Benign Prostatic Hyperplasia

Question 1

What is Benign Prostatic Hyperplasia?

Answer 1

It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.

Question 2

Present of BPH

Answer 2

Hesitancy – difficult starting and maintaining the flow of urine
Weak flow
Urgency – a sudden pressing urge to pass urine
Frequency – needing to pass urine often, usually with small amounts
Intermittency – flow that starts, stops and varies in rate
Straining to pass urine
Terminal dribbling – dribbling after finishing urination
Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night

Question 3

How to score luts symptoms?

Answer 3

IPSS

Question 4

Common causes of raised BPH?

Answer 4

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

Question 5

Treatment of BPH

Answer 5

Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate

The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate. They may be used together where patients have significant symptoms and enlargement of the prostate.

5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.

The surgical options are:

Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision

TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure. The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).

Question 6

TURP Complications?

Answer 6

Bleeding
Infection
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
Urethral strictures
Failure to resolve symptoms