MSN 621 - GU disorders exam questions
with correct answers
Define |benign |prostatic |hyperplasia. |- |CORRECT |ANSWER✔✔-the |nonmalignant |growth |or |
hyperplasia |of |prostate |tissue |and |is |a |common |cause |of |lower |urinary |tract |symptoms |in |men
What |are |the |different |ways |to |describe |BPH? |- |CORRECT |ANSWER✔✔-Several |definitions |
exist |in |the |literature |when |describing |BPH. |These |include |bladder |outlet |obstruction |(BOO), |
lower |urinary |tract |symptoms |(LUTS), |and |benign |prostatic |enlargement |(BPE). |BPH |describes |
the |histological |changes, |benign |prostatic |enlargement |(BPE) |describes |the |increased |size |of |
the |gland |(usually |secondary |to |BPH) |and |bladder |outlet |obstruction |(BOO) |describes |the |
obstruction |to |flow. |Those |with |BPE |who |present |with |BOO |are |termed |benign |prostatic |
obstruction. |Lower |urinary |tract |symptoms |(LUTS) |simply |describe |urinary |symptoms |shared |
by |disorders |affecting |the |bladder |and |prostate |(when |in |reference |to |men). |LUTS |can |be |
subdivided |into |storage |and |voiding |symptoms. |These |terms |have |largely |replaced |those |
historically |termed |"prostatism."
What |causes |the |development |of |BPH? |- |CORRECT |ANSWER✔✔-The |development |of |benign |
prostatic |hyperplasia |is |characterized |by |stromal |and |epithelial |cell |proliferation |in |the |prostate
|transition |zone |(surrounding |the |urethra), |this |leads |to |compression |of |the |urethra |and |
development |of |bladder |outflow |obstruction |(BOO) |which |can |result |in |clinical |manifestations |
of |lower |urinary |tract |symptoms |(LUTS), |urinary |retention |or |infections |due |to |incomplete |
bladder |emptying.
What |can |happen |when |BPH |is |left |untreated |for |long-term? |- |CORRECT |ANSWER✔✔-Long-
term, |untreated |disease |can |lead |to |the |development |of |chronic |high-pressure |retention |(a |
potentially |life-threatening |emergency) |and |long-term |changes |to |the |bladder |detrusor |(both |
overactivity |and |reduced |contractility).
How |do |hormonal |effects |of |testosterone |on |the |prostate |tissue |cause |BPH? |- |CORRECT |
ANSWER✔✔-Although |they |do |not |cause |BPH |directly, |testicular |androgens |are |required |in |
the |development |of |BPH |with |dihydrotestosterone |(DHT) |interacting |directly |with |prostatic |
epithelium |and |stroma. |Testosterone |produced |in |the |testes |is |converted |to |
,dihydrotestosterone |(DHT) |by |5-alpha-reductase |2 |in |prostate |stromal |cells |and |accounts |for |
90% |of |total |prostatic |androgens. |DHT |has |direct |effects |on |stromal |cells |in |the |prostate, |
paracrine |effects |in |adjacent |prostatic |cells, |and |endocrine |effects |in |the |bloodstream, |which |
influences |both |cellular |proliferation |and |apoptosis |(cell |death).
BPH |arises |as |a |result |of |the |loss |of |homeostasis |between |cellular |proliferation |and |cell |death, |
resulting |in |an |imbalance |favoring |cellular |proliferation. |This |results |in |increased |numbers |of |
epithelial |and |stromal |cells |in |the |periurethral |area |of |the |prostate |and |can |be |seen |
histopathologically
What |are |some |risk |factors |for |BPH? |- |CORRECT |ANSWER✔✔-metabolic |syndrome, |obesity, |
hypertension, |and |genetic |factors. |Increasing |in |age |drastically |increases |the |occurrence |of |
BPH.
Describe |metabolic |syndrome |and |BPH |- |CORRECT |ANSWER✔✔-Metabolic |syndrome |refers |to |
conditions |that |include |hypertension, |glucose |intolerance/insulin |resistance, |and |dyslipidemia. |
Meta-analysis |has |demonstrated |those |with |metabolic |syndrome |and |obesity |have |significantly
|higher |prostate |volumes. |Further |studies |looking |at |men |with |elevated |levels |of |glycosylated |
hemoglobin |(Hba1c) |have |demonstrated |an |increased |risk |of |LUTS.
