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Flashcards in BLADDER OUTFLOW OBSTRUCTION Deck (41)
1

What percentage of men in their fifties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?

30%

2

What percentage of men in their eighties have moderate to severe lower urinary tract symptoms consistent with bladder outflow obstruction?

50%

3

What's the difference between BPE, BPH and BOO?

BPE - Benign Prostatic Enlargement - this is a clinical finding of which BPH is a leading cause

BPH - Benign Prostatic Hyperplasia - this is a histological diagnosis characterised by an increase in the number of cells

BOO - Bladder Outflow Obstruction - This is a clinical finding which does not take cause into account

4

How do we divide up the male lower urinary tract symptoms (LUTS)?

Storage symptoms

Voiding symptoms

5

What are the male lower urinary tract symptoms (LUTS) associated with storage problems?

Frequency

Nocturia

Urgency

Urgency incontinence

6

What are the male lower urinary tract symptoms (LUTS) associated with voiding problems?

Weak urinary stream

Prolonged voiding

Abdominal straining

Hesitancy

Intermittency

Incomplete bladder emptying

Terminal and post-void dribbling

7

What is the different diagnosis for male lower urinary tract symptoms (LUTS)?

BPH

Bladder cancer

Prostate cancer

UTI

Overactive bladder syndrome (OAB)

Urethral strictures

Neurological disease

8

What investigations would you do in a man who presents with LUTS?

Validated symptom score such as International Prostate Symptom Score (IPSS) - used to assess response to treatment

Urine analysis - blood, infection or diabetes

PSA when appropriate

Urodynamic studies

Detrusor pressure

9

Why do we perform a DRE (digital rectal examination) of men with LUTS?

To make a rough estimate of prostate size

To detect locally invasive prostate cancer

10

What is the normal upper limit of PSA for someone in their 40s above which we would worry about prostate cancer? 50s? 60s? 70s?

40s: Less than 2.5

50s: Less than 3.5

60s: Less than 4.5

70s: Less than 6.5

11

In a urodynamic study, what is the normal maximum flow rate?

About 25 ml per second

12

In a urodynamic study, what would be considered a significantly reduced flow rate?

Less 10 ml per second

13

How do we measure detrusor pressure in patients with LUTS? Why is this useful?

Measure intravesical pressure and rectal pressure

Detrusor pressure then calculated by subtracting rectal pressure from intravesical pressure.

Helps to distinguish between high-pressure low-flow obstructed systems, detrusor dysfunction or atonic bladder as the cause of LUTS

14

What are the indications for urological referral and intervention in someone presenting with LUTS?

Acute urinary retention

Obstructive nephropathy

Large post-void residual volume causing UTIs

Bladder stones

Failure of medical treatment to help with LUTS

15

What are the four categories of management options available for treatment of bladder outflow obstruction?

Conservative

Medical

Surgical

Catheter

16

What are the details of conservative management of bladder outflow obstruction?

Advice on fluid intake

Reduction in caffeine and alcohol ingestion

Bladder retraining

Continence products

17

What are the first line medical management options for bladder outflow obstruction?

Alpha blockers

5-alpha reductase inhibitors

18

What are the two physiological elements involvement in bladder outflow obstruction due to BPE?

Static element - mechanical obstruction due to enlargement

Dynamic element - increased tone of prostate smooth muscle

19

How do alpha blockers work to reduce LUTS caused by BPE?

Relax prostatic smooth muscle

20

Name 5 alpha blockers used in the treatment of bladder outflow obstruction.

Terazosin

Doxazosin

Tamsulosin

Alfuzosin

Silodosin

21

What are the side effects of alpha blockers used in the treatment of bladder outflow obstruction?

Postural hypotension

Lethargy

Gastrointestinal disturbance

Nasal congestion

Ejaculatory dysfunction

22

How do 5-alpha reductase inhibitors work to reduce LUTS caused by BPE?

Reduce size by inhibiting conversion of testosterone into its active metabolite dihydrotestosterone.

23

What is the minimum prostate size and PSA level beyond which 5-alpha reductase inhibitors are recommended as first line treatment for BPE even without moderate symptoms?

30 cc (about the size of a ping pong ball)

PSA more than 1.4 ng/ml

24

Name 2 5-alpha reductase inhibitors used in the treatment of bladder outflow obstruction.

Finasteride

Dutasteride

25

In which patients do we recommend combination therapy of an alpha blocker and a 5-alpha reductase inhibitor?

Severe symptoms

Risk factors for progression

26

What are the risk factors for progressive BPH?

Age over 70 with LUTS

Moderate to severe symptoms ie IPSS of more than 7

PSA or more than 1.4 ng/ml

Prostate volume over 30 cc

Maximum flow rate of less than 12 ml/second

27

What is the most popular and widely available herbal medication used in the treatment of symptomatic BPH?

Saw Palmetto, extracted from berries of the American dwarf palm

28

In which patients with LUTS would we use anticholinergics as opposed to alpha blockers or 5-alpha reductase inhibitors?

Those with overactive bladder syndrome

29

What are the surgical management options for bladder outflow obstruction?

Transurethral resection of the prostate (TURP)

Laser surgery

30

What percentage of men will receive good symptomatic relief from transurethral resection of the prostate (TURP)?

90% - gold standard

31

How is transurethral resection of the prostate (TURP) performed?

Electrocautery through endoscopic instruments introduced via the urethra. Tissue is resected in small chips until obstruction is removed.

32

After transurethral resection of the prostate (TURP), how long must patients be catheterised for?

2-3 days

33

What are the complications of transurethral resection of the prostate (TURP)?

UTI 2%

Blood transfusion 6%

Retrograde ejaculation 70%

TUR syndrome 2%

Impotence 8%

Incontinence 1%

Failure to void 5%

34

What are the two types of laser surgery used in treatment of bladder outflow obstruction?

Holmium laser enucleation of the prostate

Laser ablation of the prostate

35

What are the complications of acute urinary retention?

Hydronephrosis

Chronic retention

Obstructive nephropathy

Bladder stones

36

What are the other non-malignant causes of bladder outflow obstruction?

Urethral strictures

Bladder neck dysfunction

37

What is the classic sign of urethral stricture seen on investigation of LUTS?

Flow rate shows a plateau with a prolonged voiding cycle

38

How do we treat short urethral strictures?

Endoscopic urethrotomy

39

In which group of men is bladder neck dysfunction typically seen as the cause of LUTS?

Younger men

40

How do we treat bladder neck dysfunction?

Alpha blockers

Surgical bladder neck incision

41

What are the complications of surgical bladder neck incision?

Retrograde ejaculation so this will affect fertility