Benign Prostatic Hyperplasia

Question 1

Epidemiology and Etiology of BPH

Answer 1

Epidemiology: Prevalence increases with age, ~50% of men by age 50, ~80% of men by age 80

Etiology:
- Hormonal factors: Androgens [DHT, gene amplification of androgen receptors]; Estrogens [mainly estradiol]; Androgen-Estrogen imbalance [with age due to decline in androgen production but no change in estrogen production; with obesity]
- Stem cell proliferation and longevity: abnormal proliferation and longer stem cell life-span
- Genetic Susceptibility: Genes involved in BPH development like growth factor genes, apoptosis genes, androgen-regulated genes

Question 2

Clinical Features of BPH

Answer 2

• Frequency of urination
• Urgency to urination
• Nocturia
• Weak stream/Hesitancy to urine aka strart micturition
• Intermittent stream
• Straining to urinate
• Emptying aka incomplete emptying feeling of bladder, terminal dribbling

Additional symptoms include Gross Hematuria and DRE findings of symetrical enlarged, smooth [no nodules], firm and nontender prostate

FUNWISE pneumonia

Most common and most likely noticed sign for BPH is Urinary issues
Categorized as STORAGE LUTS (Overactive Bladder) and VOIDING LUTS (Bladder Outflow Obstruction)
Urodynamic studies can help identify the predominant type of LUTS

Question 3

General Approach to BPH Dx

Answer 3

Suspect BPH in patients ≥ 45 years of age with uncomplicated LUTS

1.Initial Assessment: Determine if LUTS is attributable to BPH
- Obtain detailed medical history and physical examination (check for anal sphincter tone, feeling bladder), including DRE and Urinalysis
- Assess for complicated LUTS features
- Keeping a voiding diary
- Assess severity of LUTS using IPSS
- Urinalysis for all patients with LUTS

2.Additional Diagnostics: these are not routinely administered
- Serum PSA levels [shared decision making in patients where Prostate cancer could change management and for pharmacotherapy selection in BPH]
- RFT or imaging of Upper Urinary Tract [suspecion of renal impairement]
- Postvoid residue and Uroflowmetry in patients with Bladder outflow obstruction
- US/TRUS/CT or MRI Pelvis

Question 4

IPSS categories

Answer 4

• 0–7 points: mild symptoms
• 8–19 points: moderate symptoms
• 20–35 points: severe symptoms

Question 5

Causes of LUTS other than BPH and Prostate Cancer

Answer 5

• Bladder outlet obstruction
• Neurogenic bladder
• Detrusor underactivity
• Urinary tract infection
• Diuretic use

Question 6

General Approach to Treatment of BPH

Answer 6

Treatment selection should be guided by symptom severity and the size of the prostate (e.g., on imaging or as estimated using serum PSA levels)

• LUTS causing little to no bother: Watchful waiting that includes Review of medications, Dietary advice, Education about bladder emptying techniques (bladder retraining, Double voiding techniques, Urethral milking)
• Bothersome LUTS attributable to BPH: The choice of medication depends on the predominant symptoms, prostate size, and serum PSA levels. Medications include Alpha blockers (relaxes Bladder neck smooth muscles), 5-alpha reductase inhibitors (aka 5-ARIs, decreases production of DHT to decrease prostate enlargement and increase apoptosis in prostate), Antimuscarinics (symptomatic relief of Overactive bladder and decrease Detrussor muscle tone; Assess PVR volume before initiating) and Phosphodiesterase type 5 inhibitors (increase intracellular cGMP to decrease muscle tones in Detrussor, Prostate and Urethra)

Surgical therapy, like Transurethral Resection of Prostate (TURP) for insufficient pharmacotherapic effects/Development of intolerable complications with medications/BPH causing complications (Like recurrent UTIs, Urinary retention, Bladder calculi, Hydronephrosis, CKD, Gross hematuria)