Benign prostatic hyperplasia (BPH)

Question 1

What is BPH?

Answer 1

• Histological diagnosis
• Non-cancerous hyperplasia of the glandular-epithelial and stromal tissue of the prostate
• Risk increases with age
• Most common cause of bladder outlet obstruction in men

Question 2

Describe the pathophysiology of BPH?

Answer 2

• Cause unclear but likely involves:
  
  • Androgens
  • Transforming growth factor beta (TGFβ) - static component
  • Alpha adrenoreceptor-mediated prostatic smooth muscle contraction - dynamic component

Question 3

What are the risk factors for BPH?

Answer 3

• Age
• Family history
• Afro Caribbean ethnicity
• Obesity

Question 4

What are the clinical features of BPH?

Answer 4

• LUTS
  
  • Voiding symptoms
    
    • hesitance, driblling, incomplete emptying
  • Storage symptoms
    
    • nocturia, urge incontinence
• DRE

Question 5

How can LUTS be quantified in men?

Answer 5

• The International Prostate Symptom Score (IPSS)
  
  • Score 0-5
  • 0 being never, 5 being almost always
• Over the past month how often have you?

Question 6

Name some differentials for BPH?

Answer 6

• Prostate cancer
• UTI
• Overactive bladder
• Bladder cancer

Question 7

What investigations should be performed for someone with suspected BPH?

Answer 7

• Urinary frequency/volume chart
• Urinalysis
• PSA
• Ultrasound
• Urodynamic studies

Question 8

Describe the management of BPH?

Answer 8

• 1st line: Adrenoreceptor antagonist (a-blockers)
  
  • Tamsulosin: relax smooth muscle thus reducing dynamic component
• 2nd line: 5a-reductase inhibitors
  
  • Finasteride: prevent conversion of testosterone to DHT
  • Decreases prostatic volume and thus the static component
• Refractory to medical management:
  
  • Surgery

Question 9

Describe the most commonly used surgical management technique for BPH?

Answer 9

• Transurethral resection of the prostate (TURF)
  
  • Endoscopic removal of obstructive prosate tissue
  • Using diathermy loop to increase urethral lumen size

Question 10

Complications of TURP?

Answer 10

• TURP syndrome
• Haemorrhage
• Erectile dysfunction
• Retrograde ejaculation
• Urethral stricture

Question 11

Side effects of alpha adrenoreceptor blockers?

Answer 11

• Floppy iris syndrome
• Postural hypotension
• Retrograde ejaculation

Question 12

Describe the main complications of BPH?

Answer 12

• High-pressure retention
  
  • Chronic or acute-on-chronic retension causes post-renal AKI
• UTIs
• Significant haematuria episodes

Question 13

Describe TURP syndrome?

Answer 13

• TURP using monopolar energy requires hyperosmolar irrigation
• This can result in significant fluid overload and hyponatraemia as they fluid enters the circulation through exposed venous beds
• Present with confusion, nausea, agitation, visual changes

Question 14

What enzyme is responsible for converting testosterone to dihydrotestosterone?

Answer 14

5-alpha reductase

Question 15

• Which of the following would be classed as a voiding symptom rather than a storage symptom of BPH?
  
  • Nocturia
  • Increased urinary frequency
  • Hesitancy in micturition
  • Urge incontinence

Answer 15

Hesitancy in micturition