Urology Flashcards
What is BPH? Which areas enlarge?
Benign, nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate.
Enlargement of the inner transitional zone
The lower urinary tract Sx from BPH come from outlet obstruction. What are the 2 components of this?
Static component - increasing tissue bulk leads to narrowing urethral lumen
Dynamic component - increase in prostatic smooth muscle tone mediated by alpha adrenergic receptors
Name 3 Sx of BPH
Storage symptoms:
FUN -
frequency, urgency, nocturia
Voiding symptoms:
HIIPP -
hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
Name 3 Ix in BPH + 1 to rule out other cause of Sx
DRE
TRUSS ± biopsy
PSA - increased may indicate prostate cancer or prostatitis
Urinalysis
MSU/urine dip to rule out pyuria and complicated UTI
Volume chart
USS KUB
To rule out hydronephrosis, urolithiasis, mass
What is the scoring system for BPH ?
IPSS - International Prostate Symptom Score (0-35)
also includes quality of life
[Mild = 0-7, Mod = 8-19, Severe = 20+]
3 parts of behavioural Mx for BPH
Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids
Most common Mx for BPH
watch and wait
Pharma Mx for BPH
Mild (bother)
FIRST LINE: Alpha blocker (tamsulosin or doxazosin)
or 5-alpha reductase inhibitor (finasteride)
[or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)]
How do alpha blockers work for BPH ? SEs?
Smooth muscle relaxation in prostate and bladder neck:
SE: postural hypotension, dry mouth
How do 5-a reductase inhibitors work for BPH
Reduced conversion of testosterone to dihydrotestosterone
Mx of abnormal DRE / PSA ?
Surgical referral
Prostate < 80g - TURP or TUVP (transurethral resection/vaporisation)
Prostate > 80g - Open prostatectomy
Name 2 comps of BPH
Progression - reduced by alpha blockers
Sexual dysfunction - due to alpha blockers, 5-alpha reductase inhibitors or surgical management
Acute urinary retention (roughly 2.5% over 5 years)
TURP syndrome
What is TUPR syndrome? Sx?
Consequence of absorption of irrigating fluids into prostatic venous sinuses - basically goes into blood stream and fucks your system
Fluid overload, disturbed electrolyte balance, hyponatraemia and hypothermia (bladder source of heat loss)
i.e. hypertension + reflex bradycardia, restless, headache, N + V, confusion
Mx of TUPR syndrome
ABCDE
Supportive
100% O2 non-rebreather,
monitor BP with arterial line,
correct hyponatraemia
Name 3 causes of acute urinary retention ? 2 for women only?
1 drug?
BPH / Ca
Bladder/urethral calculi, bladder cancer, faecal impaction
Infective
Women - Prolapse, pelvic mass
Drugs
ANTICHOLINERGICS + ALCOHOL
Neuro Autonomic neuropathy (DM), spinal cord damage (disc disease, MS, spinal stenosis, cauda equina, cord compression), pelvic surgery
3 Ix in acute urinary retention?
USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
Urinalysis - infection, haematuria, proteinuria, glucosuria
MSU - infection
[Blood tests
FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
CT abdo pelvis - looking for mass causing bladder neck compression
MRI spine - disc prolapse, cauda equina, spinal cord compression MS]
Mx of acute urinary retention
Immediate bladder decompression with catheter
What should men be offered prior to removal of catheter in acute retention
alpha blocker
Type of Ca are prostate?
adenocarcinoma
Spread of prostate Ca? 1 is muy important
Haematogenous - *bone sclerotic (90%), lung (50%) and liver
[Local - through capsule to seminal vesicles, bladder, rectum
Lymphatic - pelvic LNs]
What is used to grade prostate cA
Gleason - level of differentiation
Who is screened for prostate Ca and how?
