W1 Obstructive Lower Urinary Tract Uropathies Flashcards
Two main symptoms of obstructive uropathies
Urinary hesitancy (rarely helpful)
Urinary urgency (at first compensatory and helpful, until it’s not)
Benign Prostatic Hyperplasia (BPH)
What is it?
WHERE is it?
Benign Prostatic Hyperplasia (BPH) is a histologic dx that refers to the proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic ⭐️transition zone (an increase in the number of prostate cells, not the size of prostate cells themselves).
BPH is ubiquitous in ________
BPH is ubiquitous in the aging male, with worldwide autopsy-proven histological prevalence starting at age 40 to 45 years, reaching 60% at age 60, and 80% at age 80
○ Symptoms however do not affect all patients w/ prostatic enlargement
○ Increase in age (increase in prostate growth) is associated with > clinical symptoms of BPH
BPH — pathogenesis
Testosterone converted to DHT by ______. As men age, this conversion ______. which leads to an increase in the rate of ______. = increase in ______.. Enlargement leads to narrowing of the ______.. More likely to see ______. because there is ______.
Given the progressive pathogenesis process, BPH at first can be ______., in which case it does not require treatment.
Testosterone converted to DHT by 5-alpha reductase. As men age, this conversion increases which leads to an increase in the rate of prostatic cellular development = no.of prostate cells. Enlargement leads to narrowing of the prostatic urethra. More likely to see growth inwards because there is less resistance
Given the progressive pathogenesis process, BPH at first can be asymptomatic, in which case it does not require treatment.
However, BPH may lead to an enlargement of the prostate (benign prostatic enlargement [BPE]) and result in (obstructive) lower urinary tract symptoms (LUTS) due to obstruction at the level of the bladder neck.
Review pathogenesis of BPH
MCC complaint early in the disease state?
BPH — early in the disease state it is usually nighttime urination (nocturia)
BPH signs and symptoms — most common?
And then what happens as the disease progresses?
Nocturia is the most common.
Also
—urgency
—frequency
—hesitancy
—⭐️ incontinence, “dribbling”
—⭐️ incomplete bladder emptying
Initially
—weak stream, hesitancy, dribbling, nocturia
—gets worse over time
late
—overactive bladder develops as compensatory mechanism to overcome the obstruction and empty the bladder, hence urinary incontinence
Age 45-65 and always get worse with time.
Progression of BPH (again)
● Early BPH may present as just urinary frequency, nocturia
● Moderate BPH may present as worsening of the above sx, associated with decreased urinary stream, sensation of incomplete bladder emptying, stranguria
● Advanced BPH may present as worsening of all the above sx, plus severe urinary urgency, incontinence eps (urge and overflow), acute urinary retention eps, new development of
urolithiasis (when pt didn’t previously have this issue), frequent UTIs (2/2 stasis of urine), etc
—________ is palpable on DRE
—Only ________ is palpable through a DRE
—________, ________ are likely to be a/w prostate cancer
—Peripheral zone is palpable on DRE
—Only 1/5th is palpable through a DRE
—firm, fixed nodules are likely to be a/w prostate cancer
BPH — physical exam
—an exquisitely tender prostate gland may reflect the presence of ______
—the presence of ______ raises the suspicion for malignancy
—______ are usually soft and easily mobile and more commonly ______
—an exquisitely tender prostate gland may reflect the presence of prostatitis
—the presence of asymmetry or nodules raises the suspicion for malignancy
—cyst like nodules are usually soft and easily mobile and more commonly BPH
BPH work up and diagnosis
—UA with micro will be ______
—______ is a common hallmark/classic presentation
—______ are usually elevated
Advanced workup
— ______ will give an assessment of prostatic size
Diagnosis is usually made ______
Notable age is ______ but more commonly ______
Can also do a trial of ______ to see if symptoms improve
—UA with micro will be negative
—ALL day symptoms, day and night are common hallmarks
—PVRs are usually elevated
Advanced workup
—transrectal u/s will give an assessment of prostatic size
Diagnosis is usually made clinically
Notable age is >45 but more commonly >50
Can also do a trial of flomax to see if symptoms improve
BPH — treatment
1st line
—______: these block the ______ (remember, SNS relaxes bladder to fill and stores it so you don’t pee) … leads to ______ and improvement in ______
—💊 example alpha blockers: ______ and ______
—side effect = ______
—give at night (HS)
2nd line
—______: prevent the conversion of ______ to ______, thereby decreasing the size of the ______.
—takes ______ to see improvement
—💊example medication: ______
1st line
—alpha blockers: these block the SNS (remember, SNS relaxes bladder to fill and stores it so you don’t pee) … leads to decreased urethral tone and improvement in urine outflow
—💊 example alpha blockers: FLOMAX (TAMSULOSIN)
—side effect = hypotension
—give at night (HS)
2nd line
—5-alpha reductase inhibitors (5-ARIs): prevent the conversion of testosterone to DHT, thereby decreasing the size of the prostate.
—takes ~3-6 months to see improvement
—💊example medication: finasteride
BPH procedural treatment
What is the most favoured procedure?
For which size prostate?
