Urology Flashcards
voiding vs storage LUTS
voiding - hesitancy, poor stream, terminal dribbling
storage - nocturia, urgency, frequency
NB normal frequency = 4-7 times per day
phimosis vs paraphimosis
phimosis = foreskin cannot be retracted
paraphimosis = can’t be pulled back up
Peyronie’s disease
due to inflammation and fibrosis of the tunica cavernosum - segments of scar tissue builds up under the skin of the penis so that it bends
is likely caued by minor injury to the penis
what sort of cancer is penile carcinoma
squamous cell carcinoma
benign prostate hyperplasia vs benign prostate enlargement
BPH - biopsy (although not routine) shows signs of hyperplastic changes
BPE describes enlargement of the prostate via BPH
5 causes of voiding LUTS
BPH/BPE - most common
drugs with antimuscurinic action - TCAs, sedating antihistamines, oxybutynin
diabetic autonomic neuropathy and neurogenic bladder
urethral stricture + phimosis
prostate/bladder/rectum cancer
causes of overactive bladder
- Weak pelvic muscles o E.g. due to pregnancy + childbirth o This can cause the bladder to sag out of its normal position - Nerve damage – brain telling the bladder to contract when it shouldn’t o Pelvic or back surgery o Herniated disc o Radiation o PD o MS o Stroke - Medications, alcohol and caffeine - Infection – can irritate the nerves - Excess weight o Being overweight places extra pressure on your bladder. This can lead to urge incontinence. - Oestrogen deficiency after menopause - Often idiopathic
drugs that can cause nocturnal polyuria
CCBs
diuretics
SSRIs
drugs that can cause stress incontinence
increase urine production - alcohol, caffeine, diuretics
relax bladder outlet and urethra - alpha blocker
Can cause urinary retention, which may result in overflow incontinence (for example sympathomimetics [such as pseudoephedrine], drugs with an antimuscarinic action [such as TCAs, sedative antihistamines, and some antipsychotics], and opioid analgesics).
Reduce awareness of the need to urinate (for example benzodiazepines and z-drugs [such as zopiclone and zolpidem]).
other asking about storage + voiding symptoms, what are some other important questions to ask in a urological history
dysuria
haematuria
suprapubic pain or discomfort
fluid intake and types of fluid
PMH: history of pelvic surgery or pelvic radiotherapy history of spinal surgery or trauma PD or diabetes previous urethral surgery
examination for someone with LUTS
- Palpate the abdomen
o Palpable bladder suggests retention of urine
o If acute (or acute on chronic) will be painful while chronic retention is painless
o Can also check for abdominal distension and suprapubic dullness on percussion - Examine the external genitalia
o A phimosis (foreskin cannot be retracted) may result in bladder outflow obstruction, as may a carcinoma of the penis.
o If the foreskin looks normal and is retractile examine the urethral meatus. Is it in a normal position? Is there any meatal stenosis?
o Palpate the penis for thickening in the urethra which may indicate the presence of a urethral stricture - Ask the patient to turn onto his left side and examine the spine
o Scars from spinal surgery, hairy naevus or post-natal dimple (spina bifida occulta) may suggest a neurological cause
o Assess saddle sensation, anocutaneous reflex and anal tone
o Abnormalities may again suggest a neurological cause for the patients LUTS - Assess saddle sensation
o Anocutaneous reflex and anal tone. Abnormalities may again suggest a neurological cause for the patients LUTS
o May also chose to do an examination of the perineum and/or LLs to evaluate their motor and sensory function - Perform a rectal examination
o Look for abnormal masses
o Faecal impaction
o Feel for the prostate
should feel two “lobes” with a depression, the median sulcus between them
example investigations for someone with LUTS
U+Es + eGFR - assess overall renal function
urine dipstick
- exclude UTI + check for haematuria (microscopic haematuria associated with malignancy in 7%)
IPSS
frequency volume chart for at least 3 days
urine flow test
abdominal US to check for residual urine after micturition
serum PSA
imaging of the urinary tract if history of stones or haematuria
2 week appointment if suspecting prostate cancer
IPSS
international prostate symptom severity score
made of up 7 symptom questions e.g. incopmlete empyting, urgency, weak stream, nocturia
each Q can be scored 0-5 with an overal score of 0-35
allows for a baseline assessment to allow assessment of subsequent symptom change
urine flow test
patient drinks 500-1000ml of fluid and is asked to wait until they need to void
2-3 tests should be done and max value used (Qmax)
at least 150ml should be passed for the test to be valid
measurement of the urinary flow rate allows an estimate of the probaility of bladder outflow obstruction to be made
If the Qmax rate is <10ml/sec the patient has a 90% chance of having bladder outflow obstruction
normal urinary flow rate
around 15-20ml/second although some sources says lower than this
normal PSA
<4nmol/ml (or 4 nanograms/ml) but increases with age, urinary tract infection, prostatic inflammation
upper limit varies according to age and race
when should you delay doing a PSA test
An active urinary infection (PSA may remain raised for many months).
