Benign Prostatic Hyperplasia

Question 1

Definition

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

Aetiology/Risk factors

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

Epidemiology

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

Presenting symptoms (obstructive)

Answer 4

o Hesitancy
o Poor or intermittent stream
o Terminal dribbling
o Incomplete voiding

Question 5

Presenting symptoms (irritative/storage)

Answer 5

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

Question 6

Mnemonic for obstructive and irritative symptoms

Answer 6

TIP: the obstructive and irritative symptoms can be remembered using the mnemonic
FUND HIPS

o Frequency
o Urgency
o Nocturia
o Dysuria
o Hesitancy
o Incomplete voiding
o Poor stream
o Smell/odour

Question 7

Presenting symptoms (retention symptoms)

Answer 7

• 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 8

Signs on physical examination (DRE)

Answer 8

• 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

Question 9

Signs on physical examination (signs of retention)

Answer 9

• 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 10

Investigations

Answer 10

• Urinalysis
o Check for UTI signs and blood

• Bloods
o U&Es - check for impaired renal function
o PSA

• Midstream Urine
o MC&S

• 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

Question 11

Management plan

Answer 11

• 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 (transurethral resection of the prostate)
o Open prostatectomy

Question 12

Possible complications

Answer 12

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

Question 13

Complications of TURP (transurethral resection of the prostate)

Answer 13

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 14

Prognosis

Answer 14

• Mild symptoms are usually well controlled medically

* Most patients get significant relief from surgery