Describe |the |relationship |of |obesity |to |BPH. |- |CORRECT |ANSWER✔✔-Obesity |has |been |shown |
to |be |associated |with |increased |risk |of |BPH |in |observational |studies. |The |exact |cause |is |
unclear |but |is |likely |multifactorial |in |nature |as |obesity |makes |up |one |aspect |of |the |metabolic |
syndrome. |Proposed |mechanisms |include |increased |levels |of |systemic |inflammation |and |
increased |levels |of |estrogens.
Describe |the |relationship |of |genetics |to |BPH. |- |CORRECT |ANSWER✔✔-Genetic |predisposition |
to |BPH |has |been |demonstrated |in |cohort |studies, |first-degree |relatives |in |one |study |
demonstrated |a |four-fold |increase |in |the |risk |of |BPH |compared |to |control. |These |findings |have
|demonstrated |consistency |in |twin |studies |looking |at |the |disease |severity |of |BPH, |with |higher |
rates |of |LUTS |seen |in |monozygotic |twins.
Describe |the |patho |of |BPH. |- |CORRECT |ANSWER✔✔-Both |the |development |of |lower |urinary |
tract |symptoms |and |bladder |outlet |obstruction |in |men |with |BPH |can |be |attributable |to |static |
,and |dynamic |components. |Static |obstruction |is |a |direct |consequence |of |prostate |enlargement |
resulting |in |periurethral |compression |and |bladder |outlet |obstruction. |Here, |periurethral |
compression |requires |increasing |voiding |pressures |to |overcome |resistance |to |flow; |in |addition,
|prostate |enlargement |distorts |the |bladder |outlet |causing |obstruction |to |flow.
Dynamic |components |include |the |tension |of |prostate |smooth |muscle |(hence |the |use |of |5-
alpha |reductase |inhibitors |to |reduce |prostate |volume |and |alpha-blockers |to |relax |smooth |
muscle). |This |is |explained |by |decreases |in |elasticity |and |collagen |in |the |prostatic |urethra |in |
men |with |BPH, |which |may |further |exacerbate |bladder |outlet |obstruction |due |to |loss |of |
compliance |and |increased |resistance |to |flow |and |may |explain |why |prostate |size |alone |is |not |
always |a |predictor |of |disease.
Describe |the |histopathology |of |BPH. |- |CORRECT |ANSWER✔✔-Histological |examination |
demonstrates |that |BPH |is |a |hyperplastic |process |with |an |increase |in |cell |number |on |histology |
(hyperplasia); |these |occur |both |in |the |periurethral |and |transition |zones. |Histological |studies |
have |demonstrated |both |glandular |and |stromal |proliferation. |Specifically, |periurethral |zones |
demonstrate |stromal |nodules, |whereas |glandular |nodular |proliferation |is |seen |within |the |
transition |zone.
Describe |the |lower |urinary |tract |symptoms |of |a |patient |with |BPH. |- |CORRECT |ANSWER✔✔-
Lower |urinary |tract |symptoms |can |be |divided |into |storage |(frequency, |nocturia, |urgency) |and |
voiding |symptoms |(stream, |straining, |hesitancy, |prolonged |micturition) |and |can |help |establish |
other |causes |of |urinary |symptoms |such |as |urinary |tract |infections/overactive |bladder, |in |
addition |to |determining |the |site |affected |(bladder |vs. |prostate). |Men |with |BPH |are |likely |to |
report |predominant |symptoms |of |nocturia, |poor |stream, |hesitancy, |or |prolonged |micturition.
Describe |red |flags |for |BPH. |- |CORRECT |ANSWER✔✔-Red |flags |help |point |to |more |sinister |
causes |of |urinary |symptoms |such |as |bladder/prostate |cancer, |neurology |such |as |cauda |equina,
|or |chronic |high-pressure |retention |(which |can |lead |to |silent |renal |failure). |The |presence |of |
these |can |be |established |by |asking |about |visible |haematuria/bone |pain/weight |loss, |
neurology, |and |nocturnal |enuresis/incontinence, |respectively.
Describe |the |physical |exam |for |a |patient |with |BPH. |- |CORRECT |ANSWER✔✔-In |the |elective |
setting, |the |examination |should |include |abdominal |examination |(looking |for |a |palpable |
bladder/loin |pain) |and |examination |of |external |genitalia |(meatal |stenosis |or |phimosis). |The |
, examination |should |then |conclude |with |a |digital |rectal |examination |making |a |note |in |
particular |of |the |size, |shape |(how |many |lobes), |and |consistency |(smooth/hard/nodular) |of |the |
prostate |(BPH |is |characterized |by |a |smooth |enlarged |prostate).
