Page 267 - Medicine and Surgery

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Chapter 6: Disorders of the bladder and prostate 263

Microscopy symptoms than α-blockers. It seems to be more effec-
Benign epithelial proliferation with large acini, smooth tive in those with very large prostates and its effects
muscleandfibroblastproliferation.Oedemaandinflam- may improve with time.
mation are common, as are areas of infarction. Transurethral resection of the prostate (TURP) has been
the standard treatment. The procedure involves removal
Complications of prostatic tissue using electrocautery via a resecto-
Bladder decompensation – due to chronically increased scope from within the prostatic urethra, under general
residualvolumes(urineretainedaftervoiding),theblad- or spinal anaethesia. Post-operatively patients require
der may become less contractile, lowering flow rates fur- a three-way catheter and continuous bladder irrigation
ther. Obstruction may lead to dilated ureters and kid- to reduce the risk of clot retention until haematuria is
ney(hydroureter,andhydronephrosis).Itmayalsocause mild.
ARF or CRF. Early complications: Post-op (immediate) haem-
orrhage, urethral blood clot and urinary retention.
Investigations Antibiotic prophylaxis is usually given to prevent
Itisimportanttoexcludeothercausesof bladderoutflow urinary tract infection. Hypervolaemia and hypona-
obstruction or bladder instability. traemia with a metabolic acidosis may occur (TURP
FBC,U&Es,serumprostatespecificantigen(PSA)and syndrome) due to absorption of irrigating fluid (may

urine microscopy and culture are routine. be > 1 L).
Urodynamics: Maximal urinary flow rates less than 10 Later complications include: ≤14% become im-

mL/second are almost diagnostic of bladder outflow potent, retrograde ejaculation, epididymo-orchitis,
obstruction.Between10and15mL/second,combined bladder neck contracture or urethral stricture requir-
pressure/flow studies may be done to exclude those ing surgery or dilatation, incontinence. About 20%
with other problems, as resection of the prostate in require further TURP within 10 years.
these patients may not relieve symptoms. The disad- Other options (not widely available) include:
vantage of the latter, is that urinary catheterisation is Stent which is cost-effective in those with a short
required. life-expectancy or temporarily for patients unfit for
Bladder scan: This simple scan uses ultrasound to surgery, e.g. due to recent MI, and has less operative

measure the post-voiding residual volume is useful. morbidity.
Patients with a high residual volume are at risk of Microwave ablation by transurethral catheter (TMT=
bladder decompensation and UTIs. transurethral microwave thermotherapy) or transrec-
If there is evidence of renal impairment, renal USS tally.

should be performed to look for hydronephrosis. Electrovaporisation utilises electrical energy to va-
porise prostatic tissue, with the advantage of no
Management further sloughing of tissue and less bleeding post-
In patients with mild symptoms, monitoring may be procedure.
advised,assymptomsoften improveovertime.Forthose Endoscopiclasermayresultinlessbleedingandshown
with moderate to severe symptoms the choice is between to be as effective with similar costs to TURP.
atrial of medical therapy or surgical therapy. Radiofrequency ‘needle’ can be used, although further
Drugsareaimedatrelaxingthecontractilecomponent treatment is often required within 5 years.
and reducing the volume of the prostate.
α-blockers such as doxazosin, terazosin and tamsu-

losin improve symptoms and bladder outflow rates Urinary incontinence
in 60–90% of patients, but may cause unacceptable
hypotension. Definition
Finasteride is a 5 alpha reductase inhibitor which in- Urinary incontinence is the involuntary loss of urine

hibits the conversion of testosterone to dihydrotestos- from the urethra. It has a major physical, psychological
terone. It is also useful, but generally less effective for and functional impact on the individual.