Makindo Medical Notes.com

Related Subjects: |Urothelial tumour s |Haematuria |Acute Urinary Retention |Anuria and Oliguria |Bladder cancer |Renal cell carcinoma |Benign Prostatic Hyperplasia |IgA nephropathy |Prostate Cancer |Henoch-Schonlein purpura |Glomerulonephritis

Usually confined to the centre of the gland in the periurethral glands and so prostate size may not correlate with degree of obstruction

About

• Prostate size alone is not a reliable or accurate predictor of the degree of urinary outlet obstruction

Pathology

• There is hyperplasia rather than hypertrophy
• Usually confined to the centre of the gland in the periurethral glands
• Prostate size may not correlate with degree of obstruction

Clinical

• Males over 50 years old and affects black > white > Asian
• Increased frequency of urination
• Nocturia, Hesitancy, Urgency, Incomplete emptying
• Weak urinary stream and terminal dribbling
• Chronic retention with large bladder
• Smooth enlarged prostate and palpable bladder

Complications

• Acute urinary retention may be worsened by drugs such as alpha-blockers, anticholinergics and anti-psychotropic
• Recurrent urinary tract infections
• Hydroureter and Hydronephrosis
• Renal failure, Infection, Calculus formation

Investigations

• Urinalysis and if positive then MSU and treat the infection. Haematuria may warrant a search for a cause.
• U&E and FBC
• PSA: increase when enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.
• X ray Kidneys-Ureter Bladder KUB - if suspect renal/bladder stones
• Post void residual volume test. This test measures whether you can empty your bladder completely. The test can be done using ultrasound or by inserting a catheter into your bladder after you urinate to measure how much urine is left in your bladder.
• 24-hour voiding chart with an assessment of frequency and volume
• Abdominal Ultrasound - renal size, obstruction, bladder size
• Flexible cystoscopy: A lighted, flexible instrument (cystoscope) is inserted into your urethra, allowing the doctor to see inside the urethra and bladder. This can be done under local anaesthetic before this test.
• Urodynamics: a urinary catheter is threaded through your urethra into your bladder. Water is slowly injected into your bladder. Your doctor can then measure bladder pressure and determine how well your bladder muscles are working. Used when there is concern over suspected neurological problems and in men who have had a previous prostate procedure and still have symptoms.

Management: General Advice

• Avoid alcohol and caffeine and excessive fluid intake in the evening. Don't drink anything for an hour or two before bedtime to avoid middle-of-the-night trips to the toilet. Limit decongestants or antihistamines. These drugs tighten the band of muscles around the urethra that control urine flow, making it harder to urinate.
• General advice is go when you first feel the urge. Waiting too long might overstretch the bladder muscle and cause damage. Try to urinate at regular times such as every four to six hours during the day to "retrain" the bladder. This can be especially useful if you have severe frequency and urgency.
• Follow a healthy diet. Obesity is associated with an enlarged prostate. Stay active. Inactivity contributes to urine retention. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.
• Urinate and then urinate again a few moments later. This practice is known as double voiding. Keep warm. Colder temperatures can cause urine retention and increase the urgency to urinate.

Management: Medications

• Alpha Blockers block alpha adrenergic-1 receptors. Tamsulosin and Alfuzosin improve lower urinary tract symptoms and can make urination easier. They can, however, cause postural hypotension.
• 5-alpha reductase inhibitors e.g. finasteride can reduce prostatic volume and give symptom relief and reduce the size by 2-30% but can take up to 6 months to work. Side effects include retrograde ejaculation.
• Combination therapy with Alpha antagonists and 5-alpha reductase inhibitors can be used in selected patients
• Anticholinergics help an overactive bladder. Oxybutynin (immediate release) but this can cause delirium in old and frail.
• Mirabegron 25-50 mg OD when antimuscarinics cannot be used for an overactive bladder. It can cause hypertension and benefits slight.

TWOC and Long term Catheter

• Catheterisation for acute retention and then removal after 1-2 days after starting Tamsulosin may be needed if this fails then a long-term catheter is usually inserted. Some prefer intermittent self-catheterization.
• Large distended floppy bladder with over 1 L residual consider intermittent self catheterisation and if that fails Long term catheterization with e.g. bag. In severe cases when a urethral catheter cannot be placed then a suprapubic catheter is placed. Often used when there is severe outflow obstruction and chronic retention with large post voiding residual

Indications for Urology referral

• Suspicions of malignancy e.g. hard firm prostate on an exam or elevated PSA
• Evidence of Obstructive uropathy - Look for AKI and elevated Urea/Creatinine
• Large bladder on USS or with retention.
• Rapidly worsening symptoms
• Failed medical therapy as above

Surgery: Transurethral resection of prostate (TURP)

• A lighted scope is inserted into the urethra, and the surgeon removes all but the outer part of the prostate. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP a catheter is placed temporarily, you need a catheter to drain your bladder.
• Complications include haemorrhage and TURP syndrome. TURP Syndrome is seen with hyponatraemia - see the topic. Also, can develop post-op clot retention. Late can develop impotence, stricture and incontinence
• Very large prostates may require Open prostatectomy