wk 13 key Flashcards
when to refer to urological for LUTS
- Failure of LUTS to respond to medical treatment
- Renal insufficiency
- Acute or chronic urinary retention
- Evidence of bladder stone
- Evidence of hydronephrosis
- Suspicious digital rectal examination
- Hematuria
- Abnormal PSA level
- Pain with urination
- Recurrent UTI
- Palpable bladder on physical examination
- LUTS with a known neurological disease
benign prostatic hyperplasia (BPH)
benign prostatic hypertrophy
benign prostatic enlargement (BPE)
bengin prostatic obstruction (BPO)
- Benign prostatic hyperplasia (BPH) – increase in total of
number of cells within the prostate transition zone - Benign prostatic hypertrophy – increase in size of individual
prostatic cells - Both lead to benign prostatic enlargement (BPE)
- Benign prostatic obstruction (BPO) results from BPE
obstructing the bladder neck (in the absence of prostate cancer)
American Urological Association (AUA)
Symptom Index aka International Prostate
Symptom Score (IPSS)
looks at the LUTS sx
- Score 0-7 = mild symptoms
- Score 8-19 = moderate symptoms
- Score 20-35 = severe symptoms
- Symptom score ≥ 8 suggests BPH treatment should be
initiated/increased/modified to provide additional relief - Severe symptom score may require surgical intervention
complications of BPH
urinary retention
UTI
bladder claculi
elevated PSA
hematuria
hydronephrosis, AKI
BPH treat
behavioural; kegels etc
meds: alpha blockers, 5 alpha reductase inhibitors
surgery: transurethral resection of the prostate (TURP)
prostate cancer (DDX from BPH)
posterior lobe of prostate gland
DRE: hard irregular nodule or diffuse dense induration
histology: Gleason grade
increased total PSA with decreased fraction of free PSA
late stage: metastasize to osteoblast; low back pain
acute bacterial prostatitis
chronic prostatitis
ABP:
- old men: same organism as UTI i.e. e coli, klebseilla, proteus
-young men: chlamydia and gonrorrheae
-systemic signs; fever, chills, malaise
chronic: bacterial or non bacterial (nerve, chemical)
- no systemic signs
bilateral urinary tract obstruction causes
AKI
test for urianry tract obstruction
best: renal ultrasound
non contrast CT
postvoid residual volume
urge incontinence
Involuntary detrusor contractions before bladder is full → sensation
of urgently need to void → contractions exceed bladder outlet
resistance → involuntary leakage of urine
caused by overactive bladder, BPH, bladder or urethral irritation (i.e. UTI, cystitis)
detrusor disinhibition/ neurogenic detrusor overactivity
Involuntary leakage of urine caused by spontaneous triggering
of spinal reflex voiding mechanism when bladder reaches a
threshold volume and there is inadequate inhibition of bladder
contractions by the central nervous system
stress incontiennce
Involuntary leakage of urine caused by increase in intra-
abdominal pressure (as produced by a cough, sneeze,
laughing, standing up or heavy lifting)
caused by: weak pelvic floor, incompetent sphincter
overflow incontinence
Urinary retention → pressure in bladder exceeds
outlet/sphincter resistance → involuntary leakage of urine until
bladder pressure drops below outlet resistance
from: bladder outlet obsutrcion, ineffective detrusor contractions, diabetic neuropathy, spinal stenosis..
Detrusor Hyperactivity with Impaired
Contractility (DHIC)
- Subtype of overflow incontinence found mainly in elderly
- Detrusor contractions are ineffective despite an overactive
bladder → bladder distention → pressure in bladder exceeds
outlet/sphincter resistance → involuntary leakage of urine until
bladder pressure drops below outlet resistance
detrusor-sphincter dyssnergy
- Subtype of overflow incontinence
- Multiple sclerosis or other conditions causing suprasacral spinal
cord lesions → failure to synchronize bladder contractions with
release of sphincter → urinary retention → pressure in bladder
exceeds outlet/sphincter resistance → involuntary leakage of
urine until bladder pressure drops below outlet resistance
functional incontience
Incontinence despite a normally functioning bladder due to
inability to reach a toilet in time
i.e. immobile, eccessive sedation, psychological disorder, diuretics
key incontience Qs on slide 44-48
When does it occur? (Are there associated activities, movements, or
circumstances related to the urinary accidents?)
* Are there warning signs? (Is the UI instantaneous, or is it preceded by an
urge to void? If there is urgency, how long between the first urge and the
involuntary loss of urine?)
