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Systems - Urinary > Benign Disease of The Prostate and Urinary Tract Obstruction > Flashcards

Benign Disease of The Prostate and Urinary Tract Obstruction Flashcards

1
Q

How big is an unenlarged prostate?

A

20 cc

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2
Q

What are the different parts of the prostate?

A
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3
Q

What are does benign prostatic hyperplasia affect?

A

Predominantly affects the transition zone

Characterised by fibromuscular and glandular hyperplasia

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4
Q

Who does benign prostatic hyperplasia affect?

A

•Part of aging process in men :

  • 50% of men at 60 years
  • 90% of men at 85 years
  • 50% of men with BPH have moderate to severe LUTS
  • Progressive condition resulting Bladder Outflow Obstruction (BOO)
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5
Q

What is the prostate symptom score sheet based on?

A

Incomplete emptying

Frequency

Intermittency

Urgency

Weak Stream

Straining

Nocturia

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6
Q

What are the voiding (obstructuve LUTs)?

A
  • Hesitancy
  • Poor stream
  • Terminal dribbling
  • Incomplete emptying
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7
Q

What are the storage (irritative) LUTs?

A

Frequency

Nocturia

Urgency +/- urge incontinence

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8
Q

What physical examinations are possible for BPH?

A

Abdomen - palpable bladder

Penis - External urethral meatal stricture, phimosis

Digital rectal examination - assessment of the prostate size, suspicious nodules or firmness

Urinalysis - blood, signs of UTI

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9
Q

What are the relevant investigations for Benign Prostate Hypertrophy?

A

•MSSU

  • Flow rate study
  • Post-void bladder residual USS
  • Bloods :

–PSA

–urea and creatinine (if chronic retention)

  • Renal tract USS if renal failure or bladder stone suspected
  • Flexible cystoscopy if haematuria
  • Urodynamic studies in selected cases
  • TRUS-guided prostate biopsy if PSA raised or abnormal DRE
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10
Q

What are the two categories of BPO?

A

Uncomplicated

Complicated

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11
Q

What is the treatment of uncomlpicated BPO?

A

•Watchful waiting

•Medical therapy

– Alpha blockers

–5 alpha reductase inhibitors (Finasteride or Dutasteride)

–Combination

•Surgical intervention

–TURP (prostate size <100cc) (transurethral resection of the prostate)

–Open retropubic or transvesical prostatectomy (prostate size >100cc)

–Endoscopic ablative procedures

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12
Q

What is the function of alpha blockers?

A

•Alpha blockers cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

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13
Q

Here are some types of alpha blockers

A

non-selective (i.e. alpha 1 and 2) : phenoxybenzamine

  • selective short acting : prazosin, indoramin
  • selective long acting : alfuzosin, doxazosin, terazosin
  • highly selective (i.e. alpha-1a) : tamsulosin

•All a-blockers appear to be equally effective but differences in side effect profiles and pharmacodynamic properties

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14
Q

What is the function of 5a reductase inhibitors?

A

Converts testosterone to dihydrotestosterone

•Role of 5ARIs :

  • reduces prostate size and reduces risks of progression of BPE

(but only if >25cc prostate)

  • also reduces LUTS (but not as effective as alpha blockers)
  • combination therapy of 5ARIs + alpha blockers most effective

in reducing risk of progression of BPE

  • can also reduce prostatic vascularity and hence reduces

haematuria due to prostatic bleeding

  • potential role in prostate cancer prevention
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15
Q

What is the gold standard for surgical intervention of BPH?

A

TURP

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16
Q

What are complications of TURP?

A

bleeding, infection, retrograde ejaculation, stress urinary

incontinence, prostatic regrowth causing recurrent haematuria

or BOO

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17
Q

What are the complications of BPO?

A

Progression of LUTS

Acute urinary retention

Chronic urinary retention

Urinary incontinence (overflow)

UTI

Bladder stone

Renal Failure from ibstructed ureteric outflow due to high bladder pressure

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18
Q

What is the treatment of complicated BPO?

A

Most require surgery - cystolitholapaxy and TURP for patients with BPO and bladder stones

If unfit for surgery:

  • urethral / suprapubic cathaterisation
  • CISC (Clean intermittent self-cathaterisation)
19
Q

What are the complications of cathaterisation?

A

Catheter trauma, blockages, frank haematuria or recurrent UTI

20
Q

What is acute urinary retention?

A

Painful inability to void with a palpable and percussible bladder

21
Q

What are the causes of acute urinary retention?

A

BPO (main risk factor)

UTI, urethral stricture, alcohol excess, post - operative causes

22
Q

What is immediate treatment of acute urinary retention?

A
  • Immediate treatment is catheterisation (either urethral or suprapubic)
  • If no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)
23
Q

What are complications of acute urinary retention?

A

UTI

Post decompression haematuria

Pathological diuresis

Renal failure

Electrolyte abnormalities

24
Q

What is chronic urinary retention defined as?

