Benign Prostatic Hyperplasia

Question 1

What is Benign Prostatic Hyperplasia?

Answer 1

A benign condition caused by hyperplasia of the stromal and epithelial cells of the prostate gland.

Question 2

Epidemiology of BPH (3).

Answer 2

1. 50% of 50 year old men have evidence of BPH - 30% have symptoms.
2. 80% of 80 year old men will have evidence of BPH.
3. Black > White > Asians.

Question 3

Clinical Presentation of BPH.

Answer 3

LUTS - Lower Urinary Tract Symptoms.

Question 4

Give 9 Clinical Features of LUTS.

Answer 4

1. Hesitancy (V/O).
2. Weak Flow (V/O).
3. Urgency (S/I).
4. Frequency (Small but Frequent) (S/I).
5. Straining to Void (V/O).
6. Terminal Dribbling (V/O + Post-Micturitive).
7. Incomplete Emptying (V/O).
8. Nocturia (S/I).
9. Intermittency (Flow Start, Stop, Restart) (V/O).

V/O = Voiding / Obstructive Symptoms.
S/I = Storage / Irritative Symptoms.

Question 5

Assessing Severity of LUTS (2).

Answer 5

1. IPSS - International Prostate Symptom Score.

2. 0-7 = Mildly Symptomatic; 8-19 = Moderately Symptomatic; 20-25 Severely Symptomatic.

Question 6

Pathophysiology of BPH (3).

Answer 6

1. Overgrowth of Prostatic Tissue in the Transitional Zone of the Prostate around the Prostatic Urethra.
2. Hyperplasia of Cellular Elements in Prostate (e.g. Epithelium, Smooth Muscle, Fibrous Tissue).
3. Formation of Large Nodules.

Question 7

Why is compression of the prostatic urethra a gradual change?

Answer 7

Hyperplasia is gradual.

Question 8

BPH Effects on Bladder (4).

Answer 8

1. Detrusor muscle of bladder has to generate higher pressure to eject urine - compensatory hypertrophy.
2. Visible as trabeculations.
3. Eventual Decompensation - Bladder will relax and become a big flabby sac with little power of contraction.
4. If obstruction is not relieved - bilateral hydroureter and hydronephrosis.

Question 9

What is Hydronephrosis?

Answer 9

Progressive Atrophy of the Renal Parenchyma leading to a progressive loss of renal function.

Question 10

What is Obstructive Nephropathy?

• Definition.
• Common Cause.
• Common Complication.

Answer 10

Definition : A state of renal dysfunction caused by obstruction to the flow of urine.
Common Cause : BPH.
Common Complication : Infection - Stasis.

Question 11

Initial Investigations of BPH (5).

Answer 11

1. DRE - Prostate Exam (Size, Shape, Characteristics).
2. Abdominal Exam - Distended Palpable Bladder.
3. Urinary Frequency Volume Chart (3 days of Fluid Intake/Output).
4. Urine Dipstick - Infection, Haematuria.
5. PSA.

Question 12

Management of Benign Prostatic Hyperplasia (3).

Answer 12

1. Reassurance and Lifestyle Management.
2. Medical Management - a-Blockers; 5-a-Reductase Inhibitors.
3. Surgical Management - TURP, TUVP, HoLEP, Open Prostatectomy.

Question 13

Lifestyle Management (3).

Answer 13

1. Urgency/Nocturia - Reduce Caffeine and Alcohol Intake.
2. Urgency - Practise Distraction Methods.
3. Voiding - Bladder Training.

Question 14

Examples of a-Blockers (4).

Answer 14

1. Tamsulosin 400mg Once Daily.
2. Alfuzosin.
3. Doxazosin.
4. Terazosin.

Question 15

Mechanism of Action of a-Blockers.

Answer 15

a-1 antagonists that relax smooth muscle in the prostate and bladder.

Question 16

Indication of a-Blockers.

Answer 16

1st line management if IPSS is 8 or more - rapid improvement in symptoms.

Question 17

Contraindication of a-Blockers.

Answer 17

Postural Hypotension.

Question 18

Adverse Effects of a-Blockers (4).

Answer 18

1. Postural Hypotension (especially after the first dose).
2. Dizziness.
3. Dry Mouth.
4. Depression.

Question 19

Examples of 5-a-Reductase Inhibitor.

Answer 19

Finasteride.

Question 20

Mechanism of Action of 5-a-Reductase Inhibitors.

Answer 20

Inhibit the enzyme that converts Testosterone into more active DHT and cause a reduction in prostate volume too.

Question 21

Indication of 5-a-Reductase Inhibitors.

Answer 21

2nd line management of BPH to slow disease progression but can take up to 6 months for symptoms to improve.

Question 22

Contraindication of 5-a-Reductase Inhibitor.

Answer 22

Pregnancy - Male Foetus (External Genitalia).

Question 23

Adverse Effects of 5-a-Reductase Inhibitors (5).

Answer 23

1. Erectile Dysfunction.
2. Reduced Libido.
3. Ejaculation Problems.
4. Gynaecomastia.
5. Hair Growth.

Question 24

What is TURP?

Answer 24

Transurethral Resection of the Prostate - resectoscope access the Prostate through penile urethra and shave off tissue using Diathermy to create a wider space for urine to flow through.

Question 25

Complications of TURP (5).

Answer 25

FIRES :-

1. Failure to Resolve Symptoms.
2. Incontinence.
3. Retrograde Ejaculation.
4. Erectile Dysfunction.
5. Strictures.
   * Bleeding, Infection, Pain.

Question 26

What is TUVP?

Answer 26

Transurethral Electrovaporisation of the Prostate - resectoscope is inserted into the urethra and then a rollerball electrode is rolled across the prostate to vaporise the tissue and create a more expansive space for urine flow.

Question 27

What is HoLEP?

Answer 27

Holmium Laser Enucleation of the Prostate - resectoscope is inserted into the urethra and then laser is used to remove prostate tissue and create a more expansive space for urine flow.

Question 28

What is an Open Prostatectomy?

Answer 28

An abdominal/perineal incision is used to assess the prostate and then the prostate is removed - less preferred due to increased risk of complications, longer hospital stay and recovery.