Benign Prostatic Hyperplasia

Question 1

Define Benign prostatic hyperplasia

Answer 1

Non-cancerous growth of the prostate gland, leading to narrowing of the urethral lumen and LUTS

Question 2

What is BPE and BOO in relation to BPH

Answer 2

Benign prostatic enlargement (BPE) = clinical finding of enlarged prostate due to BPH
Bladder outflow obstruction (BOO) = bladder outlet obstruction caused by BPH

Question 3

Aetiology of Benign prostatic hyperplasia

Answer 3

Age-related hormonal changes -> androgen/oestrogen imbalance -> Hyperplasia of epithelial and stomal compartments
Changes in prostatic stromal-epithelial interactions
Prostatitis, vascular effects and changes in the glandular capsule (pathological -> clinical)

Question 4

Risk factors for Benign prostatic hyperplasia

Answer 4

Prevalence increases with age (>50)
Global lifetime prevalence is 25%
Black > Caucasian > Asian

Question 5

Symptoms of Benign prostatic hyperplasia

Answer 5

Voiding symptoms: hesitancy, straining, poor stream, incomplete emptying, dribbling, intermittency, double micturition

Storage symptoms: frequency, urgency, incontinence, nocturia

Fever

Question 6

Signs of Benign prostatic hyperplasia on examination

Answer 6

Distended bladder/palpable suprapubic mass

Question 7

Investigations for Benign prostatic hyperplasia

Answer 7

International prostate symptoms score

DRE: smooth enlargement, size of a ping pong ball
Urinalysis + dip: rule out UTI

PSA: raised (DDx prostate cancer)

USS: rule out other causes, may show mass
CT abdomen/pelvis: rule out other causes, may show mass
Cystoscopy - mass, stone, stricture
Uroflowmetry: Peak urinary flow rate <15 L/second
Urodynamic study: abnormal bladder pressure/voiding
TRUS: rule out prostate cancer

Question 8

How is Benign prostatic hyperplasia classified

Answer 8

IPSS* and QoL score
0-7 mild
8-19 moderate
20-35 severe

Question 9

Management for mild Benign prostatic hyperplasia

Answer 9

Watchful waiting (self-monitoring and yearly follow up)

Behavioural management programme (limit fluids, bladder training, treat constipation)

Question 10

Management for moderate Benign prostatic hyperplasia

Answer 10

Medical
Alpha blocker e.g. tamsulosin oral

5 alpha-reductase inhibitor e.g. Finasteride oral

Phosphodiesterase-5 (PDE-5) inhibitor e.g. sildenafil oral

Anticholinergic e.g. tolterodine oral

Question 11

Management for severe Benign prostatic hyperplasia

Answer 11

TUIP (transurethral incision of the prostate) if prostate volume <30g

Photoselective vaporisation of prostate (PVP)

Prostatic urethral lift (PUL)

Transurethral microwave therapy (TUMT)

Transurethral resection of the prostate (TURP) (monopolar or bipolar)

Open prostatectomy or laser enucleation (HoLEP or ThuLEP)

Question 12

Complications of treatment for benign prostatic hyperplasia

Answer 12

Alpha-1 blockers (tamsulosin): dizziness, postural hypotension, dry mouth, depression
5 alpha-reductase inhibitors (finasteride): erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

TURP:
- T urp syndrome
- U rethral stricture/UTI
- R etrograde ejaculation
- P erforation of the prostate

TURP syndrome
Occurs when irrigation fluid (hypo-osmolar 1.2% glycine) enters the systemic circulation. The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity (confusion, convulsions, coma) → broken down to ammonia → visual disturbances and hyperammonaemia

Question 13

Complications of Benign prostatic hyperplasia

Answer 13

BPH progression
UTI
Renal insufficiency
Bladder stones
Haematuria
Sexual dysfunction
Acute urinary retention
Overactive bladder

Question 14

Prognosis for Benign prostatic hyperplasia

Answer 14

Majority of patients can expect at least moderate improvement of symptoms with reduced bother score and improve QoL
LUTS - may affect sexual wellbeing and erectile function
Medical therapy will affect sexual function