BPH Flashcards
definition of BPH
slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the precise prostate gland
most frequent cause of lower urinary tract syndrome in male adults
histological dx of benign prostatic enlargement
pathophysiology of BPH
from middle age
hyperplasia of para-urethral glands with associated smooth muscle and fibrous tissue growth
surrounded by false capsule of compressed peripheral zone glandular tissue
benign nodular or diffuse proliferation of muscolofibrous and glandular layers of prostate
Enlarged transitional zone of prostate – encroaches onto prostatic urethra = squashed – residual vol in bladder = more, bladder force more – wall thicker and trabeculated – go into urinary retention = need catheter
aetiology of BPH
possible hormone changes - fluctuating levels of androgens and oestrogens
a diet rich in soya and veg may reduce risk
negative association with cirrhosis
size of prostate is dictated by BPE and growing older, genetically predisposed to enlarged prostate
epidemiology of BPH
common
24% if 40-64
prevalence increases with age
70% men aged 70yrs have histological BPH, 50% of these experience significant symptoms
West>far east, Afrocarribean>Caucasian
sx of BPH
obstructive symtoms (voiding LUTS): hesitancy, poor intermittent stream, terminal dribbling, incomplete emptying, straining, double micturition
irritive/storage symptoms (LUTS): frequency, urgency, urge incontinency, nocturia, overflow incontinence - residual amount is really high
acute retention: sudden inability to pass urine, associated with severe pain
chronic retention: painless, often frequency with passage of small vols, especially at night
haematuria
UTI
signs of BPH
on DRE prostate often enlarged, poor correlation between size and symptoms
if nodular - think carcinoma
acute retention - suprapubic pain and distended, palpable bladder
chronic retention - large distended painless bladder (residual vol >1L), may be signs of renal failure
bladder stones
Ix for BPH
blood: U&E for impaired renal function, PSA
midstream urine for microscopy, culture and sensitivity
imaging:
- US imaging of renal tract to check for dilatation of upper urinary tract
- bladder scanning to measure pre- and post-voiding volumes – can have chronic retention – never empty bladder >800ml can have residual 2-3L
- TRUS +- biopsy to measure prostate size and guide biopsy
- flexible cystoscopy to visualise bladder outlet and bladder changes eg trabeculation
urinary flow studies
renal tract US
international prostate symptom score (IPSS)
size estimate – v large would have different surg approach >40cc can have diff med that doesn’t work for small
urinary flow studies for BPH
How many ml of urine in how many seconds
Should go up and down straight away
Slow up peak and long time to go down - BPH – obstructuion
Plateaud curve – urethral structure
international prostate symptom score
rates symptoms - lower score = less symptoms
0-7 mild (fluid advice, cut down things irritate bladder – caffeine, nocturia reduce fluid before bed)
8-19 moderate – med treatment (a blockers, 5a reductase inhibitors, if storage symptoms add anti-cholinergic)
20-35 severe – med but likely to need surgery and long term catheter
Mx of BPH
depends on severity of symptoms and presence of complications
emergency - in acute retention - urinary catheterisation
conservative - if mild, ‘watchful waiting’, symptom monitoring with IPSS
avoid caffeine and alcohol to reduce urgency or nocturia
relax when voiding
void twice in a row to aid emptying
control urgency by practicing distraction methods eg breathing
train bladder by holding on to increase time between voiding
medical
surgical
medical mx of BPH
selective a-blockers (1st line) relax smooth muscle of internal sphincter (bladder neck) and prostate capsule eg alfuzosin, tamsulosin (400mcg/d PO)
SE - drowsiness, depression, dizziness, reduced BP, dry mouth, ejaculatory failure, extrapyramidial signs, nasal congestion and increased weight
5a reductase inhibitors if more than 40cc - inhibit conversion of testosterone to dihydrotestosterone eg finasteride 5mg/d PO, reduce prostate size by 20%, take time
- excreted in semen so use condoms, females should avoid handling
- SE: impotenence, reduced libido, reduced prostate size over 3-6months, reduced long term retention risk*
saw palmetto - alternative medicine
Anticholinergic to counteract overactive detrusor/bladder
surgical Mx of BPH
depend on prostate size, pt fitness and pts preference
TURP: electrocautery-mediated resection from within the prostatic urethra - diathermy to cut prostate = give bigger cavity
- bleeding, clot retention and post TURP sundrome (absorption of washout = CVS and CNS disturbance), impotence, need redoing in 8yr
transurethral incision of the prostate (TUIP) - (less destruction and risk to sexual func than TURP)
- relieves pressure on urethra
- may be best surgical option if small glands <30g
open prostectomy (retropubic or suprapubic approaches) reserved for V large glands (>60g)
transurethral laser-induced prostatectomy (TULIP)
robotic prostatectomy - gaining popularity - less traumatic and minimally invasive
Holmium laser prostate surgery (HoLEP)
- laser takes out enlarged bit - pushes it into the bladder
- Morsilator – goes through urethra, bites prostate – sucks out takes it out of urethra
- safe, durable results, for large prostate, no TURP syndrome, less bleeding, shorter hospital stay, shorter post-op catheterisation period, can be performed on anti-coagulated pts, reduce need for bladder irrigation, ability to retrieve tissue for histological examination
urolift
- Implant to open prostate up, through urethra – hold prostate to side so doesn’t block the urethra
prostate artery embolisation
- Inject bead/coil into bv – cut off part of arterial supply = prostate shrink
- No anaesthesia, Day case
rezum or steam treatment
- Steam into prostate to try and shrink it down through urethra into prostate at high force = ablative necrosis of prostate – improvement in 3-6mo
post-op advice from resection of TURP
avoid driving 2wks
avoid sex 2 wks
ejaculate may be reduced (from retrograde ejaculation), harmless, urine cloudy, may mean infertile
rarely erections or orgasmic sensations reduced (sometimes erections improve)
haematuria for 2wks
at first may need to urinate more, by 6wk better
if feverish or urination hurts take urine sample
complications of BPH
recurrent urinary infections
acute or chronic retention
urinary stasis and bladder diveritculae or stone development
obstructive renal failure
post-obstructive diuresis
complications from TURP
retrograde ejaculation (common),
haemorrhage (primary, reactionary or secondary),
clot retention,
incontinency,
TURP syndrome (seizures, or CVS collapse caused by hypovolaemia and hyponatraemia due to absorption of glycine irrigation fluid),
urinary infection,
erectile dysfunction,
late: urethral stricture, infection (prostatitis), hypothermia, haematospermia, haematuria