Further |bedside |evaluation |includes
-Urine |dipstick |(rule |out |other |causes |such |as |infection)
-Post-void |residual |volume |(whether |the |bladder |is |emptied |properly)
-IPSS |(international |prostate |symptom |score)
-Frequency-volume |chart
The |IPSS |stratifies |patients |into |three |groups |on |the |basis |of |symptoms. |They |are: |- |CORRECT |
ANSWER✔✔-mild |(0-7), |moderate |(8-19), |and |severe |(20-35). |Those |with |more |severe |
symptoms |are |less |likely |to |benefit |from |conservative |or |medical |measures.
How |is |BPH |diagnosed? |- |CORRECT |ANSWER✔✔-Standard |investigation |of |BPH |may |include |
bedside |urine |dipstick, |post-void |residual, |IPSS, |and |urine |flow |studies |to |establish |if |there |is |
evidence |of |obstructive |voiding. |Further |tests |may |be |indicated |depending |on |the
|patient/history. |Other |tests |include |blood |test, |urinalysis, |PSA, |US, |flow |studies. |an |cystoscopy.
Describe |blood |tests |with |BPH. |- |CORRECT |ANSWER✔✔-Blood |tests, |including |renal |function |
tests, |are |useful |to |establish |baseline |renal |function |and |can |help |support |the |diagnosis |of |
renal |failure/acute |kidney |injury |in |someone |with |chronic |high-pressure |retention |or |acute |
retention, |for |example.
Describe |urinalysis |with |BPH. |- |CORRECT |ANSWER✔✔-Urine |specimen |testing |can |help |detect |
infection, |non-visible |haematuria, |or |metabolic |disorders |(glycosuria). |Leucocytes |and |nitrites |
are |common |findings |with |infection; |the |presence |of |proteinuria |may |point |towards |
nephrological |conditions. |The |American |urological |association |recommend |urinalysis |using |a |
dipstick |test, |further |tests |may |be |requested |based |on |abnormal |dipstick |findings |(culture, |
etc.).
with correct answers
Define |benign |prostatic |hyperplasia. |- |CORRECT |ANSWER✔✔-the |nonmalignant |growth |or |
hyperplasia |of |prostate |tissue |and |is |a |common |cause |of |lower |urinary |tract |symptoms |in |men
What |are |the |different |ways |to |describe |BPH? |- |CORRECT |ANSWER✔✔-Several |definitions |
exist |in |the |literature |when |describing |BPH. |These |include |bladder |outlet |obstruction |(BOO), |
lower |urinary |tract |symptoms |(LUTS), |and |benign |prostatic |enlargement |(BPE). |BPH |describes |
the |histological |changes, |benign |prostatic |enlargement |(BPE) |describes |the |increased |size |of |
the |gland |(usually |secondary |to |BPH) |and |bladder |outlet |obstruction |(BOO) |describes |the |
obstruction |to |flow. |Those |with |BPE |who |present |with |BOO |are |termed |benign |prostatic |
obstruction. |Lower |urinary |tract |symptoms |(LUTS) |simply |describe |urinary |symptoms |shared |
by |disorders |affecting |the |bladder |and |prostate |(when |in |reference |to |men). |LUTS |can |be |
subdivided |into |storage |and |voiding |symptoms. |These |terms |have |largely |replaced |those |
historically |termed |"prostatism."
What |causes |the |development |of |BPH? |- |CORRECT |ANSWER✔✔-The |development |of |benign |
prostatic |hyperplasia |is |characterized |by |stromal |and |epithelial |cell |proliferation |in |the |prostate
|transition |zone |(surrounding |the |urethra), |this |leads |to |compression |of |the |urethra |and |
development |of |bladder |outflow |obstruction |(BOO) |which |can |result |in |clinical |manifestations |
of |lower |urinary |tract |symptoms |(LUTS), |urinary |retention |or |infections |due |to |incomplete |
bladder |emptying.
What |can |happen |when |BPH |is |left |untreated |for |long-term? |- |CORRECT |ANSWER✔✔-Long-
term, |untreated |disease |can |lead |to |the |development |of |chronic |high-pressure |retention |(a |
potentially |life-threatening |emergency) |and |long-term |changes |to |the |bladder |detrusor |(both |
overactivity |and |reduced |contractility).
