HISTORY
1.
Introduction
a.
Age > 70
b.
Commoner in males
c.
BPH is higher in high socio-economic group
2.
Presenting complaint
a.
Weakness of lower limbs – impending cord
compression
b.
Anuria – acute renal failure
c.
Pathological fracture ( vertebrae/hip)
d.
Dehydration, nausea, vomiting – hypercalcaemia
e.
Acute urine retention
f.
LUTS symptoms
g.
UTI (recurrent)
h.
Chronic renal failure
i.
backache
3.
History of presenting complaint
a.
Symptom analysis
i.
Storage symptoms
1.
Frequency
2.
Urgency
3.
Urge incontinence
4.
Nocturia
5.
Nocturnal enuresis
ii.
Voiding symptoms
1.
Hesitancy
2.
straining
3.
Poor stream (caliber, force, length)
4.
Intermittency
5.
Double voiding
6.
Dribbling
7.
Sensation of incomplete emptying
8.
Episodes of near retention
iii.
To which extent has it affected
b.
Differential diagnosis
i.
Testicular pain
- epididymo-orchitis due to BOO reflux
ii.
Suprapubic pain – prostatitis
iii.
Chronic pelvic pain – gonorrhea – strictures
iv.
If acute urinary retention
1.
Postponement of urination
2.
Beer
3.
Confinement to bed due to illness
4.
UTI
5.
Surgery
6.
Constipation
7.
Drugs – TCA, anticholinergics
8.
Previous episodes, what was done
v.
Voiding LUTS
1.
Benign prostatic hyperplasia
a.
haematuria
2.
Prostatic carcinoma
a.
Haematuria
b.
LOW
c.
LOA
d.
Haematospermia (blood in bed clothes – in advanced
cases)
3.
Bladder neck stenosis
4.
Urethral strictures
5.
Functional obstruction
a.
Spinal cord disease
b.
Stroke
c.
Diabetes mellitus - Autonomic neuropathy
d.
Degenerative neurological disease
e.
Parkinsonism
f.
Alzeimer’s disease
vi.
Storage LUTS
1.
Infection
a.
Persistent loin pain
2.
Urinary stones
a.
Colicky pain
3.
Overactive bladder
c.
Eatiology
i.
Urethral strictures
1.
History of urethral discharge
2.
History of urethral instrumentation
d.
Complications
1.
Prostatic carcinoma
a.
Impotence
b.
Lower limb and genital oedema
c.
Constipation, alteration of bowel habits, incontinence
d.
Bone pain/back pain/pathological fractures
e.
Fits, early morning headache and vomiting
f.
Jaundice, LOA, LOW
g.
Lower limb weakness
h.
Evidence of spinal cord compression
2.
Renal failure
a.
Uremic symptoms
e.
Fitness for surgery and anaesthesia
i.
Knee and hip joint – arthritis – Treatments
taken
f.
What was done up to now
4.
PMH
a.
IHD – precipitate CCF from TURP syndrome
5.
Drug history
a.
For any psychiatric illness – TCA
b.
Aspirin
c.
Anticoagulants
d.
6.
PSH
a.
Instrumentation
b.
Urogenital surgery
c.
Spinal injury
d.
Pelvic trauma, surgery
e.
Vasectomy
f.
B/L orchidectomy
7.
Allergies – contrast
8.
FH
a.
Prostate Ca
b.
Breast Ca (BRACA 2)
9.
Social history
a.
Smoking – prostate cancer
b.
Alcohol – BPH
c.
Completed family? Post TURP – impotence,
retrograde ejaculation
d.
Exposure to cadmium (in rubber industry) –
prostate cancer
EXAMINATION
General Examination
1.
BMI
a.
Obese – BPH
b.
Wasted – advanced Ca
c.
Febrile
d.
Icterus
e.
CRF features
f.
Bone tenderness – spine
Abdominal
Examination
1.
Distended bladder – loss of suprapubic skin
crease
2.
Renal angle tenderness
3.
Bladder –
a.
Chronic retention - above umbilicus, painless
b.
Acute retention – below umbilicus, pain++
4.
Loin masses – hydronephrosis
5.
Hepatomegally – liver 2ries
External Genitalia
1.
Meatal stenosis
2.
Ballanitis
3.
phemosis
4.
Urethra strictures
a.
Examine the urethra from end to end for a
stricture/palpable thickening
b.
Extensive strictures are associated with a large
palpable area of scarring in the perineum
c.
distended proximal part of the urethra ending in
a firm fibrous stricture
d.
examine membranous urethra during PRE
5.
Scars on scrotum and perineum
6.
Stones
7.
Hard and swollen testes – recurrent epididymo-
orchitis
8.
Hernias
DRE
1.
Sacral sensation
2.
Reduces anal tone – rectal invasion of Ca
3.
Constipation
4.
Prostomegally
a.
Median groove +/-
b.
Consistency
i.
Hard à
malignant
ii.
Smooth, soft à
benign
c.
Mucosa
i.
Fixed – post TURP, after prostate biopsy, Ca
5.
Firm mass above prostate à Ca bladder
6.
