Benign prostatic hyperplasia (BPH) Flashcards
What is BPH?
Multi-factorial disease involving smooth muscle hyperplasia, prostate enlargement and bladder dysfunction, as well as input from the CNS.
How does BPH present?
Presents with both storage symptoms (frequency, urgency, nocturia and incontinence) and voiding symptoms (weak stream, dribbling, dysuria and straining).
What would a physical examination show?
Prostate volume > 30g
Nodules or tenderness suspicious of prostate cancer or prostatitis.
How can BPH cause lower urinary tract symptoms (LUTS)?
This is predominantly due to 2 components:
- Static component related to an increase in benign prostatic tissue narrowing the urethral lumen
- Dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors.
Aetiology of BPH
Hyperplasia of the epithelial and stromal compartments, particularly in the transitional zone.
Hyperplasia may be attributed to various factors such as:
Shifts in age-related hormonal changes creating androgen/oestrogen imbalances.
Signs and symptoms of BPH
Storage symptoms
Void symptoms
Urinary retention (uncommon)
Fever with dysuria (uncommon)
Risk factors
Older than 50 Weak: FHx Non-Asian race Cigarette smoking Male pattern baldness Metabolic syndrome
Investigations of BPH
Urinalysis
PSA -increased PSA suggests prostate cancer or prostatitis.
IPS score- self-administered patient questionnaire
Consider:
Ultrasound
CT abdomen/pelvis
Cystoscopy- mass, stone, stricture
Uroflowmetry-Less than 20ml/second
Urodynamic study- Abnormal bladder pressure
Differentials of BPH
Overactive bladder Prostatitis Prostate cancer UTIs Bladder cancer Neurogenic bladder Urethral stricture
Management
-The main goal is to improve LUTS to improve quality of life.
-Patients should be advised to (behavioural management programme):
Limit fluids
Bladder training
Treatment of constipation
-Watchful waiting & behavioural management programme
for mild symptoms
-Bothersome symptoms with no indications for surgery:
Alpha-blocker + behavioural management programme
Or 5- alpha-reductase inhibitor (finasteride, dutasteride)
Or phosphodiesterase-5(PPE-5) inhibitor (Sildenafil, tadalafil, vardenafil)
Or Anticholinergic agent (Tolterodine, fesoterodine, oxybutynin, solifenacin)
2nd line: the combination of an alpha-blocker with one of the above drugs (usually 5-alpha-reductase inhibitors)
How does 5-alpha-reductase inhibitor work?
5-alpha-reductase inhibitors work through reduction of serum dihydrotestosterone (DHT), via inhibition of DHT formation, reducing prostate volume by 20% to 25%.
They require several months of use to improve symptoms.
How do alpha-blockers work?
Alpha-blockers work through smooth muscle relaxation in the prostate and bladder neck.
The predominant receptor type in the prostate and bladder is the alpha-1A receptor.
Alpha-blockers are efficacious within a matter of a few days and are usually well tolerated.
When is surgery indicated as a treatment for BPH?
Surgery is indicated in patients if they have: chosen surgery as primary treatment; refractory responses to medication; complications attributed to BPH such as renal insufficiency, bladder stones, recurrent haematuria or UTIs, or the development of urinary tract retention.
Surgery in BPH
Prostate < 80g:
-Minimally invasive therapy-
Minimally invasive therapies include transurethral micro therapy (TUMT), transurethral needle ablation (TUNA), and prostatic urethral lift (PUL).
-Moderately invasive therapy-
Moderately invasive procedures are TURP and transurethral vaporisation of the prostate (TUVP) and laser vaporisation.
Prostate > 80g:
Open prostatectomy has become less common for LUTS as other techniques have continued to gain acceptance.
It is generally only recommended for patients who are good surgical candidates and have significantly enlarged prostates (typically ≥80 grams).
Clinicians should consider laser enucleation (holmium laser enucleation [HoLEP] or thulium laser enucleation [ThuLEP]), depending on their expertise with either technique, as prostate size-independent suitable options.
Complications of BPH
Acute urinary retention Overactive bladder Short: BPH progression UTIs Renal insufficiency Bladder stones Haematuria Sexual dysfunction
