Urinary Symptoms

BPH

• Non-malignant growth of the prostate with age
• It is not a precursor of prostate cancer
• Cause of the enlargement is unknown (hormonal changes that occur with aging are thought to be involved)

First symptoms usually appear in 50's or 60's and are often progressive in nature.

• Decreased force and calibre of their urinary stream
• Difficulty starting their stream and may have to strain in order to empty their bladders
• Flow may stop and start and they may dribble after they have finished voiding
• Urge to void only minutes after they leave the washroom
• If complete obstruction they present to the ED with severe supra pubic pain
• Often also complain of irritative voiding symptoms in addition to the obstructive ones

Rectal exam usually reveals a symmetrically enlarged smooth prostate.

• If the prostate is hard and asymmetrical or if nodules are felt then malignancy must be considered
• Check for a palpable / percussable bladder
• Post void residual (ultrasound or catheter) is helpful. Any volume greater than 100 cc is significant
• Alpha blockers such as Terazosin have been shown to be effective in some
• A 5-aplha reductase inhibitor (blocking the production of DHT) can shrink the prostate and relieve symptoms
• Surgery (TURP) is the standard treatment

Prostate Cancer

• Adenocarcinoma of the prostate has become the most common cancer in men
• Uncommon in men younger than 50 years of age
• The cause is unknown
• Most men with prostate cancer are asymptomatic but they can present with local or metastatic signs and symptoms
• Local symptoms include obstructive voiding, haematuria and perineal pain
• Metastatic symptoms include bone pain, fatigue, weight loss and malaise
• On physical exam one typically feels a hard discrete nodule on the prostate
• PSA is a serum marker for prostate cancer however its specificity is poor (also ↑ in BPH and prostatitis )
  • A value under 4.0 makes prostate cancer unlikely while a value over 10.0 makes one suspicious
• A transrectal ultrasound of the prostate - a TRUSP - can be booked through a urologist
• Once Dx is confirmed pathologically, the extent of the disease must be ascertained
  • CXR & bone scan will detect distant metastases
• If tumour confined to the prostate then the patient is offered watchful waiting, radical prostatectomy, radical radiotherapy or brachytherapy (based on cancer and patient characteristics)
• If extended outside the prostate removing the prostate will be of no benefit, radiotherapy is an option
• If distant spread - hormone therapy i(elimination of androgens)s needed

Urethral Strictures

• Are fibrotic narrowing (scar tissue) within the urethra
• M >> F
• Most are due to trauma or infection
• Most are strictures or iatrogenic
• Patients usually have a Hx of urethral instrumentation or STD's
• Symptoms of progressively weakening stream with hesitancy, straining at urination, and post void dribbling It is not uncommon for them to develop a prostatitis
• If the stricture is not too severe it can be manually dilated with male sounds (tapered metal rods)
• Restenosis is common

Hypotonic Bladder

• Detrusor muscle is too weak to empty
• Often secondary to chronic obstruction
• A hypotonic bladder may be able to hold a few litres of urine without causing much discomfort
• Often older men with a long-standing history of untreated BPH
• If obstructions are treated, detrusor muscles may regain some contractility
• Unfortunately, many of these patients require clean intermittent catheterisation - CIC - in order to empty their bladders

Detrusor Sphincter In-coordination

Normally, the urethral sphincter must relax just as the detrusor muscle of the bladder contracts. In-coordination occurs in patients who for one reason or another are not able to relax their sphincter at the appropriate time.

• These patients complain of painful voiding with stop and go stream
• Subjective feeling of being unable to completely empty their bladders
• Dx made with urodynamics