BPH

Question 1

What can cause a raised PSA?

Answer 1

Prostate cancer, prostatitis, BPH, granulomatous disease.

Question 2

What is BPH?

Answer 2

Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate in the transitional (inner) zone.

Question 3

What is the hormonal imbalance at fault in BPH?

Answer 3

1. Oestrogen increases androgen receptor expression in prostate.
2. Stromal cells produce more androgens which increases androgen levels in the prostate.
3. This increases the growth of stromal and epithelial cells, positive feedback.

Question 4

What causes the gradual urinary tract obstruction in BPH?

Answer 4

1. Increased tone of smooth muscle in prostate.

2. Increased mechanical effort due to the physical bulk of the prostate.

Question 5

What happens to the bladder in BPH?

Answer 5

1. Detrusor muscle undergoes compensatory hypertrophy.
2. It eventually decompensates and relaxes.
3. Bladder dilates continuously until it becomes a big loose sac.

Question 6

What are the risk factors for BPH?

Answer 6

1. Age (particularly over 50) and FHx of BPH.

2. Anti-cholinergic, A-agonists and diuretics may mimic symptoms.

Question 7

What is this a presentation of?
>50 year old male. Hesitancy, weak stream, straining, incomplete voiding, post-micturition dribbling. Frequency, urgency, nocturia. UTI, acute urinary retention.

Answer 7

BPH

Question 8

How is suspected BPH investigated?

Answer 8

1. MSU to rule out UTI
2. PSA (before PR exam) - age related reference ranges
3. USS to identify post-voidal bladder volume.
4. Urodynamics - for flow rate
5. PR exam - diffusely enlarged
6. Transperineal or transrectal US biopsy

Question 9

What is the lifestyle advice given in BPH?

Answer 9

Avoid caffeine and alcohol, relax when voiding, void twice in a row to aid emptying.

Question 10

What are the two main medications for BPH, how do they work, and what are their side effects?

Answer 10

1. Alpha-blockers (tamsulosin) - 1st line, work within a few days, reduce smooth muscle tone. SE: falls, drowsiness, hypotension, nasal congestion, ejaculatory dysfunction.
2. 5a reductase inhibitors (finasteride) - larger prostates, reduce prostate size, several months. SE: impotence, reduced libido.
3. Consider PDE-Vi if there is erectile dysfunction.

Question 11

What is the surgical management for BPH?

Answer 11

If refractory to medical therapy/chosen by patient/complicated BPH:

1. Minimally invasive - transurethral needle ablation (TUNA), prostatic urethral left (PUL)
2. More invasive, better outcomes - transurethral resection of the prostate

Question 12

What are the complications of a TURP procedure?

Answer 12

TUR syndrome, dilutional hyponatraemia, urethral stricture, retrograde ejaculation, perforation of prostate.

Question 13

What are the complications of BPH?

Answer 13

1. If not relieved - hydroureter and hydronephrosis bilaterally
2. Progressive loss of renal function
3. Prone to infection
4. Development of hypertension