1. Urology outpatients

2. Case 1 52 year old man Presents with increasing hesitancy of micturition Frequency Nocturia

3. Case 1 - Questions What are the main symptoms that suggest prostatic hypertrophy How are these symptoms subdivided? How is prostatic hypertrophy assessed clinically? Which two main groups of drugs are used in this condition and can you explain their actions?

4. “Prostatism” Prostatism is an imprecise term that is commonly used to group together symptoms of frequency, nocturia, urgency, hesitancy, a poor stream, and post-micturition dribbling The term is to be avoided as it implies a diagnosis. Terms such as bladder outflow obstruction are preferred. Benign prostatic hyperplasia is a common condition in older men and may even be regarded as a natural part of ageing. It is unusual before 50 years of age and is most common between 60 and 70. The cause of the hyperplasia is uncertain. Hormonal and neoplastic explanations have been proposed. The condition is not thought to be premalignant.

5. Presentation Patients usually present with the typical symptoms of bladder outflow obstruction, or with complications such as retention, infection or stone formation. Obstructive symptoms Irritative symptoms Acute retention may be precipitated by overfilling the bladder from excessive fluid intake

6. Treatment Watchful waiting – many men do not deteriorate over 5 year period Medical Alpha adreno-receptor blockade relax the proximal urethra and improve urinary flow 5 alpha reductase inhibitors Surgical Only if severe symptoms or complications

7. Case 2 Mr Roberts is 67 years of age He has driven back from Bristol He has lower abdominal pain and is sweating profusely Unable to pass urine

8. Can you answer the following What is the most likely cause of his problem? Why has this happened today? Can this occur in women too, why? What treatment is required? What might precipitate this in a patient in hospital?

9. Urinary retention - causes Acute urinary retention often appears suddenly in patients with longstanding symptoms of bladder outflow obstruction, for example benign prostatic hypertrophy, bladder neck hypertrophy, or prostatic carcinoma. Other causes include - as a complication of surgery, due to fluid overload, drugs, pain, anxiety, embarrassment or the supine posture. Less common causes include: stones or blood clots in the urethra urethral stricture constipation pregnancy - particularly associated with a retroverted uterus pelvic tumour genital herpes - painful ulceration may result in urinary retention

10. Urinary retention - diagnosis History and examination - classically the patient is anuric, in great discomfort and has an intense desire to micturate. The bladder is palpable and there is suprapubic dullness to percussion. Passing a urethral catheter releases a large volume of urine - more than 500 ml in an adult - which confirms the clinical diagnosis. Passing a catheter helps to exclude renal failure as a cause of anuria.

11. Urinary retention - management The first objective is to relieve the patient of the discomfort so provide some strong opiate analgesia. Try conservative methods first - privacy, sound of running water, and making the patient stand up. Catheterise if these conservative methods do not provide relief. First, try a Foley catheter inserted via the urethra; if unsuccessful, try a suprapubic catheter. Some factors that should discourage an attempt at simple urethral catherisation include:

12. Case 3 Mr Joseph Green age 54 Comes for routine check up on his blood pressure Asks if he should have a blood test for prostate cancer Examination – small nodule PSA 8.6

13. Questions to consider What is PSA and what is its function? Is it a reliable predictor of Prostate cancer? What is the role of clinical examination? What precautions are required before testing? What might happen next if it is raised? Do we know what to do with early Prostate cancer?

14. PSA Prostate-specific antigen (PSA) is a serine protease which is usually specifically expressed in the prostate. Measurement of serum PSA in serum is used widely for the diagnosis and monitoring of prostate cancer. Elevation of serum PSA is more a sensitive and specific indicator of prostatic carcinoma than prostatic acid phosphatase (PAP), being raised in over 90% of cases when carcinoma is first detected by comparison to 50% for PAP. However, PSA lacks the required specificity to be a test for prostatic cancer as it is also increased in most patients with benign prostatic hypertrophy. There has been recent guidance as to the level of PSA test that indicates further investigation is required (1). This reference range takes into account the patients age. PSA is also used as a means of monitoring disease

15. PSA test practicalities PSA is stable in whole blood for up to 16 hours at room temperature - therefore the specimen should reach the laboratory and be separated within this time frame before having a PSA test men should NOT have: an active urinary infection ejaculated in the previous 48 hours exercised vigorously in the previous 48 hours or had a prostate biopsy in the previous 6 weeks it is advised to do the PSA test before the digital rectal examination if possible. If this is not possible then delay the test for one week after the digital rectal examination

16. What is PSA and what else causes it to be raised? The functions of PSA are thought to be: PSA in the serum is found as an proteolytically inactive complex with the serine protease inhibitor alpha1- antichymotrypsin. The causes of a high PSA concentration include: old age acute urinary retention urinary catheterisation prostatitis prostate carcinoma transurethral resection of the prostate benign prostatic hyperplasia

17. PSA VS AGE AGE (YEARS) 50-59 60-69 >70 PSA CUT OFF (ng/ml) >3.0 >4.0 >5.0