Ejaculation in the previous 48 hours.
Vigorous exercise in the previous 48 hours.
A prostate biopsy in the previous 6 weeks
management of voiding symptoms
PATIENT EDUCATION + reassurance - can offer active surveillance
CONSERVATIVE MANAGEMENT
pelvic floor muscle training + bladder training
advise not excessively limit fluid intake (->UTIs)
limit caffeine, artifical sweeteners, fizzy drinks
use of containment products like pads, waterproof pants, external sheath
MEDICAL
of moderate to severe voiding symptoms then alpha blocker then reassess with IPSS
if enlarged prostate then 5 alpha reductase inhibitor
if voiding symptoms + enlarged prostate then both
if mixed picture with storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, consider adding an antimuscarinic (anticholinergic) drug
SURGICAL
TURP, TUEVAP, HoLEP, TUIP, open prostatectomy
alpha blockers for voiding symptoms
tamsulosin
alfluzosin
doxazosin
trazosin
5 alpha reductase inhibitors for enlarged prostate
finasteride
dutasteride
antimuscurinics for mixed picture of storage and voiding symptoms that persist despite treatment with an alpha blocker alone
oxybutynin
tolterodine
darifenacin
why shouldn’t you offer oxbutynin to older frail men
due to the risk of impairment of daily functioning, chronic confusion, or acute delirium
what is TURP
Uses a wire loop with electrical current flowing in one direction to excise tissue via the resectoscope
done under spinal or Ga
what is TUEVAP
transurthreal electro-vaporization of the prosate
Instead of using an electrical current loop as is done in the TURP procedure, TUEVAP uses a roller ball to heat the prostate so that it is reduced to vapor
what is HoLEP
Holmium laser enucleation of the prostate
what is TUIP
Transurethral incision of the prostate
A less invasive and safer procedure than TURP
A combined visual and surgical instrument (resectoscope) is inserted – then grooves are cut to open the urinary channel
open prostastectomy
Done if the prostate is very large – involves a lower abdominal incision
Is different to a radical prostatectomy because it just removes the obstruction part of the prostate
what sort of cancer is prostate cancer and where does it occur
adenocarcinoma - 95%
cancers of glandular cells
usually develops in the outer zone of the prostate where it seldom causes symptoms
risk factors for prostate cancer
age
black
FHx
obesity
investigations for prostate cancer
DRE - hard and nodular (if this is the case then refer) - although a normal DRE does not exclude prostate cancer
PSA - if >3nanograms/ml then refer for 2 week appointment
once referred, will get a TRUS biopsy (transrectal US guided) - this takes 10-12 cores of prostatic tissue thorugh the rectum
NICE recommends that for men with a negative TRUS biopsy, multiparametric MRI (mpMRI) is considered to determine whether a further biopsy is required (false negative rates can be as high as 45%)
a decision aid to help men decide whether or not to have a PSA test
SWOP - an online decision aid developed by the department of urology in the netherlands
managemnet of prostate cancer
perform risk stratisifcation based on Gleason score, TNM and PSA
low risk - active surveillance or watchful waiting for those with older men, or those with significant comorbidities or those that are likely to die from other causes. or radical prosatectomy or radical radiotherapy (external-beam radiotherapy or brachytherapy)
intermediate risk - radical prostatecomty or radical radiotherapy with 6 months of androgen deprivation therapy (before, during or after radiotherapy) can be offered
other treatments can be considered like watchful waiting, active surveillance, high dose brachytherapy in combination with EBR
high risk - basically same as above
active surveillance vs watchful waiting for prostate cancer
Watchful waiting = followed up in primary care – regular clinical assessments and repeat PSA (not DRE or prostate biopsies)
Active surveillance = same at watchful waiting but repeat prostate biopsy as well (and some other things involved – see NICE guidelines)
Active surveillance is the preferred option for men with low prognostic risk who are suitable for radical treatment in the event of disease progression – good for men who do not wish to have immediate radical prostatectomy or radical radiotherapy
types of androgen deprivation therapy
- Androgen withdrawal — surgery (bilateral orchidectomy) or medical, with LHRH agonists (such as goserelin, leuprorelin, triptorelin), or antagonists (such as degarelix).
- Androgen blockade — with drugs that bind to and block the hormone receptors of cancer cells (for example, cyproterone acetate), thus preventing androgens from stimulating cancer growth
- Hormone therapy can be used as neoadjuvant therapy (before radical treatment), concurrent therapy given at the same time as radiotherapy or adjuvant therapy
