Urinary incontinence and BPH Flashcards
What are McNeal’s prostate zones?
- zones of prostate
- transition zone: 10% of glandular tissue of prostate, site of origin of BPH
- central zone: 25% of glandular tissue of prostate
- peripheral zone: 65% of glandular tissue of prostate
What is the function of the prostate?
liquefy ejaculate
What is benign prostatic obstruction?
bladder outflow obstruction caused by benign prostatic enlargement
What is the pathophysiology of BPH?
- inc. number of epithelial and stromal cells in the peri-urethral area of prostate
- in response to testosterone and growth factors
- leads to inc. urethral resistance–> compensatory changes in bladder–> inc. detrusor pressure–> reduced urinary flow, frequency and urgency, and nocturia
- N.B. size of prostate does not equal degree of obstruction
What is the most abundant adrenoceptor subtype in the human prostate?
alpha 1A- regulates active smooth muscle tone
What obstruction-induced bladder changes occur in BPH?
- detrusor instability (bladder becomes overactive) and reduced compliance–> frequency and urgency
- reduced detrusor contractility–> hesitancy, intermittency, inc. residual urine and sometimes detrusor failure (retention)
What are voiding symptoms in BPH?
- reduced flow
- hesitancy
- incomplete emptying
- strangury (strain passing urine)
What are storage symptoms in BPH?
- inc. daytime frequency and nocturia
- urgency
- incontinence
What examinations would you do for a person with LUTS / BPH symptoms?
- general exam
- palpable bladder
- ballotable kidneys
- phimosis (narrowing of foreskin so can’t pull back)
- meatal stenosis (scarring/narrowing of opening of urethra)
- DRE looking for enlarged prostate, nodules, anal tone and sensation
What investigations would you do for a man with presumed BPH?
- urine dipstick
- flow rate + PVR
- IPSS questionnaire (to assess symptoms related to BPE)
- bladder diary
- USS KUB if impaired renal function, loin pain, haematuria, renal mass on examination
- PSA, creatinine
- flexible cystoscopy
- TRUS to look at prostate
- urodynamic studies (pressure flow)
How do we manage BPH?
- watchful waiting
- lifestyle changes–> what they drink, how much they drink
- pharmacological treatment:
- -> alpha-adrenergic antagonists e.g. Tamsulosin, alfuzosin, doxazosin- relax bladder neck
- -> 5-alpha reductase inhibitors e.g. Finasteride, dustasteride- shrink prostate, preventing disease progression and need for surgery
- -> combination therapy
- surgery:
- -> TURP
- -> Rezume
- -> uroLIFT
- -> Millin’s prostatectomy
- -> embolisation
- -> HoLEP
What is urinary incontinence?
complaint of any involuntary loss of urine
What is stress urinary incontinence?
- complaint of involuntary leakage on physical exertion/sneezing/coughing
- more common in women of young-middle age
- uncommon in men who haven’t had prostate surgery
- usually due to weakening/damage to the muscles that prevent urination, such as the pelvic floor muscles and the urethral sphincter
What is urge urinary incontinence?
- complaint of involuntary leakage accompanied by or immediately following urgency
- usually caused bu overactivity of the detrusor muscles, which control the bladder
What is mixed urinary incontinence?
complaint of involuntary leakage of urine associated w/ urgency and also exertion, effort, sneezing, or coughing
What is continuous incontinence?
continuous leakage- worrying sign
What is overflow incontinence?
leakage associated w/ urinary retention
What is nocturnal enuresis?
complaint of loss of urine during sleep
What is postmicturition dribble?
complaint of involuntary loss of urine immediately after passing urine
What are the risk factors for urine incontinence?
- increasing age
- pregnancy and vaginal delivery
- obesity
- constipation
- drugs e.g. ACEIs
- smoking
- family history
- gynaecological surgery e.g. hysterectomy
- menopause
What investigations would you do for urinary incontinence?
- urine dipstick
- flow rate and post void residual (high= overflow incontinence)
- bladder diary
- 24h pad tests
- patient symptom scores/validated quality of life questionnaire
- urodynamic/video-urodynamic studies
What are the non-surgical treatments for stress urinary incontinence?
- lifestyle changes e.g. weight loss, stop smoking, modifying fluid intake
- supervised pelvic floor exercises
- bladder re-training
What are the pharmacological treatments for stress urinary incontinence in women?
- topical oestrogen therapy if evidence of atrophy
- oral medical therapy in rare cases
What are the surgery options for stress urinary incontinence?
- occlusive e.g. bulking (injection to cause physical obstruction to urethra), compressive (artificial urinary sphincter)
- supportive (mid-urethral sling, colposuspension)
- ileal conduit diversion in end stage cases
What are the 3 causative theories of stress urinary incontinence in men?
- sphincter incompetence
- reduction in urethral sphincter length
- post-operative strictures
What are the pharmacological treatments for stress urinary incontinence in men?
oral medical therapy in rare cases (if not fit for surgery)
What is overactive bladder syndrome?
- OAB= urinary frequency, urgency, nocturia with or without leak
- men have higher prevalence of OAB without leaking
- women have higher prevalence of OAB w/ leaking
What are other differentials for urge urinary incontinence?
- UTI
- urethral syndrome
- urethral diverticulum
- interstitial cystitis
- bladder cancer
- large residual volume
What are the non-surgical treatments for urge urinary incontinence?
- decreasing caffeine intake
- stop smoking
- losing weight if obese
- bladder retraining
- pelvic floor muscle exercises
What are the pharmacological treatments available for urge urinary incontinence?
- anticholinergics e.g. solifenacin, tolterodine, trospium
- beta-3-agonists e.g. betmiga
- side effects: dry mouth, constipation, blurry vision, inc. bp
What are the surgical treatment options for urge urinary incontinence?
- posterior tibial nerve stimulation (PTNS)
- intravesical injection of botulinum toxin A every 6-9 months
- neuromodulation
- clam cystoplasty
- urinary diversion if very severe cases (stoma bag)
