Week 4- Bladder Obstruction Flashcards
What is the innervation of the kidneys, ureters, bladder and urethra?
Kidney:
- T10-L1 (SNS)
- vagus (PNS)
- Only SNS feels pain?
Ureter
- T11-L2 (SNS)
- S2,3,4 (PNS)
- Both can feel pain
Bladder
- Same as ureter, BUT PNS has the pain fibers
Urethra
- L1,2 (SNS)
- S2,3,4 (PNS)
Trace the path of a sympathetic neuron going to the bladder. What does it innervate?
Pre-ganglionic neuron comes out of the spinal cord at T11-L2, goes through the white rami communicans an to a pre-aortic ganglion. Then intermesenteric plexus, then superrior hypogastric plexus, which bifurcates. And then goes to innervate the:
- detrusor (B-adrenergic= relax)
- internal sphincter (alpha-adrenergic= contract)
- seminal vesicles (ejaculate)
Trace the path of a parasympathetic neurons going to the bladder. What does it innervate?
Preganglionic comes out of S2,3,4, synapses in the hypogastric plexus. Innervates:
- detrusor (msucarinic ACh= contract)
- internal spincter (=relax)
- penis (erection)
Trace the path of a sympathetic nerve going to the kidney
The pre-ganglionic nerve comes out of T10-L1, goes through the white ramus communicans, then synapses in the renal ganglion and continues on to the kidney.
Trace the path of a parasympathetic nerve going to the kidney
The vagus nerve (cranial nerve X) goes there….
What is LUTS?
Lower Urinary Tract Symptoms. A constellation of symptoms from either obstructive or irritative voiding disturbances.
- Urinary frequency
- Nocturia
- Urgency, with or without incontinence
- Hesitancy in initiating the stream
- Weak stream
- Dysuria
- Sense of incomplete bladder emptying
- Post void or terminal dribbling
What the the differential for LUTS?
Huge!
What to ask your patient with LUTS?
What are irritative vs. obstructive voiding dysfunction symptoms?
Are dysuria, microhematuria and incontinence normally seen in BPH?
Not in uncomplicated cases
What is IPSS?
International prostate symptom score
What would you always do with a man with prostate enlargement? What would you sometimes do?
Always:
- IPSS
- Urinanalysis
Sometimes:
- PSA
- Serum creatinine (if suspected hydronephrosis)
- cytology (if predominantly irritative symptoms)
- urodynamic studies (e.g. post-void residual volume)
What are BOO, BPE and BPH?
BOO: bladder outlet obstruction (a clinical term)
BPE: benign prostate enlargement (a clinical term)
BPH: benign prostate hyperplasia (a histological diagnosis)
Does BPH progress? What are predictors of progression?
Yes- in some patients- the prostate continues to enlarge. Age, prostate volume and PSA levels are all negative. Symptoms can worsen, or acute urine retention
What is the treatment algorithm for BPH? (see other slides for the rationale of each treatment)
What are lifestyle measures for treating BPH?
“sleep apnea” means treating sleep apnea because it can cause nocturia.
Are the alpha-adrenergic blockers used for BPH selective or non-selective for urinary tissue? What are side-effects
They are selective. Older drugs were not selective.
Tamulosin (Flowmax) can produce retrograde ejaculation (not a problem except for fertility), but not erectile dysfunction
Is viagra (PDE5i’s) safe with non-selective alpha blockers? Selective alpha blockers?
Can result in hypotension with non-selective , but is safe with selective alpha blockers
How is cell growth promoted in the prostate? (e.g. what hormone, and how is this targeted)
Testosterone: converted to its more powerful self, DHT intracellularly by either Type 1 or Type 2 5-alpha-reductase. Type 2 is found only in the prostae, type 1 is found in the skin, liver, bladder.
Can block Type 2 (finasteride)
What are the important side effects of type 2 5-alpha reductase inhibitors?
What is the great thing about them?
Sexual side effects (ED….)
They reduce the risk of prostate cancer by 25%
How to treat: low IPSS, large prostate and PSA?
With a 5ARi alone. Don’t need in combination with an alpha-blocker because the alpha-blocker deals mostly with the symptoms
How to treat: low IPSS, small prostate and low PSA.
No treatment.
How to treat: high IPSS, bother, small prostate, low PSA
An alpha blocker to treat symptoms. They won’t benefit from shrinking the prostate
How to treat: high IPSS, bother, large prostate, high PSA level
WIth combination therapy. 5ARi shrinks the prostate, and the 5 alpha blocker helps with symptoms
What are absolute indications for prostate surgery in someone with BPH?
Urinary retention
Renal failure
What is the main surgery performed for BPH?
TURP (TUPR)
Scrapes away the transition zone of the prostate
If you’ve had one TURP, will you need another?
Maybe. About 10% do within 10 years.
What are the chronic complications of BPH?
- Decreased QoL
- worsening of LUTS
- acute urinary retention
- recurrent UTI
- stones
- renal failure
Why do men with BPH have voiding symptoms?
