Benign prostatic hyperplasia

Question 1

Define benign prostatic hyperplasia

Answer 1

Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland

It is the most frequent cause of LUTS in adult males

Question 2

Explain the aetiology/risk factors of benign prostatic hyperplasia

Answer 2

UNKNOWN

Link with hormonal changes (e.g. androgens)

Risk Factors: reduced risk with soya/vegetable based diets and negative association with cirrhosis

Question 3

Summaries the epidemiology of benign prostatic hyperplasia

Answer 3

COMMON

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

More common in the west than the east

More common in Afro-Caribbeans

Question 4

Recognise the presenting symptoms of benign prostatic hyperplasia

Answer 4

Hesitancy
Poor or intermittent stream
Terminal dribbling
Incomplete voiding
Irritative/Storage Symptoms
Frequency

Urgency
Urge incontinence (leakage of urine that accompanies an intense desire to pass
water with failure of restraint)
Nocturia

Acute Retention Symptoms
Sudden inability to pass urine
Associated with SEVERE PAIN

Chronic Retention Symptoms
Painless
Frequency - with passage of small volumes of urine
Nocturia is a major feature

Question 5

Recognise the signs of benign prostatic hyperplasia on physical examination

Answer 5

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
Suprapubic pain
Distended, palpable bladder

Signs of Chronic Retention
A large distended painless bladder (volume > 1 L)
Signs of renal failure

Question 6

Identify appropriate investigations for benign prostatic hyperplasia

Answer 6

Urinalysis - Check for UTI signs and blood

Bloods

U&Es - check for impaired renal function

PSA

Midstream Urine

MC&S

Imaging

US of urinary tract (check for hydronephrosis)

Bladder scanning to measure pre-and postvoiding volumes

Transrectal Ultrasound Scan (TRUS) - allows assessment of bladder size and volume

Flexible Cystoscopy

Question 7

Generate a management plan for benign prostatic hyperplasia

Answer 7

In Emergency (acute urinary retention) - Catheterisation

Conservative (if mild) - Watchful waiting

Medical - Selective a-blockers, (e.g. tamsulosin) relax the smooth muscle of the internal urinary sphincter and prostate capsule

5a-reductase inhibitors, (e.g. finasteride) will inhibit the conversion of testosterone to dihydrotestosterone, which can reduce prostate size by around 20%

Surgery
TURP
Open prostatectomy

Question 8

Identify possible complications of benign prostatic hyperplasia

Answer 8

Recurrent UTI
Acute or chronic urinary retention
Urinary stasis
Bladder diverticular
Stone development
Obstructive renal failure

Post-obstructive diuresis

Complications of TURP
Retrograde ejaculation (you ejaculate up into your bladder because the internal urinary sphincter is relaxed)
Haemorrhage
Incontinence
TURP syndrome = DEFINITION: seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid

Urinary infection
Erectile dysfunction
Urethral stricture

Question 9

Summarise the prognosis for patients with benign prostatic hyperplasia

Answer 9

Mild symptoms are usually well controlled medically

Most patients get significant relief from surgery