How |do |hormonal |effects |of |testosterone |on |the |prostate |tissue |cause |BPH? |- |CORRECT |
ANSWER✔✔-Although |they |do |not |cause |BPH |directly, |testicular |androgens |are |required |in |
the |development |of |BPH |with |dihydrotestosterone |(DHT) |interacting |directly |with |prostatic |
epithelium |and |stroma. |Testosterone |produced |in |the |testes |is |converted |to |
,dihydrotestosterone |(DHT) |by |5-alpha-reductase |2 |in |prostate |stromal |cells |and |accounts |for |
90% |of |total |prostatic |androgens. |DHT |has |direct |effects |on |stromal |cells |in |the |prostate, |
paracrine |effects |in |adjacent |prostatic |cells, |and |endocrine |effects |in |the |bloodstream, |which |
influences |both |cellular |proliferation |and |apoptosis |(cell |death).
BPH |arises |as |a |result |of |the |loss |of |homeostasis |between |cellular |proliferation |and |cell |death, |
resulting |in |an |imbalance |favoring |cellular |proliferation. |This |results |in |increased |numbers |of |
epithelial |and |stromal |cells |in |the |periurethral |area |of |the |prostate |and |can |be |seen |
histopathologically
What |are |some |risk |factors |for |BPH? |- |CORRECT |ANSWER✔✔-metabolic |syndrome, |obesity, |
hypertension, |and |genetic |factors. |Increasing |in |age |drastically |increases |the |occurrence |of |
BPH.
Describe |metabolic |syndrome |and |BPH |- |CORRECT |ANSWER✔✔-Metabolic |syndrome |refers |to |
conditions |that |include |hypertension, |glucose |intolerance/insulin |resistance, |and |dyslipidemia. |
Meta-analysis |has |demonstrated |those |with |metabolic |syndrome |and |obesity |have |significantly
|higher |prostate |volumes. |Further |studies |looking |at |men |with |elevated |levels |of |glycosylated |
hemoglobin |(Hba1c) |have |demonstrated |an |increased |risk |of |LUTS.
Describe |the |relationship |of |obesity |to |BPH. |- |CORRECT |ANSWER✔✔-Obesity |has |been |shown |
to |be |associated |with |increased |risk |of |BPH |in |observational |studies. |The |exact |cause |is |
unclear |but |is |likely |multifactorial |in |nature |as |obesity |makes |up |one |aspect |of |the |metabolic |
syndrome. |Proposed |mechanisms |include |increased |levels |of |systemic |inflammation |and |
increased |levels |of |estrogens.
Describe |the |relationship |of |genetics |to |BPH. |- |CORRECT |ANSWER✔✔-Genetic |predisposition |
to |BPH |has |been |demonstrated |in |cohort |studies, |first-degree |relatives |in |one |study |
demonstrated |a |four-fold |increase |in |the |risk |of |BPH |compared |to |control. |These |findings |have
|demonstrated |consistency |in |twin |studies |looking |at |the |disease |severity |of |BPH, |with |higher |
rates |of |LUTS |seen |in |monozygotic |twins.
Describe |the |patho |of |BPH. |- |CORRECT |ANSWER✔✔-Both |the |development |of |lower |urinary |
tract |symptoms |and |bladder |outlet |obstruction |in |men |with |BPH |can |be |attributable |to |static |
,and |dynamic |components. |Static |obstruction |is |a |direct |consequence |of |prostate |enlargement |
resulting |in |periurethral |compression |and |bladder |outlet |obstruction. |Here, |periurethral |
compression |requires |increasing |voiding |pressures |to |overcome |resistance |to |flow; |in |addition,
|prostate |enlargement |distorts |the |bladder |outlet |causing |obstruction |to |flow.
Dynamic |components |include |the |tension |of |prostate |smooth |muscle |(hence |the |use |of |5-
alpha |reductase |inhibitors |to |reduce |prostate |volume |and |alpha-blockers |to |relax |smooth |
muscle). |This |is |explained |by |decreases |in |elasticity |and |collagen |in |the |prostatic |urethra |in |
men |with |BPH, |which |may |further |exacerbate |bladder |outlet |obstruction |due |to |loss |of |
compliance |and |increased |resistance |to |flow |and |may |explain |why |prostate |size |alone |is |not |
always |a |predictor |of |disease.
