Final MBBS Notes: February 2012

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

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

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

b. Laparoscopic

ACKNOWLEDGEMENT

Final MBBS Notes

Tuesday, February 21, 2012

Acknowledgement

Saturday, February 18, 2012

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