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PROSTATE (URINARY RETENTION (the definitive treatment of urinary retention…

- - - - HX - Renal failure is suggested by headaches, anorexia, vomiting and confusion
      - EXAMINATION - is the pt pale and drowsy with the dry coated tongue of uraemia?
        is there periph oedema?
        is the bp elevated?
      - SPECIAL IX - an elevated creatinine suggests renal impairment
  - - - EXAM - chest, CV system and BP
      - SPECIAL IX - CXR, ECG if necessary. Hb level is checked
      - HX - cardioresp co-morbidity assessment
  - - - prostate cancer
        
        in presence of mets spread, hormone therapy is commenced
        endoscopic prostatectomy is required for localised tumours, or large if symptoms persist on hormonal therapy
      - urethral stricture
        
        catheter won't pass and urethra must be gently dilated under local or GA. following this it may be possible to cath or may be first necessary to divide the stricture endoscopically with an optical urethrotome.
        if the stricture is impassable, a temporary suprapubic catheter may be needed before urethrotomy
        sometimes permanent urethroplasty is needed and sometimes permanent suprapubic drainage is required
      - BPH
        
        consider prostatectomy as soon as convenient if renal function and general condition of pt are satisfactory
        if renal damage or general poor condition precludes operation, drainage by urethral catheter is continued until these can be improved
        if the pt is in such poor health that op is inappropriate, then he may be managed by permanent urethral or suprapubic catheter drainage, or by being taught intermittent self-catheterisation
    - - catheter cannot pass = stricture
        
        dilation
        
        suprapubic cystostomy if impassable
      - catheter passes (exclude general causes)
        
        prostate
        
        benign hypertrophy
        
        fit pt
        
        prostatectomy
        
        unfit pt
        
        continue drainage until fit for surgery
        
        malignant
        
        hormone therapy
        
        endoscopic prostatectomy if necessary
- - - - T2 = a hard nodule in one lobe of the prostate or abolishing the normal su;cus between 2 lateral lobes. tumour confined to prostate
      - T3 = a hard mass in the prostate together with infiltration of the tissues on either side of the prostate or into the seminal vesicles
      - T1 = prostate feels benign, no palpable tumour
      - T4 = hard mass in the prostate which is fixed to the pelvic side wall or is invading the bladder
    - - Bone pain, pathological factures, and features of hypercalcaemia are occasional presenting features due to metastases.
      - May be diagnosed by digital rectal examination; areas of firmness or palpable nodules are suggestive of malignant change.
      - The majority of men present with LUTS:
        
        Refers to a group of symptoms that typically affect the ageing male.
        
        Often caused by bladder outflow obstruction related to prostatic enlargement.
        
        Includes symptoms related to both voiding and storage.
        
        Voiding symptoms. Poor urine flow, hesitancy, post-micturition dribbling.
        
        Storage symptoms. Frequency, nocturia, urgency, urge incontinence.
        
        International prostate symptom score (IPSS) is a validated questionnaire to estimate the patient's perception of severity of symptoms.
  - - - small well differentiated tumours in elderly men may be treated by watchful waiting, particularly if LE is poor (<10yrs)
      - radical treatment
        
        RADICAL PROSTATECTOMY
        
        remove prostate, eminal vesicels and pelvic lymph nodes with anastamosis of the bladder neck to the urethra just distal to the prostate
        
        SE = impotence in half the pts and urinary incontinence in a significant number
        
        confined space so use robot
        
        RADICAL RADIOTHERAPY
        
        with or without hormone treatment has a lower impotence rate than surgery and a very low chance of incontinence, but may leave proctitis or bladder irritation
        
        can be given by external beam or transperineal placement of radio-iodine seeds (brachytherapy)
        
        long term efficacy yet to be confirmed by full RCT - Prostate has slow growth - so long term follow up
    - - Prostate cancer often discovered at a stage when it has already spread beyond the prostatic capsule and may well have involved other organs, particularly the bladder base and bone
        the mainstay of treatment of advanced disease is androgen suppression or the use of specific androgen antagonists, which will produce symptomatic relief in disseminated prostatic cancer in about 75% of pts.
      - Gonadotrophin releasing hormone agonists - eg BUSERELIN and GOSERELIN they inhibit release of LH from the ant pit = reduction of testicular production of testost.
        initiation of therapy may cause a flare of testost and hence a flare of disease, so a short 3wk course of androgen therapy is given
      - orchidectomy = seldom done these days, but can often relieve symptoms and produce dramatic remissions in the course of the disease
      - cyproterone acetate = steroid androgen antagonist
      - oestrogen administration eg STILBOESTROL (with aspirin to prevent thromboembolic disease) used when disease becomes refractory.
        stilboestrol may produce gynaecomastia, nipple and scrotal pigmentation and testicular atrophy.
        more importantly, it may result in fluid retention and precipitate congestive cardiac failure
      - palliation produced by hormonal treatment of prostatic cancer suppresses PSA to normal levels for an avg of 2yrs, after which it slowly rises, with symptoms returning a few months later. When the cancer is refractory to hormone therapy, the avg LE is 6mths
      - radiotherapy may relieve the pain of bony deposits and can also be used for local control to supplement hormonal therapy
      - urinary obstruction due to prostate cancer may resolve on hormonal therapy; if not, an endoscopic prostatectomy is indicated
- - - - urinary infection - may occur (Esp after catheterisation)
      - hydronephrosis - results from back oressure on the ureters which may result in renal failure
      - bladder stones - form as a consequence of urinary stasis, particularly in diverticula
      - renal failure - due to progressive hydronephrosis, resulting in anaemia and uraemia. It is commonly referred to as obstructive nephropathy
      - bladder diverticula - form from saccules between muscle bands
  - - - voiding symptoms due to bladder outlet obstruction
        
        narrowing of prostatic urethra by the lateral lobes on each side and the possible median lobe enlargement may cause difficulty in passing urine, sometimes with a poor and intermittent stream
      - symptoms of the sequelae such as infection or renal failure
        
