Benign prostatic hyperplasia

Question 1

What is benign prostatic hyperplasia (BPH)?

Answer 1

Very common benign condition in men of increasing age caused by hyperplasia of the stromal and epithelial cells of the prostate

Question 2

How common is BPH?

Answer 2

Affects up to 40% of men over 40, and 90% of men over 80

Question 3

What causes BPH?

Answer 3

Lifelong exposure to androgens
Genetic component
Dietary components (E.g. High red meat diet)

Question 4

Describe the pathophysiology of BPH

Answer 4

• Microscopically there is hyperplasia of both the connective (stromal) tissue, and of the glandular (epithelial) tissue
• Thought to be the result of a failure of apoptosis
• The prostate naturally grows throughout life - it grows in response to dihydrotestosterone (breakdown product of testosterone)
• The majority of growth occurs in the transitional zone

Question 5

Does BPH increase cancer risk?

Answer 5

No
BPH occurs in transitional zone
Prostate cancer occurs in peripheral zone

Question 6

What is meant by LUTS?

Answer 6

Lower Urinary Tract Symptoms

Question 7

How will BPH present?

Answer 7

LUTS:
- Frequency
- Nocturia
- Hesitation
- Reduced force
- Post-void dribbling
- Urinary retention
- Incontinence

Question 8

What is meant by urinary frequency?

Answer 8

Increased number of toilet trips required

Question 9

What is meant by urinary urgency?

Answer 9

An increased need to urinate urgently

Question 10

What is the main symptom score used in BPH?

Answer 10

IPSS - International Prostate Symptoms Score

Question 11

What investigations are required in BPH?

Answer 11

Urine dipstick
PSA blood test
Bladder diary
Fluid chart - Input and output
Rectal exam
Uroflow? Ultrasound? Bladder scan?

Question 12

What are some lifestyle management options in BPH?

Answer 12

• Reduce caffeine
• Reduce citrus intake
• Reduce spicy food intake
• Reduce alcohol intake
• Increase water intake
• Stop drinking fluids 2-3 hours before bed

Question 13

What are some drugs used to manage BPH?

Answer 13

Alpha-Blockers
5-alpha reductase inhibitors

Question 14

What is the MOA of alpha-blockers in BPH?

Answer 14

They relax the smooth muscle of the prostate

Question 15

Example of an alpha blocker in BPH management

Answer 15

Tamsulosin (400mcg OD)

Question 16

MOA of 5-alpha reductase inhibitors in BPH

Answer 16

Block testosterone and actually help reduce the size of the prostate

Question 17

Example of a 5a reductase inhibitor in BPH

Answer 17

Finasteride

Question 18

Side effects of 5a-reductase inhibitors

Answer 18

• Decreased libido
• Depression
• Anxiety
• Erectile dysfunction

Question 19

What are the 2 types of catheter?

Answer 19

• Transurethral
• Suprapubic

Question 20

How is suprapubic catheterisation performed?

Answer 20

With ultrasound, usually in theatre and passes through the skin and into the bladder

Question 21

What are some surgical management options in BPH?

Answer 21

Trans-urethral resection of the prostate (TURP)
Trans-urethral electrovaporisation of the prostate (TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via abdominal or perineal incision

Question 22

What is involved in transurethral resection of the prostate?

Answer 22

Question 23

What is involved in holmium laser enucleation of the prostate (HoLEP)

Answer 23

• Follows the anatomical plane between the gland and capsule
• Minimal bleeding
• Next day discharge without catheter

Question 24

What are some indications for prostate surgery in BPH?

Answer 24

• Failed medical treatment and lifestyle changes
• Recurrent retention
• High pressure chronic retention - Renal impairment
• Recurrent haematuria related to enlarged prostate
• Bladder stones
• Bladder diverticulum
• Recurrent infections