* How long has it been occurring, and has it been getting worse?
* What is the frequency, severity, and diurnal pattern of UI? Severity can be
measured indirectly by having the patient estimate the number of pads,
incontinence briefs, or other protective devices used per day
* For patients with a prior history of incontinence:
* Note changes in the frequency, severity, and diurnal pattern
* Note previous treatments for UI, their effectiveness, and side effects
Overactive Bladder Symptom Score
(OABSS)
4 sx:
* Daytime frequency
* Nighttime frequency
* Urgency
* Urge incontinence
tx for urge and stress incontiennce
- For urge incontinence and stress incontinence:
- Bladder retraining exercises
- Topical estrogens may improve mild UI
- Anticholinergic medications for urge incontinence
tx for pelvic floor dysfunction or sphincter incompetence
Surgical interventions and artificial sphincters for severe UI
A 65-year-old man presents with a history of difficulty in urination, nocturnal enuresis, and a recent episode of acute urinary retention. His medical history is significant for diagnosed BPH. A physical examination reveals an enlarged, non-tender prostate.
Which one of the following complications is most likely responsible for his current renal function deterioration?
Question 1 Answer
a.
Urinary tract infection due to incomplete bladder emptying
b.
Bladder calculi resulting from stagnant urine
c.
High-pressure chronic retention leading to hydronephrosis
d.
Haematuria due to increased vascularity of the prostate
c.
High-pressure chronic retention leading to hydronephrosis
A 64-year-old man is consults his naturopathic doctor about worsening lower urinary tract symptoms (LUTS). His current medications include diphenhydramine (an antihistamine) for seasonal allergies, sildenafil (a PDE5 inhibitor) for erectile dysfunction, a multivitamin, and saw palmetto (Serenoa repens) for his lower urinary tract symptoms.
Which of these medications is most likely to be contributing to his worsening LUTS?
Question 2 Answer
a.
Saw palmetto
b.
The multivitamin
c.
Diphenhydramine
d.
Sildenafil
c.
Diphenhydramine
A 66-year-old man with peripheral neuropathy due to poorly-controlled diabetes presents with a 1-year history increasing urinary frequency, nocturia, and a sensation of incomplete bladder emptying. He reports no history of urinary tract infections or hematuria. On digital rectal examination, his prostate is found to be enlarged and smooth. His International Prostate Symptom Score (IPSS) is 18.
Based on the provided information, which of the following is the most appropriate next step in the evaluation of this patient?
Question 3 Answer
a.
Performing a targeted neurological examination including assessment of sphincter tone and lower extremity reflexes
b.
Arranging a frequency volume chart (FVC) for a more detailed evaluation of his voiding pattern
c.
Arranging referral for prostate biopsy to rule out prostate cancer
d.
Arranging initiation of alpha-blocker therapy for symptom relief
a.
Performing a targeted neurological examination including assessment of sphincter tone and lower extremity reflexes
A patient diagnosed with BPH who has been experiencing some weak stream and straining inquires about the prognosis for his LUTS. His IPSS is 3 and he scores the question “If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?” as 2 (“mostly satisfied”).
What education is most appropriate for this patient regarding prognosis?
Question 4 Answer
a.
Several complications are likely to result if this remains untreated, including recurrent urinary tract infection, bladder stones, overflow incontinence, gross hematuria, hydronephrosis, and renal disease
b.
There is a high chance that he will develop urinary retention or require surgical intervention in the future
c.
He is unlikely to develop serious health problems due to BPH; it is appropriate to monitor his symptoms at the next visit
d.
Over two-thirds of cases of BPH develop acute urinary retention, and 15% of those who experience acute urinary retention experience another episode in the future
c.
He is unlikely to develop serious health problems due to BPH; it is appropriate to monitor his symptoms at the next visit
A 74-year-old male patient has lower urinary tract symptoms (LUTS) and his naturopathic doctor is considering the value of ordering a PSA test.
Which of the following is the best justification for ordering PSA in this context?
Question 5 Answer
a.
The lower the PSA value, the greater the risk of clinical progression of LUTS
b.
In patients with LUTS, PSA can be useful in detecting prostate cancer as a cause
c.
Routine PSA testing is recommended for patients this age in any case
d.
PSA will help to determine whether his LUTS are due to 5-alpha-reductase inhibitors because these drugs increase serum PSA levels
b.
In patients with LUTS, PSA can be useful in detecting prostate cancer as a cause
