Bladder outflow obstruction

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

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.  Lancet 2003;  361:  1359-1367.

 

 
 

Copyright © 1997- 2012 Surgical-tutor.org.uk