Urinary tract obstruction Flashcards
Which 3 overlapping symptoms contribute to Benign prostatic hyperplasia (prostate gland enlargement)?
Lower urinary tract symptoms
Bladder outflow obstruction
Benign prostatic enlargement
What is prostate gland enlargement?
A common condition as men get older - 50% of men at 60 years
Characterised by fibromuscular and glandular hyperplasia
Can cause uncomfortable urinary symptoms - for example blockage of outflow tract
How are LUTS symptoms scored?
International Prostate Symptom Score
7 questions related to voiding and storage symptoms - Incomplete emptying, Frequency, Intermittency, Urgency, Weak Stream, Straining + Nocturia
Total score out of 35
Mild - 0-7
Moderate - 8-19
Severe - >20
What voiding symptoms are assessed?
Hesitancy
Poor stream
Terminal dribbling
Incomplete emptying
What storage symptoms are assessed?
Frequency
Nocturia
Urgency
+/- urge incontinence
Physical examinations done for suspected urinary tract obstruction?
Abdomen - do they have a palpable bladder
Penis - is there an external urethral meatal stricture or phimosis
Rectal examination - assess prostate size, feel for any suspicious nodules or firmness
Urinalysis - ? blood, ? signs of UTI
Investigations for urinary tract obstruction
MSSU - mid stream urine sample
Flow rate study
Post-void bladder residual USS
Bloods : PSA, urea and creatinine (if chronic retention)
Renal tract USS if renal failure or bladder stone suspected
Flexible cystoscopy if haematuria (camera to look at bladder)
Urodynamic studies in selected cases
TRUS-guided prostate biopsy => >do this if PSA raised or abnormal rectal exam
What is a PSA blood test?
Prostate specific antigen
Produced by both cancerous and noncancerous tissue - it is age dependent
2 classes of Benign prostate obstruction (BPO)
Complicated
Uncomplicated
Treatment of uncomplicated BPO
Watchful waiting
Medical therapy - 5 alpha reductase inhibitors (Finasteride or Dutasteride), Alpha blockers or Combination
Surgical intervention - TURP, Open retropubic or transvesical prostatectomy, Endoscopic ablative procedures
What is TURP?
Transurethral resection of the prostate - surgery to remove part of the prostate - remains gold standard
Done if prostate size is <100cc
What is the main treatment of LUTS associated with prostate enlargement? Why?
Alpha blockers - help give relief of symptoms and improve QOL
Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction.
Smooth muscle of bladder neck (i.e. intrinsic urethral sphincter) and prostate innervated by sympathetic alpha-adrenergic nerves (mostly alpha-1a subtype)
What are the different types of alpha blockers?
Non-selective (i.e. alpha 1 and 2) : phenoxybenzamine
Selective short acting : prazosin, indoramin
Selective long acting : alfuzosin, doxazosin, terazosin
Highly selective (i.e. alpha-1a) : tamsulosin
What do 5a-reductase inhibitors do?
They convert testosterone to dihydrotestosterone which reduces prostate size and the risk of progression of prostate enlargement.
They also reduce LUTS (but not as effective as alpha blockers)
Can also reduce prostatic vascularity and hence reduces haematuria due to bleeding
Potential role in prostate cancer prevention
What is the most effective therapy for reducing the risk of benign prostate enlargement?
Combination therapy of 5ARIs + alpha blockers
What is the gold standard surgery for prostate enlargement?
Transurethral resection of prostate (TURP)
Complications with TURP (5)
Bleeding
Infection
Retrograde ejaculation
Stress urinary incontinence - coughing, sneezing or exercising can cause urine to leak out
Prostatic regrowth causing recurrent haematuria or Bladder Outflow Obstruction
Complications of Benign prostatic obstruction
Progression of LUTS Acute urinary retention Chronic urinary retention Urinary incontinence (overflow) UTI Bladder stone Renal failure from obstructed ureteric outflow due to high bladder pressure
Treatment of complicated obstruction caused by enlarged prostate?
No role for medical therapy (except for acute urinary retention)
Most patients will require surgery eg. cystolitholapaxy (breaks up bladder stones into smaller pieces) and TURP for patients with BPO and bladder stones
Alternative treatment options (eg. patients unfit for surgery) = long term urethral or suprapubic catheterisation, clean intermittent self-catheterisation
May develop problems with difficult catheterisation - catheter trauma, blockages, frank haematuria or recurrent UTI
Upper urinary tract obstruction (3)
PUJ - pelvic ureteric junction obstruction
Ureter
VUJ - vesico ureteric junction obstruction
Intrinsic causes of ureter obstruction
Stone Ureteric tumour (TCC) Scar tissue Blood clot Fungal ball
Intrinsic cause of Vesico-ureteric junction (VUJ) obstruction
Stone
Bladder tumour
Ureteric tumour
Prostate cancer
Intrinsic cause of Pelvi-ureteric junction (PUJ)
obstruction
PUJ obstruction (scar tissue) Stone Ureteric tumour (TCC) Blood clot Fungal ball
Extrinsic causes for obstruction of the ureter
Lymph nodes (tumour, retroperitoneal fibrosis)
Iatrogenic
Abdominal/pelvic mass (tumour, pregnant uterus)
Extrinsic causes for obstruction of the Pelvi-ureteric junction (PUJ)
Pressure from a crossing vessel
Tumour - LN enlargement putting pressure on the PUJ
Abdominal mass (tumour)
Symptoms of urinary tract obstruction
Pain
Frank haematuria (macroscopic)
Symptoms of complications
Signs of urinary tract obstruction
Palpable mass
Microscopic haematuria
Signs of complications
Complications of urinary tract obstruction
Infection and sepsis
Renal failure
Management of emergency upper urinary tract obstruction
Resus - ABCs, IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring, IV fluids, broad-spectrum antibiotics (if appropriate), Analgesia, HDU care +/- renal replacement therapy (if appropriate)
Investigations (including imaging: Bladder scan, USS renal tract)
Emergency treatment of obstruction (for unremitting pain or complications) -
Urethral catheterisation OR Suprapubic catheterisation
What are some alternative new endoscopic ablative procedures done insetad of TURP
Transurethral laser vaporisation
Urolift