Fluctuating mass above the prostate à residual urine
7.
VE in Females
1.
Uterine prolapsed
2.
Cystocoele
Nervous System
1.
Quada equine syndrome (S2-S4)
a.
Can feel pin prick sensation beside the anus
2.
Anal reflex
3.
Patulous anal sphincter
4.
Parkinsonism
5.
DM neuropathy
6.
Gait
INVESTIGATIONS
1.
Urine full report to see
a.
Pus cells à
infections, stones, tumors
b.
Red blood cells à Stones, infection, prostate carcinoma
2.
Urine culture and antibody sensitivity test
3.
Urine cytology à
if carcinoma in situ is suspected
4.
X-ray KUB
5.
USS KUB
a.
Oedema
b.
Hydronephrosis
c.
Hydroureter
d.
Bladder trabeculations, diverticuli,
hypertrophy, stones
e.
Prostate
f.
Post voidal residual volume - > 40 % of
prevoidal, > 1000ml is significant
6.
Renal function assessment
a.
Serum creatinine
b.
Serum electrolyte
c.
Blood urea
7.
TRUS
a.
Exact size of prostate
b.
Echogenicity
8.
Prostate biopsy
a.
Indications – malignant features, DRE, increased
PSA, mets disease
b.
Complications
i.
Bleeding in to the bladder, rectum, seminal
vescicle ( stop aspirin, anticoagulants 2 weeks prior)
ii.
Infection – founier’s gangrene ( ciprofloxacine
500 mg 1 hour before, post biopsy………….)
iii.
Inflammation à
oedema à
acute retention
9.
Ascending urogram – urethral strictures
10. PSA
a.
For screening in people with
i.
Hard irregular
prostate
ii.
Obliteration of median grove
iii.
Positive family history (only indication in SL)
iv.
Backache with LUTS
v.
Sclerotic bone lesions
vi.
Afro Caribbeans at 50 years
b.
To follow response to treatment
i.
PSA velocity - % rise
1.
Normal
< 10 % within 1 year
2.
> 20 %
abnormal
ii.
Free : total
1.
BPH à
increased free and total
2.
Ca à
reduced free and increased total
3.
Cut off is 20 %
11. Early
prostate cancer antigen
a.
Experimental
12. Urine
flow metry
a.
Normal volume is >150 ml
b.
Normal flow is > 15 ml/s
c.
If <10 ml à
treatment is recommended
d.
Record 2 or 3 voids
BOO à
significant symptoms + benign prostate + low maximum flow rate (<10-12 ml/s)
for a good voided volume (>200 ml)
13. Pressure
flow urodynamic study
a.
In neurogenic bladder to identify the type
b.
To distinguish BOO from idiopathic detrusor
instability in males
c.
Indications
i.
Suspected neuropathy (Parkinson’s, dementia, DM,
previous strokes, multiple sclerosis)
ii.
Dominant history of irritative symptoms, urgency
and frequency
iii.
In patients with doubtful history and near
normal urine flow rate
iv.
Men with invalid flow rate measurement due to
inadequate voided volumes
14. Cystourethroscopy
a.
Immediately prior to the prostatectomy
b.
To exclude urethral strictures, bladder
carcinoma and non-opaque vesicle calculus
15. Investigation
to stage
a.
Liver
i.
SGOP/PT
ii.
Increased ALP
b.
Bone – Tc 99 bone scan
c.
CXR
d.
X-ray abdomen
e.
Monoclonal antibodies
f.
CT/MRI pelvis
16. CT/
MRI if radical prostatectomy is planned
17. FBC
18. Investigations
to see fitness for anaesthesia
MANAGEMENT
1.
flow rate >15 and residual volume < 100 ml
à safe à reassurance and review
2.
Indications for treatment
a.
Acute retention
b.
Severe symptoms and large residual volumes
c.
Chronic retention and renal impairment
i.
Residual urine >200 ml
ii.
Raised blood urea
iii.
Hydroureter, hydronephrosis
iv.
Uremic symptoms
d.
Complications of BOO
i.
Stone
ii.
Infection
iii.
Diverticulum
iv.
haemorrhage
v.
severe symptoms
3.
Emergencies
a.
Impending cord prolapsed
i.
Immediate presentation – B/L orchidectomy (IV
stillbsterol is not present in SL)
ii.
Late presentation – neurosurgical decompression
b.
Hypercalcaemia
i.
IV fluids - / + Ca binding resins
c.
Acute renal failure (B/L ureteric obstruction)
i.
Percutaneous nephrostomy
4.
Treatment
a.
Watchful waiting
b.
Life style adjustment
i.
No alcohol, coffee, chocolate
ii.
Less busy life style
c.
Uropharmoceuticles
i.
Alpha blockers
ii.
ADR - Postural hypotension – take when going to
bed
iii.
Retrograde ejaculation
iv.
5 alpha reductase inhibitors
1.
6 months to take effect
2.
For larger prostates
3.
½ the PSA level and shrinks the gland
d.
Phytotherapy
i.
Saw palmetto, pumpkin seeds
5.
Monitoring treatment
a.
IPSS
b.
Flow rate
c.
