benign prostatic hyperplasia

Question 1

symptoms, signs

Answer 1

Lower urinary tract symptoms!

Storage symptoms:
Frequency, urgency, nocturia, dysuria (painful urination)
Voiding symptoms:
Hesitancy, incomplete emptying, poor stream, straining, intermittency, post-void dribbling

Question 2

epidemiology

Answer 2

men above 50 y/o

Question 3

investigation

Answer 3

1st investigations:

• PSA (not very accurate at all)
• urinalysis (check for UTI)
• international prostate symptom score
• global bother score
• volume charting

other:

• ultrasound *
• CT abdo/pelvis *
• cytoscopy * (Indicated in patients for direct visualisation or intervention as indicated, following urinary tract imaging.)
• uroflowmetry
• urodynamic study
• imaging usually for patients with history of urinary tract surgery, recurrent UTIs, or haematuria, presence of urolithiasis or renal insufficiency. Preferred imaging in patients with renal insufficiency or diabetes

Question 4

treatment

Answer 4

• watchful waiting if not bothersome. behavioural management: bladder retraining, restricting fluid intake, review of medication that may exacerbate symptoms
• for bothersome but not indicated for surgery:
  1. tamsulosin (alpha antagonist) – smooth muscle relaxation in the prostate and bladder neck. works within a few days
  2. finasteride (5-alpha-reducatase inhibitor) – reduction of serum dihydrotestosterone (DHT), via inhibition of DHT formation, reducing prostate volume by 20% to 25%. needs few months for effect
  3. sildenafil (phosphodiesterase-5 inhibitor) – PDE-5 inhibitors may improve lower urinary tract symptoms (LUTS), erectile function, and quality of life, and can be considered for patients with comorbid BPH and erectile dysfunction
  4. oxybutynin (anticholinergic agent) – Anticholinergic therapy may benefit men with LUTS that are primarily storage symptoms (also known as irritative symptoms, e.g., frequency and urgency) and in whom the post-void residual volume is not elevated (i.e., is less than 250 mL).

++ all plus behavioural management

• bothersome with indication for surgery, prostate <80g
  1. minimally invasive: TUMT, TUNA, PUL
  moderately invasive: TURP, TUVP, laser vaporisation
• bothersome with indication for surgery, prostate >80g
  1. open prostatetectomy or laser enucleation (HoLEP or ThuLEP)