A

Painless, palpable and percussable bladder after voiding

25
Q

What is the main aetiological factor for chronic urinary retention?

A

•Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

26
Q

What does chronic urinary retention present with?

A

LUTS

Complications (e.g. UTI, bladder stones, overflow incontinence, post - renal or obstructive renal failure) or incidental finding

27
Q

What are complications of chronic urinary retention?

A

UTI

Post decompression haematuria

Pathological diuresis

Electrolyte abnormalities

Renal dysfunction - as a result of acute tubular necrosis

28
Q

What are the electrolyte abnormalities seen in chronic urinary retention?

A

Hyponatraemia

Hyperkalaemia

Metabolic acidosis

29
Q

What are the features of pathological diuresis?

A

•Pathological diuresis features : urine output >200ml/hr + postural hypotension (systolic differential >20mm Hg between lying and standing) + weight loss + electrolyte abnormalities

30
Q

What is the longer term treatment for chronic urinary retention?

A

•Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP

31
Q

What are the types of urinery tract obstruction?

A

•Upper tract (i.e. supra-vesical)

  • PUJ
  • ureter
  • VUJ

•Lower tract (i.e. bladder outflow obstruction)

  • bladder neck
  • prostate
  • urethra
  • urethral meatus
  • foreskin (e.g. phimosis)
32
Q

What are the intrinsic causes of upper tract obstruction?

A

PUJ, ureter and VUJ:

Stone

Ureteric tumour

PUJ and ureter: blood clot and fungal ball

33
Q

What are the extrinsic causes of upper tract obstruction?

A

PUJ - PUJ obstruction by crossing vessel, lymph nodes, abdominal mass

Ureter - Lymph nodes, abdominal / pelvic mass, iatrogenic

VUJ - cervical tumour, prostate cancer

34
Q

What is the presentation of upper tract obstruction?

A

Symptoms: Pain, frank haematuria, symptoms of complications

Signs: Palpable mass, microscopic haemauria, signs of complications

35
Q

What are the complications of upper tract obstruction?

A

Infection and sepsis

Renal failure

36
Q

What is management of upper urinary tract obstruction?

A

•Resuscitation

- ABCs

  • IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
  • IV fluids, broad-spectrum antibiotics (if appropriate)
  • Analgesia
  • HDU care +/- renal replacement therapy (if appropriate)
  • Investigations (including imaging)
  • Emergency treatment of obstruction (for unremitting pain or complications)
  • Percutaneous nephrostomy insertion OR
  • Retrograde stent insertion

•Definitive treatment of obstruction

  • Treat underlying cause
  • e.g. stone – ureteroscopy and laser lithotripsy +/- basketing or ESWL - Extracorpeal shockwave lithotripsy
  • e.g. ureteric tumour – radical nephro-ureterectomy
  • e.g. PUJ obstruction – laparoscopic pyeloplasty

pyeloplasty - Pyeloplasty is the surgical reconstruction or revision of the renal pelvis to drain and decompress the kidney

37
Q

Define nephrostomy

A

Urinary diversion from the kidney to the skin

38
Q

How is nephrostomy carried out?

A
  • Usually under LA + sedation
  • US or xray guidance
39
Q

What is the presentation of lower tract obstruction?

A

•Lower urinary tract symptoms

  • including urinary incontinence
  • Acute urinary retention
  • Chronic urinary retention
  • Recurrent urinary tract infection and sepsis
  • Frank haematuria
  • Formation of bladder stones
  • Renal failure
40
Q

What is the difference between acute and chronic urinary retention in patient presentation?

A

Acute - Can’t pee, in agony, creatinine - 70

Chronic - Peeing fine, pain free, creatinine - 170

41
Q

What is the management for lower tract obstruction?

A

•Resuscitation

  • ABCs
  • IV access, bloods, ABG, urine and blood cultures, fluid balance monitoring
  • IV fluids, broad-spectrum antibiotics (if appropriate)
  • Analgesia
  • HDU care +/- renal replacement therapy (if appropriate)
  • Investigations (including imaging: Bladder scan, USS renal tract)
  • Emergency treatment of obstruction (for unremitting pain or complications)
  • Urethral catheterisation OR
  • Suprapubic catheterisation

•Definitive treatment of obstruction

  • Treat underlying cause
  • e.g. BPE – TURP
  • e.g. Urethral stricture – Optical urethrotomy
  • e.g. Meatal stenosis – Meatal dilatation
  • e.g. Phimosis – Circumcision
42
Q

What is decompression haematuria?

A

Shearing of small vessels due to differing compliance of tissue layers

Usually self - liiting

43
Q

What is post obstructive diuresis

A

Postobstructive diuresis. Postobstructive diuresis is a polyuric state in which copious amounts of salt and water are eliminated after the relief of a urinary tractobstruction. In most patients, the diuresis will resolve once the kidneys normalize the volume and solute status and homeostasis is achieved.

Systems - Urinary (28 decks)

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