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39 Cards in this Set

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In order, what are the top 3 prostatatic problems?
1) benign prostate hypertrophy
2) prostate cancer
3) prostatitits
What area of the prostate is BPH most commonly found?
transition zone and periuretral zone
What region of the prostate is prostate cancer most likely to be found?
peripheral zone
How does benign prostate hyperplasia usually present itself (7)
1) lower urinary tract symptoms (LUTS)
2) urinary retention
3) utrinary tract infection
4) urinary incontinence
5) gross hematuria
6) bladder stones
7) renal insufficiency
What are LUTS (lower urinary tract symptoms)?
lower urinary tract symptoms attributable to voiding disturbances:
1) voiding (obstructive) Sx
2) storage (irritative) Sx
70%-80% men undergoing prostatectomy for benign prostate hypertrophy develop this....
retrograde ejaculation
What are the 7 elements of the American Urologists Association (AUA) Symptom Index?
1) Frequency
2) Hesitancy
3) Intermittency
4) Urgency
5) Nocturia
6) Incomplete Voidings
7) Weak Stream

(Frequent Hesitation during Intermittent Urgency Nocturia IncompleteVoiding is WeakStream.)
Which medications would be used for immediate treatment for BPH symptoms?
alpha1 adrenergic receptor antagonists:
terazosin (non-specific)
doxazosin (non-specific)
tamsulosin (specific)
alfuzosin (specific)
Which medications should be used for long-term maintenence of BPH?
5-alpha-reductase inhibitors

finasteride
dutasteride
What drug class do terazosin and doxazosin belong to?
non-selective alpha1 adrenergic receptor blockers
What class of drugs do tamsulosin and alfuzosin belong to?
specific alpha1a adrenergic reeptors
What class of drugs do finasteride and dutasteride belong to?
5-alpha-reductase inhibitors (induces apoptosis)
Where are alpha1 receptors located in the lower urinary tract?
1) trigone of bladder (a1d)
2) neck of the bladder (a1d)
3) urethra (a1d)
4) smooth muscle cells of prostate gland (a1a)
What are indications for prostate surgery in a BPH patient?
1) refractory urinary retention
2) recurrent UTI's
3) recurrent gross hematuria
4) renal insufficiency
5) bladder stones
6) large bladder diverticula due to BOO (bladder outlet obstruction)
What are the 2 components to BOO (bladder outlet obstruction?)
1) Dynamic or physiologic (increased tone due to stimulation of alpha 1 adrenergic receptors)

2)Fixed or structural component (enlarged prostate and its effect on the bladder neck and prostatic urethra)
What are the therapeutic options for BPH?
1) Watchful waiting
2) Medical Therapy (alpha1 adrenergic antagonists, 5-alpha reductase inhibitors or combined)
3) minimally invasive therapies (TUNA, TUMT)
4) surgical therapies (TURP, Laser, open prostatectomy)
5) emerging therapies
How are alpha-1a and alpha-1d receptors distributed in the lower urinary tract?
1) alpha-1d in the bladder and bladder neck
2) alpha-1a in the prostate
What is the most significant side effect of terazosin or doxazosin on BPH patients?
hypotension
What is the reationale for treatment of BPH patients with 5-alpha reductase inhibitors?
Block the catalytic activity of 5-alpha reductase in conversion of testosterone to dihyrotestosterone (DHT), a compound which increases prostate size. Requires treatment for at least 6 mos. before improvement of Sx.
What is the generic name for PROSCAR?
finasteride
What are the main side effects of 5-alpha reductase inhibitors?
1) decreased libido
2) erectile dysfunction
What has been the primary treatment for BPH and BOO patients?
Transurethral Resection Prostate (TURP)
What forms the border between the upper and lower urinary tracts?
uretal vesicle junction
How is the lower urinary tract of men different from women?
1) longer urethra
2) presence of prostate gland
What muscles are involved in control of micturation? What nerves innervate them?
1) detrusor m. (bladder)
- sympathetic (hypopgastric n.= T10-S2, alpha1)
- parasympathetic (pudendal n.=S1-S3, muscarinic M2,M3)

2) pelvic floor m. (levator ani)/external urinary sphincter m.'s
- pudendal nerve (S2,3,4 nAchR)
What nerves provide sympathetic innervation to the bladder smooth muscle?
hypogastric nerves (T10-L2)
What nerves provide parasympathetic innervation to the bladder smooth muscle?
pelvic nerves (S2,3,4)
Which branch of the autonomic nervous system leads to voiding of the bladder?
parasympathetic :
- pelvic nerves (S1,2,3)
- m2,m3 cholinergic receptors
Which branch of the nervous system helps to maintain storage of urine in the bladder?
sympathetic
- hypogastric nerves (T10-S2)
- alpha1: incr. outlet tone
- beta2: bladder detrusor muscle relaxation
Are men more prone to urinary incontinence or urinary retention and why?
urinary retention, as due to anatomical differences (e.g. longer urethra, prostate) men experience greater outlet resistance.
What are the distribution and results of activating the following receptors in the lower urinary system:
a) m3
b) m2
c) B2
d) a1
e) nAchR
a) m3 - detrusor SMC contraction

b) m2 - inhibit sympathetically mediated detrusor muscle relaxation (for release)

c) B2 - relaxation of detrusor muscle (for storage)

d) a1 - contraction of bladder trigone, neck and urethra

d) nAchR - contract pelvic floor muscles (levator ani, external urethral sphincter)
What are the 4 types of voiding dysfunctions?
1) Urge Incontinence

2) Stress (Exercise-Related) Incontinence

3) Bladder Outlet Obstruction Retention (anatomic/fixed and/or physiologic/increased alpha tone)

4) Failure of Bladder to Contract leading to urinary retention (could be neurologic- check rectal tone: S2,S3,S4)
Name differential diagnoses for urgency?
1) bladder stones
2) bladder tumors
3) foreign objects
4) UTI
5) suburethral diverticulum with stone

stimulate receptors in bladder wall and cause reflexive involuntary detrusor contraction and urine loss.
What are 3 signs of an overactive bladder (OAB)?
1) urinary urgency
2) urinary incontinence
3) urinary frequency
What are the 2 different types of OAB and which is the more common of the two?
1) wet OAB- w/leakage
2) dry OAB- w/o leakage, more common (2/3 of OAB patients)
What are urodynamics?
invasive measurement of bladder pressure and urinary sphincter activity during the micturition cycle
What are the 4 different subtype classifications of urinary incontinence and what causes them?
1) urge incontinence - increased bladder pressure

2) stress incontinence - decreased outlet resistance

3) mixed incontinence - urge and stress

4) overflow incontinence - elevated outlet resistance
How can an overactive bladder (OAB) be controlled?
1) behavioral
- pelvic muscle rehab (biofeedback, electrical stim)
- bladder training

2) pharmacological

- anticholinergics, antimuscarinics (oxybutynin chloride, tolterodine tartrate-less side effects)

- Antispasmodics (dicyclomine HCl/ocybutynin chloride)

- tricylic antidepressants (imipramine, doxepine, desipramine, nortriptyline)
If a voiding dysfunction is suspected, what tests might be performed to further diagnose the patient?
1) post void residual
2) urinalysis
3) urodynamics
4) cystoscopy

- history
- medical and neurological Hx
- meds
- physical and pelvic exam