?PSA + DRE
40s 2.5, 50s 3, 60s 4, 70s 5
1 argument for and 1 against prostate screening
For: commonest cancer in men, 3% men die of PC
Against: uncertain natural history, PSA not specific
Name 2 Sx of pres for prostate Ca and 2 features that would indicate advanced metastatic
LUTS: fill and void
Haematuria
Advanced metastatic:
Weight loss/anorexia/lethargy
Bone pain
Palpable LNs
3 Ix in prostate Ca
PSA (protease responsible for liquefaction of semen - prostate specific not prostate cancer specific)
Normal = 0-4 ng/ml
DRE - hard and irregular prostate
TRUSS + biopsy (infection 1pc serious, bleed, retention, fp)
Abnormal cells in 2 different samples
MRI + CT for staging
Isotope bone scan for metastasis (If
PSA > *20)
Testosterone (baseline if considering androgen deprivation)
FBC/LFT - normal
Active surveillance is an option for very low risk prostate Ca.
What other Mx could you do for low risk?
brachytherapy (radioactive source to prostate)
external beam radiotherapy
Mx of high risk prostate Ca ? ( T3/4, PSA > 20, Gleason 8-10)
Radical prostatectomy plus pelvic LN dissection
External beam radiotherapy (every day M:F 7-8W) + brachytherapy/androgen deprivation (shrinks tumour)
Mx of mets in prostate Ca
They are usually androgen sensitive:
Androgen deprivation therapy
chemical castration
Surgical castration
Drug used for chemical castration
Goserelin (GnRH analogue -
[stimulates then inhibits pituitary gonadotrophin so symptoms may get worse, offer an anti-androgen e.g. flutamide]
Main comp in surgical castration
risk of impotence if cut cavernous nerve of penis
Mx if prostate mets are castration resistant?
Bisphosphonates - reduce pain
palliative radiotherapy
Name 3 comps of prostate Ca mx
Erectile dysfunction - radiation, surgery, androgen deprivation
Hormone induced gynaecomastia
Hormone induced hot flush
Radiation induced LUTS for a few weeks + haematuria + bowel bleeding
How to prevent hormone induced gynaecomastia
tamoxifen
Usual Ca in bladder? what if schisto?
Transitional cell carcinoma (90%)
Squamous
Name 3 RFs for bladder Ca ? genetic cause?
Smoking (50%)
Occupational: aromatic amines (rubber + dye), polycyclic aromatic hydrocarbons (aluminum and coal)
Age, 70% > 65
Pelvic radiation (prostate Ca)
Men > Women
HNPCC for upper tract urothelial cancers
Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
Bladder Ca stage
Ta - non-invasive papillary carcinoma
T1 - tumour invades subepithelial connective tissue (lamina propria)
Not felt
T2 - tumour invades superficial muscle (detrusor or muscularis propria)
Rubbery thickening
T3 - tumour invades perivesical tissue
Mobile mass
T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall
Fixed mass
Where does bladder Ca spread?
Lymphatic: Pelvic
Haematogenous: liver and lungs
How does bladder Ca present?
Painless haematuria (frank or microscopic), dysuria, abdominal mass, RFs,
systemic weight loss + bone pain
Name 4 Ix in bladder Ca
Urine dip
Haematuria (80% of patients) ± pyuria
Urine MC + S - cancers may cause sterile pyuria
KUB USS
Bimanual EUA for staging
*Flexible cystoscopy with biopsy TURBT
CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour or obstruction
Urinary cytology - abnormal cells
FBC - mild anaemia
CXR, isotope bone scan, alkaline phosphatase etc…..
3 Comps of bladder Ca
Hydronephrosis Upper tract TCC Prostatic urethral TCC Urinary retention Recurrence
Most bladder Ca presents with low-grade non muscle invasiion.
Mx?
Transurethral Resection of Bladder Tumour
+intravesical chemo (direct into bladder through catheter)
+intravesical BCG (bacille Calmette-Guerin) immunotherapy)
Mx of invasive bladder Ca?
mets?
cystectomy with pelvic LN dissection + chemo
mets = chemo