Episodes of AUR
d.
Residual volume
e.
Prostate size by TRUS
6.
Treatment for inoperable patients
a.
Prostatic stent under local anaesthsia
b.
TUMT
c.
TUNA
d.
HIFU
e.
Transurethral vaporization of the prostate
f.
Indwelling urethral or suprapubic catheter
g.
Self interval catheterization
7.
Management of acute retention
a.
IM pethidine
i.
Reduce agitation à
sphincter relaxes à
easy to pass the catheter
b.
Catheterize ASAP
i.
If spasms +ve à
put under sustained pressure
ii.
Prophylactic gentamycin 80 mg
iii.
Record date, time of catheterization, number of
attempts and residual volume
c.
If failed à
suprapubic catheterization
d.
Monitor input and output
e.
If first presentation of AUR
i.
>1000 ml à
uropharmaceuticles are not effective
ii.
<1000 ml à
alpha blocker + s alpha reductase
1.
If alpha 1a receptor blocker is given à peak dose in 48 hours à remove catheter and
review in 2 days
2.
If alpha
blocker + finesteride à
catheter off trial in 1 week
a.
Catheter off trial
i.
Remove catheter
ii.
Drink fluids
iii.
1 pint N/S
iv.
If passes >200 ml urine for
v.
3-4 times à
normal
vi.
If not à
catheterize
8.
Chronic retention
a.
Clean intermittent catheterization
i.
Males – 16 G, females – 14 G
ii.
Wash hands with soap and water
iii.
Introduce catheter and remove urine
iv.
Wash catheter if reused
v.
Complications
1.
Decompression haematuria
2.
Post obstructive diuresis, especially in uremic
patients
9.
Surgery
a.
Transurethral
i.
TURP
ii.
TUIP
iii.
Laser prostatectomy
b.
Open prostatectomy
i.
Retropubic
ii.
Transvesicle
iii.
Perineal
c.
Indications
i.
Uremia and hydronephrosis
d.
Relative indication
i.
AUR
ii.
Recurrent UTI + BPO
iii.
Recurrent haematuria
iv.
Persistent symptoms
e.
Consider surgery in
i.
High IPSS score
ii.
Low urine flow metry
iii.
USS – high
residual volume (> 1000 ml)
f.
Advantages of spinal anaesthesia over GA
i.
Has post-op analgesic effect
ii.
No period of nill by mouth
iii.
Urethra is dialated à easy access
iv.
Hypotension prevents bleeding
v.
Easy to identify TURP syndrome
g.
Post-op management
i.
22-24 G catheter inserted and bulb inflated with
20 cc, continuous irrigation started.
ii.
KUO for bleeding
iii.
Input output chart
iv.
Continue bladder input
v.
IV gentamycin stat dose
vi.
Monitor pulse, BP, RR
vii.
IV N/S over 6 hours
viii.
Pethidine 50 mg
ix.
Phenagon 25 mg
x.
Diclofenac sodium 100 mg suppository SOS
xi.
Diclofenac sodium 50 mg bd
xii.
Omeprazole 20 mg bd
xiii.
Dulcolax to prevent straining
xiv.
Irrigate with N/S until urine is clear ( 1 hr,
500 ml)
h.
On ward round D1
i.
Colour of urine
ii.
Stools passed?
iii.
PR,BP
iv.
Advise not to strain
v.
Cough syrup if cough present
vi.
Strict bed rest
i.
D2
i.
Mobilize the patient
ii.
If urine colour is normal, stop irrigation
iii.
If urine becomes dark, increase oral fluid
intake up to 2 l
j.
D3
i.
Remove catheter
ii.
Measure each void and record
k.
Open prostatectomy à remove catheter in D7
l.
Complications
i.
Immediate (1-2 %)
1.
TURP
syndrome à
convulsion, arrhythmias, pulmonary oedema
a.
To prevent –
i.
Pre-op correction of electrolytes
ii.
Use of isotonic fluids
1.
5% dextrose
2.
Glycine
iii.
Do not resect beyond the capsule
iv.
Limit duration of surgery
b.
Treatment
i.
HDU
ii.
Restrict water
iii.
Osmotic dieretics
2.
Local haemorrhage
3.
Perforation of prostate capsule
4.
Sepsis
ii.
Early
1.
Secondary haemorrhage
a.
Treatment - Rest and increase fluid
b.
Clot retention
i.
Treatment – bladder irrigation
2.
Sepsis
iii.
Late
1.
Strictures and bladder neck stenosis 10%
2.
Urinary incontenance 1%
3.
Erectile dysfunction 5%
4.
Retrograde ejaculation 50%
Carcinoma of the Prostate
1.
Watchful waiting
a.
For elderly patients with low grade, low volume
disease
2.
Localized disease
a.
Brachytherapy
b.
Radical surgery
3.
Locally advanced disease
a.
Radical radiotherapy
b.
Hormonal therapy
4.
Metastasis
a.
Androgen deprivation
i.
B/L orchedectomy
ii.
Medical
1.
Antiandrogens
2.
LHRH agonists
5.
Curative surgery – radical prostatectomy
a.
Retropubic
