Benign Prostatic Hyperplasia Flashcards
What is BPE?
Enlargment most commonly due to BPH.
What is BPH?
A histological diagnosis and is characterised by non-cancerous hyperplasia of the glandular epithelial and stromal tissue of the prostate.
Why might you see LUTS in BPH?
Because BPH is the most common cause of Bladder Outlet Obstruction
However 15-30% of men over 65 have LUTS regardless of BPH
Pathophysiology
The exact mechanism is unknwon.
Androgens seem to play a role, particularly in the development of the gland in adolescence and then future development of BPH.
Prostate converts testosterone to dihydrotestostone DHT using the enzyme 5-alpha reductase.
DHT is more potent and accounts for 90% of androgen in the tissue.
The prostate retains the ability to respond to testosterone and thus levels of DHT also remain high throughout life.
Risk factors
Age
FH
Afro-Caribbean ethnicity
Obesity
Clinical features
LUTS with either voiding (hesitancy, weak strea, terminal dribbling or incomplete emptying) or storage (urinary frequency, nocturia, nocturnal enuresis or urge incontinence)
Other less common symptoms are haematuria and haematospermia
Examinations
DRE is essential especially to distinguish between BPH and prostate cancer
Firm, smooth and symmetrical prostate is a reassuring sign
International Prostate Symptom Score should be done as well IPSS
Explain IPSS
A screening tool used to evaluate and quantify LUTS
Dx
Prostate cancer - may present with LUTS but is usually asymmetrical, craggy/nodular prostate + raised PSA
UTI
Overactive bladder
Bladder cancer
Initial investigations
Urinary frequency and volume chart should also be done in LUTS
Bedside urinalysis to exclude UTI
Post-void bladder scan if there is any retention
PSA might be done if indicated from DRE, it can however be increased in BPH as well.
Imaging
USS-KUB might be done to calculate the volume of the prostate alongside assessment of the rest of the urinary tract for urinary retention and hydronephrosis.
Urodynamic studies can also show bladder contractility, flow rate and storage capacity. Bladder outlet obstruction index (BOOI) can help diagnose obstructive voiding related to BPH
On USS-KUB what is defined as an enlarged prostate?
>30ml
Initial management
Since it is an incidental finding quite commonly patients just needs to be reassurd.
Ask patient to keep a symptom diary and provide a medication review
Give suitable lifestyle advice about moderate caffeine intake and alcohol intake.
Indications of medical management
Most men with symptomatic BPH
Medical management
First line is an alpha blocker like Tamsulosin
They act by relaxing the prostatic smooth muscle by blocking alpha-receptor leading to a reduction in the dynamic component.
They provide symptomatic benefit within a few days.
Side effects of tamsulosin
Postural hypotension
Retrograde ejaculation
Floppy-Iris Syndrome
What should be tried if the patient remains symptomatic despite alpha blocker?
5alpha-reductase inhibitors like Finasteride which prevent the conversion of testosterone to DHT leading to a decrease in prostatic volume.
Note that it can take up to 6 months to perceive any symptomatic benefit
Indications of surgical management
Refractory through medical management or develop signficant sequale of BPH like high pressure retention
Surgical approaches
TURP (most commonly used=
Holmium laser enucleation of the prostate (HoLEP)
PVP
TUVP
TUMT
Explain TURP
This involves endoscopic removal of obstructive prostate tissue by using a diathermy loop to increase the urethral lumen size.
Complications include haemorrhage, sexual dysfunction, retrograde ejaculation and urethral strictures.
Explain HoLEP
Holmium:YAG laser is used to heat and dissect section of the prostate into the bladder.
It is becoming more popular due to excellent outcomes and reduced post-op complications
It is only used in a limited fashion due to it being a technically challenging procuedure
What is PVP, TUVP and TUMT?
PVP = Photoselective vaporisation of the Prostate
TUVP = Transurethral vaporisation of the prostate
TUMT = Transurethral microwave thermotherapy
Complications of BPH
High-pressure retention with chronic or acute-on-chornic urinary retention leading to post AKI
Recurrent UTI
Significant haematuria
TURP syndrome
What is TURP syndrome?
A rare but potentially life-threatening complication of TURP
TURP needs hypoosmolar irrigation during the procedure it can lead to significant fluid overload and hyponatraemia when the fluid enter the circulation through exposed venous beds.
Clinical features of TURP syndrome
Confusion
Nausea
Agitation
Visual changes
This needs urgent management by carefully reducing the level of hyponatraemia.
