Benign prostatic hyperplasia Flashcards
What is benign prostatic hyperplasia?
● Benign glandular and stromal hyperplasia of the transitional zone of the prostate
● The inner transitional zone enlarges rather than peripheral layer expansion seen in prostate carcinoma
● It is the most frequent cause of LUTS (lower urinary tract symptoms) in adult males
What causes BPH?
- DHT is a potent prostatic growth factor
- Link with hormonal changes (e.g. androgen/oestrogen imbalance as men age)
- Progression from pathological BPH to clinical BPH (i.e. the presence of symptoms) may require additional factors
What are the risk factors for BPH?
> 50 yrs old and positive family history
- reduced risk with soya/vegetable based diets and negative association with cirrhosis
Summaries the epidemiology of benign prostatic hyperplasia
● COMMON
● 70% of men > 70 yrs have histological BPH (50% of them will experience symptoms)
● 24% if ages 40-64
● More common in the west than the east
● More common in Afro-Caribbeans
What are the presenting symptoms of benign prostatic hyperplasia?
- Typically manifests with features of uncomplicated lower urinary tract symptoms (LUTS)
- Storage (aka irritative) Symptoms → frequency, urgency, nocturia
- Voiding (aka obstructive) Symptoms (often predominant symptom) → weak stream, hesitancy (difficulty initiating urination), intermittency, straining to urinate, sensation of incomplete emptying, and post-void dribbling - May have fever with dysuria → suggestive of a complicated UTI
- FUN (Storage) WISE (Voiding)
“FUNWISE”:
- Frequency
- Urgency
- Nocturia
- Weak stream/hesitancy
- Intermittent stream
- Straining to urinate
- Emptying (incomplete)
What signs of benign prostatic hyperplasia can be found on physical examination
- DRE - the prostate is usually smoothly enlarged with a palpable midline groove
- NOTE: there is poor correlation between the size and the severity of the symptoms
- Signs of Acute Retention
o Suprapubic pain
o Distended, palpable bladder - Signs of Chronic Retention
o A large distended painless bladder (volume > 1 L)
o Signs of renal failure
What investigations are used to diagnose/ monitor BPH?
- Transrectal ultrasound-guided needle biopsy → gold standard.
- Urinalysis → normal in uncomplicated BPH; pyuria (pus in urine) may indicate UTI; haematuria might indicate cancer
- PSA → increased PSA may suggest the presence of underlying prostate cancer or prostatitis. Results can guide treatment in men with LUTS.
- Postvoid Residual Volume → measure of urinary retention (>300 mL)
- DRE → smoothly enlarged prostate, palpable midline groove
How is BPH managed?
- Conservative → monitor symptom progression (watchful waiting), lifestyle (avoid caffeine)
- Medical Therapy → α1-blockers (tamsulosin - relax smooth muscle of bladder to decrease resistance to urinary flow), 5α-reductase inhibitors (finasteride - reduced conversion of testosterone to DHT leads to reduced prostate growth)
- Tamsulosin ⇒ dizziness, postural hypotension, retrograde ejaculation.
- Finasteride ⇒ diminished libido, erectile dysfunction, gynaecomastia. Also decreases levels of PSA. May take 6 months before results seen. - Surgical Therapy → Transurethral Resection of the Prostate (TURP)
- Side Effects (TURP) ⇒ TURP syndrome (hyponatraemia, fluid overload, glycine toxicity), urethral stricture/UTI, retrograde ejaculation (most common), perforation of prostate
What possible complications may arise from benign prostatic hyperplasia?
● Recurrent UTI
● Acute or chronic urinary retention
● Urinary stasis
● Bladder diverticula
● Stone development
● Obstructive renal failure
● Post-obstructive diuresis
● Complications of TURP
Summarise the prognosis for patients with benign prostatic hyperplasia
● Mild symptoms are usually well controlled medically
● Most patients get significant relief from surgery
