical therapy in rare cases

Question 35

what is the surgical treatment of stress UI?

Answer 35

* Occlusive e.g. bulking, compressive (AUS) * Supportive (mid-urethral sling, colposuspension) * Ileal conduit diversion

Question 36

what are the causes of Stress UI in men?

Answer 36

* Sphincter incompetence * Reduction in urethral sphincter length * Post-operative strictures

Question 37

what are the structures controlling continence in men?

Answer 37

* Detrusor muscle * Internal sphincter * Ureterotrigonal muscles * Levator muscles * Rhabdosphincter (external sphincter muscle)

Question 38

what is the male urinary anatomy?

Answer 38

Question 39

what is the prevalence of urge urinary incontinence?

Answer 39

* Prevalence 16% in men and women * Men higher urgency without leaking * Women higher urgency with leaking

Question 40

what are the differential diagnoses of urge UI?

Answer 40

* UTI * DO * Urethral syndrome * Urethral divertivulum * Interstitial cystitis * Bladder cancer * Large residual volume

Question 41

what is the treatment for urge UI?

Answer 41

lifestyle changes bladder re-training pelvic floor muscle exercises pharmacotheraphy surgery

Question 42

what are the lifestyle changes of urge UI?

Answer 42

decreasing caffeine intake stopping smoking losing weight if obese

Question 43

what is the pharmacotherapy treatment for urge UI?

Answer 43

* Efficacy is 50-75% * Anti-cholinergics e.g. solifenacin, tolterodine, trospium * Beta-3-agonists e.g. betmiga

Question 44

what are the options for surgery for urge UI?

Answer 44

* 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