Describe |the |histopathology |of |BPH. |- |CORRECT |ANSWER✔✔-Histological |examination |
demonstrates |that |BPH |is |a |hyperplastic |process |with |an |increase |in |cell |number |on |histology |
(hyperplasia); |these |occur |both |in |the |periurethral |and |transition |zones. |Histological |studies |
have |demonstrated |both |glandular |and |stromal |proliferation. |Specifically, |periurethral |zones |
demonstrate |stromal |nodules, |whereas |glandular |nodular |proliferation |is |seen |within |the |
transition |zone.
Describe |the |lower |urinary |tract |symptoms |of |a |patient |with |BPH. |- |CORRECT |ANSWER✔✔-
Lower |urinary |tract |symptoms |can |be |divided |into |storage |(frequency, |nocturia, |urgency) |and |
voiding |symptoms |(stream, |straining, |hesitancy, |prolonged |micturition) |and |can |help |establish |
other |causes |of |urinary |symptoms |such |as |urinary |tract |infections/overactive |bladder, |in |
addition |to |determining |the |site |affected |(bladder |vs. |prostate). |Men |with |BPH |are |likely |to |
report |predominant |symptoms |of |nocturia, |poor |stream, |hesitancy, |or |prolonged |micturition.
Describe |red |flags |for |BPH. |- |CORRECT |ANSWER✔✔-Red |flags |help |point |to |more |sinister |
causes |of |urinary |symptoms |such |as |bladder/prostate |cancer, |neurology |such |as |cauda |equina,
|or |chronic |high-pressure |retention |(which |can |lead |to |silent |renal |failure). |The |presence |of |
these |can |be |established |by |asking |about |visible |haematuria/bone |pain/weight |loss, |
neurology, |and |nocturnal |enuresis/incontinence, |respectively.
Describe |the |physical |exam |for |a |patient |with |BPH. |- |CORRECT |ANSWER✔✔-In |the |elective |
setting, |the |examination |should |include |abdominal |examination |(looking |for |a |palpable |
bladder/loin |pain) |and |examination |of |external |genitalia |(meatal |stenosis |or |phimosis). |The |
, examination |should |then |conclude |with |a |digital |rectal |examination |making |a |note |in |
particular |of |the |size, |shape |(how |many |lobes), |and |consistency |(smooth/hard/nodular) |of |the |
prostate |(BPH |is |characterized |by |a |smooth |enlarged |prostate).
Further |bedside |evaluation |includes
-Urine |dipstick |(rule |out |other |causes |such |as |infection)
-Post-void |residual |volume |(whether |the |bladder |is |emptied |properly)
-IPSS |(international |prostate |symptom |score)
-Frequency-volume |chart
The |IPSS |stratifies |patients |into |three |groups |on |the |basis |of |symptoms. |They |are: |- |CORRECT |
ANSWER✔✔-mild |(0-7), |moderate |(8-19), |and |severe |(20-35). |Those |with |more |severe |
symptoms |are |less |likely |to |benefit |from |conservative |or |medical |measures.
How |is |BPH |diagnosed? |- |CORRECT |ANSWER✔✔-Standard |investigation |of |BPH |may |include |
bedside |urine |dipstick, |post-void |residual, |IPSS, |and |urine |flow |studies |to |establish |if |there |is |
evidence |of |obstructive |voiding. |Further |tests |may |be |indicated |depending |on |the
|patient/history. |Other |tests |include |blood |test, |urinalysis, |PSA, |US, |flow |studies. |an |cystoscopy.
Describe |blood |tests |with |BPH. |- |CORRECT |ANSWER✔✔-Blood |tests, |including |renal |function |
tests, |are |useful |to |establish |baseline |renal |function |and |can |help |support |the |diagnosis |of |
renal |failure/acute |kidney |injury |in |someone |with |chronic |high-pressure |retention |or |acute |
retention, |for |example.
Describe |urinalysis |with |BPH. |- |CORRECT |ANSWER✔✔-Urine |specimen |testing |can |help |detect |
infection, |non-visible |haematuria, |or |metabolic |disorders |(glycosuria). |Leucocytes |and |nitrites |
are |common |findings |with |infection; |the |presence |of |proteinuria |may |point |towards |
nephrological |conditions. |The |American |urological |association |recommend |urinalysis |using |a |
dipstick |test, |further |tests |may |be |requested |based |on |abnormal |dipstick |findings |(culture, |
etc.).
