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

• Obstructive Symptoms
• Irritative/Storage Symptoms
• Acute Retention Symptoms
• Chronic Retention Symptoms

Question 5

Obstructive Symptoms

Answer 5

Hesitancy

Poor or intermittent stream

Terminal dribbling

Incomplete voiding

Question 6

Irritative/Storage Symptoms

Answer 6

Frequency

Urgency

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

Nocturia

Question 7

FUND HIPS

Answer 7

Frequency

Urgency

Nocturia

Dysuria

Hesitancy

Incomplete voiding

Poor stream

Straining

Question 8

Acute Retention Symptoms

Answer 8

Sudden inability to pass urine

Associated with SEVERE PAIN

Question 9

Chronic Retention Symptoms

Answer 9

Painless

Frequency - with passage of small volumes of urine

Nocturia is a major feature

Question 10

Recognise the signs of benign prostatic hyperplasia on physical examination

Answer 10

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 11

Identify appropriate investigations for benign prostatic hyperplasia

Answer 11

Urinalysis-Check for UTI signs and blood

Bloods

• U&Es - check for impaired renal function
• ProstateSpecificAntigen

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 12

Generate a management plan for benign prostatic hyperplasia

Answer 12

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- transurethral resection of the prostate

Open prostatectomy

Question 13

Complications of TURP

Answer 13

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 14

Identify possible complications of benign prostatic hyperplasia

Answer 14

Recurrent UTI

Acute or chronic urinary retention

Urinary stasis

Bladder diverticula

Stone development

Obstructive renal failure

Post-obstructive diuresis

Question 15

Summarise the prognosis for patients with benign prostatic hyperplasia

Answer 15

Mild symptoms are usually well controlled medically

Most patients get significant relief from surgery