Benign prostatic hyperplasia

Question 1

Define

Answer 1

• Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland
• Multi-factorial involving smooth muscle hyperplasia, prostatic enlargement, and bladder dysfunction, as well as input from the central nervous system.

Question 2

Explain the pathology

Answer 2

• Lower urinary tract symptoms (LUTS) caused by bladder outlet obstruction due to benign prostatic hyperplasia (BPH), also known as benign prostatic enlargement (BPE), are predominantly due to 2 components: a static component related to an increase in benign prostatic tissue narrowing the urethral lumen and a dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors. Symptoms related to bladder outlet obstruction may also be contributed by bladder over-activity.

Question 3

What is LUTS further defined as?

Answer 3

LUTS are further defined as storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining)

Question 4

What are the risk factors?

Answer 4

• UNKNOWN
• Age over 50 years
• Link with hormonal changes (e.g. androgens)
• Risk Factors: reduced risk with soya/vegetable based diets and negative association with cirrhosis

Question 5

What are the presenting symptoms?

Answer 5

•	Obstructive Symptoms
o	Hesitancy 
o	Poor or intermittent stream 
o	Terminal dribbling 
o	Incomplete voiding 
•	Irritative/Storage Symptoms
o	Frequency 
o	Urgency 
o	Urge incontinence (leakage of urine that accompanies an intense desire to pass water with failure of restraint)
o	Nocturia
•	TIP: the obstructive and irritative symptoms can be remembered using the mnemonic FUND HIPS
o	Frequency
o	Urgency
o	Nocturia
o	Dysuria (uncommon, more suggestive of UTI)
o	Hesitancy
o	Incomplete voiding 
o	Poor stream
o	Smell/odour
•	Acute Retention Symptoms
o	Sudden inability to pass urine 
o	Associated with SEVERE PAIN
•	Chronic Retention Symptoms
o	Painless
o	Frequency - with passage of small volumes of urine 
o	Nocturia is a major feature

Question 6

What are the signs?

Answer 6

• 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

Question 7

What are the 1st investigations?

Answer 7

•	Urinalysis
o	Check for UTI signs and blood – result is pyuria
o	MSU
•	Bloods
o	U&Es - check for impaired renal function 
o	PSA
o	International prostate symptom score
•	Global bother score
•	Volume charting

Question 8

What are some investigations to consider?

Answer 8

• Imaging
o US of urinary tract (check for hydronephrosis)
o Bladder scanning to measure pre- and postvoiding volumes
o Transrectal Ultrasound Scan (TRUS) - allows assessment of bladder size and volume
o Flexible Cystoscopy
• Uroflowmetry

Question 9

How do you manage?

Answer 9

•	In Emergency (acute urinary retention)
o	Catheterisation 
•	Conservative (if mild)
o	Watchful waiting 
•	Medical
o	Selective -blockers (e.g. tamsulosin) relax the smooth muscle of the internal urinary sphincter and prostate capsule 
o	5-reductase inhibitors (e.g. finasteride) will inhibit the conversion of testosterone to dihydrotestosterone, which can reduce prostate size by around 20%
•	Surgery
o	TURP
o	Open prostatectomy

Question 10

What are the possible complications?

Answer 10

• Recurrent UTI
• Acute or chronic urinary retention
• Urinary stasis
• Bladder diverticula
• Stone development
• Obstructive renal failure
• Post-obstructive diuresis

Question 11

What are the complications of TURP (transurethral resection of prostate)?

Answer 11

o	Retrograde ejaculation (you ejaculate up into your bladder because the internal urinary sphincter is relaxed)
o	Haemorrhage 
o	Incontinence 
o	TURP syndrome 
•	DEFINITION: seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid
o	Urinary infection 
o	Erectile dysfunction 
o	Urethral stricture

Question 12

What’s the prognosis?

Answer 12

• Mild symptoms are usually well controlled medically

* Most patients get significant relief from surgery

Question 13

Epidemiology

Answer 13

COMMON

70% of men > 70 yrs have histological BPH (50% of them will experience symptoms)

Prevalence increases with age

More common in the west than the east

More common in Afro-Caribbeans

It is the most frequent cause of LUTS in adult males