Men with BPH have a bladder outflow obstruction. This leads to obstructive symptoms (hesitancy, dribbling/reduced caliber) and bladder hypertrophy. Bladder hypertrophy leads to irritability of the detrusor and this leads to irritative bladder symptoms (urgency, frequency, nocturia
Why isn’t PSA used as a universal screening tool for prostate cancer? What are the limitations of PSA measurements?
- It has a high sensitivity but a low specificity
- results in overdiagnosis and treatment
- many prostate cancers progress slowly
It is used in those with high risk of prostate cancer (including age) and who do not have significant comorbidities and who have a life expectancy >10 yrs
limitations: there are reasons besides cancer that the PSA could be elevated.
What are the parts of the bladder (x2) and the outlet (x2)
Bladder=detrusor + trigone
Outlet= bladder neck + urethra
What feature of the bladder allows for urine storage? What nerves/receptors meadiate this?
A relaxed detrusor has a high compliance, allowing the bladder to store urine at low pressure.
Bladder relaxation: sympathetic B3 receptor, direct CNS inhibition of detrusor motor neurons.
Outlet contraction: sympathetic alpha receptor
What is the voiding reflex?
Distention of the bladder –> activation of PNS afferents –> sacral spinal –> activation of PNS efferents (muscarinic) contracts detrusor, inhibits sympathetic (detrusor and internal sphincter) and pudendal (external spincter)
How is the bladder outlet controlled when we want to store urine?
- SNS (alpha) contracts internal sphinter
- Pressure from urine building up causes pudendal nerve to clamp the external sphincter down and create a mucosal seal
Where does the CNS control of voiding come from?
The pontine micturition centre (PMC)…receives input from the cortex
What is the basic classification of urinary incontinence?
Failure to store OR failure to empty caused by
A problem with the bladder OR a problem with the outlet
Briefly define types of urinary incontinence:
- stress incontinence
- urge incontinence
- overflow (incomplete emptying)
- total
- functional
Stress UI: leakage when laughing, coughing, change in position etc.. seen in young women
Urge: incontinence preceded by urgency. detrusor overacitivty
Overflow: incomplete emptying (bladder outlet obstruction until proven otherwise)
Total: leaking all the time. fistula between bladder and something
Functional: inability to get to a toilet (usually mobility issues)
Causes of transient reversible urinary incontinence
DIAPERS
Delirium
Infection
Atrophic vaginitis/urethritis
Pharmacologic
Excess urine output
Restricted mobility
Stool impaction
What are the indications for anticholinergics in the treatment of urinary incontinence? S/E?
Overactive bladder/urge incontinence. Anticholinergics would reduce PNS mediated detrusor muscle spasm.
Oxybutinin (Ditropan) is the only one covered in BC
Side effects:
- dry mouth
- dry eyes
- blurred vision
- constipation
- flushing
- confusion
What are the risk factors for prostate cancer?
Age
FHx (especially a 1st degree relative)
African- American
Previous abnormal biopsy
When does prostate cancer cause symptoms?
When it is advanced or metastatic
When is PSA elevated?
- prostate cancer
- increased size of prostate (BPH)
- post-instrumentation
- following DRE
- inflammation (prostatitis)
What is the differential of a prostatic nodule?
What are the limitations in using DRE for the detection of prostate cancer?
~15% of cancers do not arise peripherally (where they can be palpated)
there are otehr causes for nodules besides cancer
…best used in combination with PSA
What is the diagnostic approach to prostate cancer?
DRE, PSA (abnormally high, or rising quickly) –> transrectal US biopsy
After diagnosis, how is prostate cancer graded and staged and how is risk of progression assesed?
Grading:
- Because prostate cancer is heterogeneous, you give the 2 most common groups of cancerous cells a grade out of 5 each, and then you combine the grades into the Gleason Score
Staging:
- TNM
Risk of Progression is based on tumour grade, stage, PSA and determines future treatment
Is prostate cancer unifocal/multifocal and homegenous/heterogeneous?
It is almost always multifocal and heterogenous (can have several different tumours). This is why the entire prostate is removed.
What are treatment options for localized prostate cancer?
Radical prostatectomy
- retropubic
- perineal
- laproscopic, robotic
Radiation
- external beam
- brachytherapy
Active surveillance
- only appropriate for low risk, compliant, low-anxiety patients.
- periodic DRE, PSA and biopsies
What are the big complications of surgical treatment of prostate cancer?
- bleeding (the prostate is highly vascular)
- erectile dysfunction, no ejaculation (orgasm and genital sensation should not be affected)
- urinary incontinence (10%, stress incontinence)
What are the big complications of radiation therapy for prostate cancer?
- damage to pelvic nerves leading to ED
- incontinence
- late secondary malignancies
What are the treatment options for locally advanced or metastatic prostate cancer?
Standard care is hormone therapy.
If refractory to hormone therpay, can use chemo (docetaxel)
What is the endocrine axis for testorone?
lack of androgen receptor stimulation in HT–> LHRH (GnRH) secretion from HT–> stimulation of pituitary to release LH–>LH binds in testes, causes testosterone production–> testosterone binds androgen receptor in HT and turns off LHRH
How could DM cause overflow incontinence?
Damage to peripheral nerve endings
