Benign Prostatic Hyperplasia

Question 1

Definition

Answer 1

Hyperplasia of the stromal and epithelial cells of the prostate without malignancy. It usually presents with lower urinary tract symptoms.

Question 2

Where does it most commonly affect?

Answer 2

The transition zone of the prostate. Leads to compression of the prostatic urethra.

Question 3

Epidemiology + Risk factors

Answer 3

MEN
Over 50
Affects afro-carribeans > Whites > Asians
Family history
Castration is protective

Question 4

Aetiology

Answer 4

Increased alpha 5 reductase due to ageing which causes an increase in dihydrotestosterone

Question 5

Pathophysiology

Answer 5

With age there is an increased alhpa-5-reductase activity
Testosterone -> dihydrotestosterone (+ also leads to increased oestrogen)
= 10 X more potent = can bind to androgen receptors in the prostate for longer = HYPERPLASIA
Affects the INNER transitional zone of prostate (muscular gland) proliferative + narrows urethra
Compression of the prostatic urethra = difficult to pass urine = builds up in the bladder = smooth muscle walls of bladder contract harder = bladder hypertrophy
Stagnation of urine in bladder can promote bacterial growth = UTI’s

Question 6

Signs and symptoms

Answer 6

lower abdominal tenderness
smooth, enlarged, non-tender prostate
LUTS
Totally occluded urethra = RETENTION, hydronephrosis, UTI, stones
rare: haematuria, haematospermia

Question 7

LUTS

Answer 7

Voiding systems: (Obstructive)
- Weak of intermittent urinary flow
- Straining
- Hesitancy
- Terminal dribbling
- Incomplete emptying
Storage symptoms (irritative)
- urgency
- frequency
- urinary incontinence
- nocturia
- intermittency
Post micturition
- dribbling

Question 8

Diagnosis

Answer 8

FIRST LINE = DRE: shows smooth but enlarged prostate with maintained central sulcus
PSA: high due to more prostate cells
Urinary frequency volume chart: Diary of freq + volume of voiding = minimum 3 days
Urine dipstick: infection, haematuria (bladder cancer)
U+E: if chronic retention

Question 9

Grading score

Answer 9

Intermittent prostate symptom score: tool for assessing severity of LUTS
- 0-7 = mildly symptomatic
- 8-19 = moderate symptomatic
- 20-35 = severely symptomatic

Question 10

Treatment

Answer 10

FIRST LINE = TAMSULOSIN, alfuzosin = alpha-1 antagonist
- decrease smooth muscle tone of the prostate + bladder
- first line if IPSS > 8
- side effects = dizziness, POSTURAL HYPOTENSION, dry mouth, depression
SECOND LINE = FINASTERIDE = 5-alpha reductase inhibitors
- blocks conversion of testosterone to dihydrotestosterone = reduction in prostate volume may slow disease progression
- can take 6 months for symptoms to improve
- side effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
THIRD LINE = Tamsulosin + Finasteride