Procedural Interventions
Classic Procedural Interventions:
Photo Vaporization of the Prostate (commonly a laser PVP)
—Typically reserved for patients with small = moderate size prostates (roughly <70 cc)
⭐️Transurethral Resection of the Prostate (aka TURP)
—May be performed at any prostate size, but is the far more favored procedure to relieve bladder outlet obstruction from BPH for larger prostates (meaning prostates roughly >70 cc tend to need TURP as management as other procedures are less efficacious for these larger size)
Radical Prostatectomy
(simple vs open, both uncommon for BPH)
More Novel Intervention Examples:
—Rezum (essentially a steam vaporization of prostate, similar to PVP), Urolyft (pinning back of prostate)
Later - Stage Interventions:
Clean Intermittent Catheterization
—frequency variable, but often recommended at least 2-4x / day
Chronic Indwelling Foley (urethral, suprapubic catheter)
—typically exchanged q 1-3 months, closer to q 1 mo leads to less UTIs (but more bothersome, $)
Either of the above may also be considered earlier on depending on the pt circumstances (think pt’s who cannot
tolerate or who do not want to undergo aggressive procedures / surgeries)
What are 3 examples of non BPH bladder outlet obstructions (BOO) that impact ability of bladder to empty?
- ⭐️Extrinsic:
—pelvic organ prolapse
—uterine fibroid or tumour
—post anti-incontinence procedure - ⭐️ Urethral
—stricture
—meatal stenosis
—urethral caruncle
—diverticulum
—skene’s gland cyst - ⭐️ Luminal
—stone
—bladder/urethral tumour
—uretercoele
—foreign body
What should be on your differential if a pt presents w/ mixed symptoms of storage and non-storage symptoms ?
What would be the treatment?
Pelvic floor dysfunction (gain of tone)
Pelvic floor PT with the goal to help relax pelvic floor muscles
Urethral stricture disease
Development of ______ within or around the urethral mucosa that results in ______ or ______ of the urethral lumen
⭐️Definitive tests
—______
—______
Common Etiologies Include:
—______
—______
Development of scar tissue within or around the urethral mucosa that results in subsequent narrowing or obstruction of the urethral lumen
⭐️Definitive tests
—cysto
—retrograde urethrogram (RUG)
Common Etiologies Include:
—Urethral Trauma: Extrinsic from pelvic or penile trauma, intraluminal from frequent cystoscopies, frequent / traumatic foley placements (these are good iatrogenic examples), urethral injury f/ stones
—Chronic Urethral Inflammation: Chronic or recurrent STIs or UTIs (resulting in chronic inflammation), history of pelvic / GU radiation (treatments for malignancies)
Urethral stricture disease
Treatment
—1st line is endoscopic/urethral stricture dilation done either by intermittent catheterization, guidewire f/b foley or other semi-rigid dilator, or urethral sounds (wider more rigid dilators introduced through the urethra, more aggressive approach)
Surgical Approaches:
—Urethral stricture resection f/b urethral re-anastomosis
—Urethral Reconstructive Surgery / Urethroplasty (occasionally requires grafts from other mucosal tissue)
URETERal stricture disease
What is it?
2 common etiologies
Diagnostic study of choice
Ureteral Stricture (definition): Development of scar tissue within or around the ureteral mucosa that results in subsequent narrowing or obstruction of the ureteral lumen
Common Etiologies Include (similar to urethral stricture):
● Ureteral Trauma: Extrinsic from abdominal trauma, extrinsic iatrogenic ureteral injuries related to other surgical procedures (the intra-op “nicked ureter”, intraluminal from frequent stones, frequent ureteroscopies
● Chronic Ureteral Inflammation: Chronic or recurrent UTIs (chronic inflammation), history of pelvic / GU radiation (tx for malignancies) ● Scarring down of ureteral tissue → development of ureteral stricture
Diagnostic study:
—ureteroscopy, CT A/P w/ contrast, MRI
⭐️retrograde pyelogram / ureterogram ⭐️
URETERAL stricture disease
Treatments
Ureteral dilation and stenting via ureteroscopy:
—Often more successful in strictures of shorter length
—Often requires leaving a stent in place for period of time (several weeks to 2-3 months) after dilation
Partial Ureterectomy vs Ureteroplasty:
—can be more invasive procedure as it is often a formal intra abdominal approach
—Also requires stent post-op
Percutaneous Nephrostomy Tubes (PCN):
—Help relieve upper urinary tract obstruction (less aggressive treatment option but not a definitive tx of the stricture)
Urolithiasis intro
Which size can usually pass?
Nephrolithiasis:
—urolithiasis present in the kidney (often situated in the renal pelvis)
Cystolithiasis:
—urolithiasis present in the bladder
Small stones (~ <5 mm) sometimes can pass f/ the bladder, through the bladder neck, & out the urethra
Larger stones however may become lodged within the bladder neck or urethral when attempting to pass to the outside world, and can create an acute obstruction of the bladder outlet
FYI: some stones (> 0.5 - 1 cm) can even become obstructed in the upper tracts (this is your classic obstructive kidney stone picture that you think of w/ severe flank pain / renal colic)
Final Notes on Obstructive LUT Uropathies 1/2
Read and make sure you know all of this
Final Notes on Obstructive LUT Uropathies 2/2
Read and make sure you know all of this
When in doubt about symptoms, start with a gentle ______ like ______
If the patient has BPH and hypotension, try ______
What is the classic surgical intervention for BPH? ______
When in doubt about symptoms, start with a gentle alpha blocker like flomax
If the patient has BPH and hypotension, try silodosin
What is the classic surgical intervention for BPH? TURP
