Urology (5) (Misc) Flashcards
BPH
BPH
Very common conditions affecting men in older age (usually >50).
Cause
Hyperplasia of the stromal and epithelial cells of the prostate- in the transitional zone.
presentation of BPH
Presentation
There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:
- Hesitancy – difficult starting and maintaining the flow of urine
- Weak flow
- Urgency – a sudden pressing urge to pass urine
- Frequency – needing to pass urine often, usually with small amounts
- Intermittency – flow that starts, stops and varies in rate
- Straining to pass urine
- Terminal dribbling – dribbling after finishing urination
- Incomplete emptying – not being able to fully empty the bladder, with chronic retention
- Nocturia – having to wake to pass urine multiple times at night
scoring system for LUTS
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms
investigations BPH
- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
- Abdominal examination to assess for a palpable bladder and other abnormalities
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
-
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
- Unreliable- non-specific
- Counsel patients to make an informed decision
prostate examination
- A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
- A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
first line management of BPH
-
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
- Used to treat immediate treatment
second line management of BPH
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
- Used to treat the enlargement
- MOA: 5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone
- Inhibiting 5-alpha reductase reduces DHT in tissue, inc prostate- reduction in prostate size
- Takes up to 6 months to improve symptoms
surgical option for BPH
- Transurethral resection of the prostate (TURP)- most common
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- Open prostatectomy vis perineal incision
Transurethral resection of the prostate (TURP)
It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
- Major complications:
- Bleeding
- Infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
- Urethral strictures
- Failure to resolve symptoms
erectile dysfunction RF
- Inactivity
- Obesity
- Smoking
- Hypercholesterolaemia
- Hypertension
- DM
causes of ED
-
Vascular factors (if person presents with ED vascular health should be investigated)
- CVD
- Atherosclerosis
- Hypertension
- DM
- Smoking
- Neurological
- Parkinsons
- MS
- Tumours
- TBI
- Peripheral
- Polyneuropathy
- Peripheral neuropathy
- DM
- Alcoholism
- Hormonal
- Hypogonadism
- Hyperprolactinaemia
- Anatomical
- Peyronies
- Drugs
- Antihypertensives
- B blocker
- Diuretics
- Antidepressants e.g. SSRI
- Psychosocial factors
management of ED -first line
- Vacuum devices – air pumped out, resulting in engorgement of penis with blood
- Oral agents
- Phosphodiesterase inhibitors e.g. sildenafil → improves relaxation of smooth muscle (contraindicated in pts on vasodilation)
management of ED- second line
- MUSE- intraurethral alprostadil (prostaglandin E1)
management of ED- third line
- Penile prosthesis
peyronies disease
Peyronie’s disease is where plaques (segments of flat scar tissue) form under the skin of the penis. These plaques can cause the penis to bend or become indented during erections. The plaques can often be felt through the skin and can be painful.
causes of peyronies disease
Minor injury to penis- e.g. caused by vigorous sex
presentation peyronies disease
- Form on the top of the penis normally
- Plaques make tunica albuginea less flexible and causes the penis to bend upwards during erection
other signs
- bent/curved penis
- lumps in the penis
- painful erections
- soft erections
- having trouble with sex because of a bent/curved penis
RF for peyronies
Connective tissue disorder
stages of peronie
- acute phase – 5-7 months
- chronic phase- plaque stops growing and penis doesn’t bend further
treatment of peyronies
- Oral drugs
- Oral vitamin e
- Tamoxifen
- Colchicine
- Penile injection
- Verapamil
- Interferon injections
- Surgery