Causes of bladder outflow obstruction
- Congenital - urethral valves & strictures
- Structural
- Benign prostatic hyperplasia
- Carcinoma of the prostate
- Bladder neck stenosis
- Urethral stricture
- Functional
- Bladder neck dyssynergia
- Neurological disease - spinal cord lesions, MS, diabetes
- Drugs - anticholinergics, antidepressants
- Prostate cancer develops in the periphery of the gland
- BPH affects urethral glands in the transitional zone of the prostate
Benign prostatic hyperplasia
- Affects 50% men older than 60 years
- Affects 90% of men older than 90 years
- Presents with obstructive and irritative symptoms
- Obstruction causes poor stream, hesitancy, dribbling and retention
- Irritation causes frequency, nocturia, urgency and urge incontinence
- Diagnosis can be confirmed by uroflowmetry
- Only 70% of men with lower urinary tract symptoms have proven
bladder outflow obstruction
- Other investigations should include
- Urea and electrolytes to check renal function
- Ultrasound to excluded hydronephrosis and measure post-micturition
volume
- Serum PSA to excluded malignancy
Management
The aims of treatment are to:
- Relieve symptoms and include quality of life
- Relieve bladder outflow obstruction
- Treat complications resulting from bladder outflow obstruction
Treatment options
- Observation
- Pharmacological
-
a-adrenergic antagonists
- 5a-
reductase inhibitors
- LHRH antagonists
- Surgery
- Transurethral prostatectomy
- Transurethral or interstitial thermotherapy
- Urethral stents
- Interstitial laser prostatectomy
Complications following TURP
- Early
- Primary haemorrhage
- Extravasation
- Fluid absorption (TUR syndrome)
- Infection
- Clot retention
- Epididymo-orchitis
- Incontinence
- Intermediate
- Secondary haemorrhage
- Retrograde ejaculation
- Erectile dysfunction
- Late
- Bladder neck stenosis
- Urethral stricture
Urethral strictures
Aetiology
- Congenital
- Trauma - instrumentation, urethral rupture
- Infection - gonocococcal, non-specific urethritis, syphilis, TB
- Inflammatory - balanitis xerotica obliterans
- Neoplasia - squamous, transitional cell or adenocarcinoma
Management
- Dilatation - gum-elastic bougie, metal sounds
- Urethrotomy - internal or external
- Urethroplasty
Bibliography
Barbagli G, Palminteri E, Lazzai M et al.
Anterior urethral strictures. BJU Int 2003; 92:
497-505.
Connelly S S, Fitzpatrick J M. Medical management of benign
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73-78.
Foley C L, Bott S R, Arya M, Kirby R S. Benign
prostatic hyperplasia: solutions to an ageing problem. Hosp Med
2002; 63: 460-464.
Lam J S, Cooper K L, Kaplan S A. Changing aspects in
the evaluation and treatment of patients with benign prostatic
hyperplasia. Med Clin North Am 2004; 88: 281-308.
McNeill A S. The role of alpha-blockers in the management of
acute urinary retention cause by benign prostatic obstruction.
Eur Urol 2004; 45: 325-332.
Thorpe A, Neal D. Benign prostatic hyperplasia.
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