Benign Prostatic Hyperplasia Flashcards
Benign prostatic hyperplasia (BPH) is characterised by hyperplasia resulting in … … tract symptoms
Benign prostatic hyperplasia (BPH) is characterised by hyperplasia resulting in lower urinary tract symptoms (LUTS).
In BPH, prostatic hyperplasia (increased cell … leading to …) leads to urinary frequency, incomplete emptying, dribbling, hesitancy and nocturia. It may also be complicated by acute or chronic urinary ….
In BPH, prostatic hyperplasia (increased cell proliferation leading to enlargement) leads to urinary frequency, incomplete emptying, dribbling, hesitancy and nocturia. It may also be complicated by acute or chronic urinary retention.
BPE vs BPH?
You may come across the term benign prostatic enlargement (BPE). This refers to a clinical finding on digital rectal examination (DRE), BPH refers to a histological diagnosis.
BPH is common with incidence increasing with … ….
BPH is common with incidence increasing with advancing age.
What age do patients usually get BPH?
Whilst rare before the age of 40, it affects 30-40% of men older than 50. It is seen in around 90% of men aged 90. Men of African origin are more commonly affected.
Aetiology of BPH:
The aetiology of BPH is poorly understood.
BPH is common with increasing age. It is a hormone-dependent process involving testosterone and dihydrotestosterone production. A failure of normal apoptosis and abnormal epithelial and stromal proliferation have been implicated.
This proliferation occurs primarily in the transition zone of the prostate, this leads to restriction of the prostatic urethra and urinary flow.
Clinical features of BPH: (7)
Urinary frequency Nocturia Incomplete emptying Decreased urinary flow Dribbling Hesitancy Retention (acute or chronic)
Urinary frequency Nocturia Incomplete emptying Decreased urinary flow Dribbling Hesitancy Retention (acute or chronic)
All symptoms of what?
BPH
What is the name for the score that categorises the impact of prostate symptoms?
The International Prostate Symptom Score is a questionnaire that categorises the impact of prostate symptoms. (IPSS)
What are the IPSS categories?
It consists of seven questions about symptoms, each of which can be rated 0-5 depending on the frequency with which the symptoms are experienced. The scores of the seven symptomatic questions can be categorised as mild, moderate or severe.
A final (eighth) question asks about quality of life based upon the impact of the disease on a scale of 0-6.
What exam is vital in assessing the prostate?
Digital rectal examination
This is a key component of the examination and allows for assessment of the rough size of the prostate.
Irregular enlargement should raise concerns and further investigation for cancer. Evidence of reduced anal tone may be indicative of neurogenic causes of LUTS.
Urinary investigations in suspected BPH
Dip & MSU: in patients with LUTS, infection must be considered. This can be evaluated with a urine dipstick and MSU.
Post-void residual: bladder USS can be used to quantify residual volume (post-void refers to scanning after the patient has passed urine).
Bloods for suspected BPH (3)
FBC
UEs
LFTs (ALP may be elevated in prostatic cancer with bony metastasis)
Prostate-specific antigen (PSA) helps to do what?
Helps stratify the risk of prostate cancer. PSA is by no means a perfect test and may be elevated in the absence of malignancy.
Vigorous exercise and ejaculation should be avoided for 48hrs prior to the test. PSA may be elevated in (or following) urinary or prostatic infections or in the 6 weeks following a prostatic biopsy.
Imaging for suspected BPH
USS: this can be abdominal or transrectal. It can evaluate the size of the prostate. Also used in patients with urinary retention to evaluate for hydronephrosis.
MRI prostate: typically reserved for evaluation and diagnosis of malignancy.
Uroflowmetry for suspected BPH:
Urinary flow assessment is a non-invasive test that evaluates urodynamics. Two parameters that you will likely hear mentioned are Qmax (the maximum flow rate) and flow pattern, calculated with a void volume > 150ml. Different threshold values may be used (giving different sensitivities and specificities) and within-subject variability is seen.
Conservative management of BPH:
Consider watchful waiting in those with mild disease and symptoms. Medical and surgical therapies have complications that may be avoided or delayed.
In certain circumstances, a long-term catheter (changed every 3 months) is used for management.
Medical management of BPH:
Alpha-blockers (e.g. Tamsulosin): these inhibit the action of noradrenaline on the smooth muscle in the prostate resulting in reduced tone. Though they help with LUTS, alpha-blockers do not appear to prevent urinary retention or reduce the proportion that eventually needs surgery.
5-alpha reductase inhibitors (e.g. Finasteride): these reduce the production of dihydrotestosterone (DHT) which mediate androgen effects on the prostate. This leads to apoptosis of prostatic epithelial cells and reduction in prostate volume. They take up to 6 months to start having a clinically apparent effect. They have been shown to reduce the rate of acute urinary retention and the need for surgery.