        SYMPTOMS OF RENAL FAILURE: obstruction of outflow of bladder may result in RF with nausea, lethargy, drowsiness, headache and confusion
      - filling symtpoms due to assoc bladder over-activity
        
        frequency, urgency, nocturia and urgency incontinence, singly or in combination, characterise an overactive bladder. Urinary tract infection may exacerbate the symptoms or precipitate acute retention
  - - - size of prostate may appear larger than really is if bladder is grossly enlarged and pushes prostate down towards the examining finger so palp again after catheterisation
      - if only middle lobe enlarged - size appears normal on PR in spite of symptoms
    - - PSA - prostate cancer (<4ng/ml = normal). free/total PSA ratio >0.15 in normal men
      - urinanalysis - presence of leucocytes - culture if pos analysis. most pts with prostatic disease dont have infected urine until bladder and urethra been instrumented
      - Hb is estimated since chronic RF results in dec erythropoietin production = anaemia
      - serum creatinine (Assess renal function)
      - freq/vol chart
      - urine flow rate assessment - at least 150ml required for adequate asssessment. max flow rate <12ml/sec = obstruction or weak bladder conttractility >15 bladder obstruction unlikely
      - urodynamics (pressure flow assessment) distinguish outflow obstruction from poor detrusor contraction which wont improve following prostate surgery
      - US - demonstrate residual volume after voiding , retention or hydronephrosis - normally no signif residual vol; however in presence of bladder eoutflow obstruction, bladder cant be completely emptied
  - - - diverticula
      - urinary retention
      - stone formation
    - - hydronephrosis
      - renal failure
    - - chronic retention
      - haemorrhage
      - acute retention
  - - - If have few symptoms - lifestyle advice eg adjusting fluid intake and reduce caffeine
    - - in moderate symptoms
        
        selective alpha adrenergic antagonists (alpha blockers, eg tamsulosin or alfuzosin) for lower tract symptoms - act by relaxing smooth muscle in bladder neck
        
        5 alpha reductase eg finasteride or dutasteride blocks the conversion of testosterone to activve metabolite, dihydrotestosterone in prostate - may take 6mths to see benefit
    - - ENDOSCOPIC PROSTATECTOMY
        
        prostate can be removed endoscopically by means of of an operating cystoscope using a diathermy cutting loop (TRANSURETHRAL PROSTATECTOMY, TURP) or laser fibre (most commonly holmium laser prostatectomy, HoLEP). The mortality and morbidity is low. removal of too much gland may damage the urethral sphincter mechanism. HoLEP is increasignly used for very large prostates, and open prostatectomy is now rarely done
        
        COMPLICATIONS
        
        transurethral resection (TUR) syndrome - absorption of large vol of irrigating fluid through open prostatic veins may result in hyponatraemia and confusion
        
        infection is particularly common in pts who are catheterised before surgery; prophylactic abx given
        
        Haemorrhage - primary haemorr. more common with malig glands, with large resections and in pts on aspirin or clopidogrel
        
        retrograde ejaculation almost certain after TURP
        
        impotence in 5-15%
        
        bladder neck stenosis - due to stricturing, presents with outflow obstruction
        
        urinary incontinence - uncommon ut may occur if resection is extended below verumontanum with damage to urethral sphincter
        
        recurrent lower urinary tract symptoms - late recurrence may be due to either regrowth of adenoma or malig change
- - - - chronic bacterial prostatitis
        
        presents a recurrent UTIs
        prostate feels much firmer and may resemble cancer
        diagnosis - by urine samples before and after prostatic massage and appropriate abx therapy started
      - chronic pelvic pain syndrome
        
        common insidious problem affecting up to 9% of men
        symptoms are typically pain in the perineum, scrotum, tip of penis or bladder, along with pain on ejaculation or micturition
        symptoms of urinary frequency and a feeling of incomplete emptying are common
        aetiology of the syndrome is unclear; an autoimmune process and pelvic muscle abnormality have all been suggested
        treatment options include pelvic floor relaxation, doughnut seat cushions, alpha blockers, NSAIDs, abx and repetitive prostatic massage
      - acute bacterial prostatitis
        
        pt presents with fever, rigors, perineal pain and difficulty voiding, together with symptoms of a UTI; he may present with acute retention retention.
        pain on ejeculation and blood in the semen (haematospermia) may be present
        rectal exam reveals enlarged, exquisitely tender prostate and occassionally an abscess may be palpable
        epididymitis is a common accompaniment owing to infection passing along the vas def
        treatment is a 6wk course of abx with good prognostic penetration (eg CIPROFLOXACIN or TRIMETHOPRIM)