BPH

Question 1

What is BPH caused by?

Answer 1

Hyperplasia of stromal and epithelial cells of the prostate due to increased DHT

Question 2

How does BPH usually present?

Answer 2

Lower urinary tract symptoms

Question 3

What are the typical lower urinary tract symptoms that occur with prostate pathology?

Answer 3

Hesitancy– Difficulty starting and maintaining flow

Weak flow

Urgency – Sudden urge to pass urine

Frequency – Needing to pass urine often, usually with small amounts

Intermittency – Flow that starts, stops and varies in rate

Straining to pass urine

Terminal dribbling – Dribbling after finishing urination

Incomplete emptying – Unable to fully empty bladder, with chronic retention

Nocturia – Having to wake to pass urine multiple times at night

Question 4

What scoring system can be used to assess severity of lower urinary tract symptoms?

Answer 4

IPSS (international prostate symptom score)

Question 5

What is done on initial assessment of men with LUTS?

Answer 5

DRE
Abdominal exam
Urinary frequency volume chart
Urine dipstick
Prostate-specific antigen

Question 6

Why is it essential to counsel patients before testing PSA?

Answer 6

75% false positives
15% false negatives

False positive leads to further investigations, may lead to complications etc.

False negatives may lead to false reassurance

Question 7

What can cause raised PSA?

Answer 7

Prostate cancer
BPH
Prostatitis
UTI
Vigorous exercise (cycling especially)
Recent ejaculation or prostate stimulation

Question 8

On examination of the prostate what does a benign prostate feel like vs a cancerous prostate?

Answer 8

Benign
-Smooth
-Symmetrical
-Slightly soft
-Central sulcus

Cancerous
-Firm/hard
-Asymmetrical
-Craggy or irregular
-No central sulcus

Question 9

What medical options are used to manage BPH?

Answer 9

Alpha-blockers
Tamsulosin- rapidly improves symptoms, A1 blocker can cause postural hypotension

5-alpha reductase inhibitors
Finasteride- prevents DHT formation, reducing size of the prostate

Question 10

Why does finasteride take 6 months for there to be improved symptoms?

Answer 10

5-alpha reductase converts testosterone to DHT, which is more potent

With reduced DHT the prostate no longer grows, but it does not shrink straight away, it takes a while for the prostate to reduce in size

Therefore, it takes time before symptoms improve

Question 11

What surgical options are available for BPH?

Answer 11

Transurethral resection of the prostate (TURP)

Transurethral electrovapourisation of the prostate (TEVAP/ TUVP)

Holmium laser enucleation of the prostate (HoLEP)

Open prostatectomy, via abdominal or perineal incision

Question 12

What is the most common surgical treatment of BPH?

Answer 12

Transurethral resection of the prostate

Question 13

What are the major complications of transurethral resection of the prostate?

Answer 13

Bleeding

Infection

Urinary incontinence

Erectile dysfunction

Retrogade ejaculation

Urethral strictures

Failure to resolve symptoms