Prostatic Hyperplasia

Question 1

What is the prostate?

What is its function?

Answer 1

An exocrine gland, found at the base of the bladder, surrounding the urethra

It secretes a thick white fluid that is mixed with sperm to produce semen, this fluid is alkaline to neutralise the acidity of the vagina

Prostate also contains smooth muscle to help expel semen during ejaculation

Question 2

What are the causes of prostate enlargement?

Answer 2

Benign prostatic hyperplasia (BPH)

Prostate cancer

Question 3

What is BPH?

Answer 3

Hyperplasia (increased no. of cells) of the prostate

Not caused by malignancy

Question 4

Which men are most often affected by BPH?

Answer 4

Men over 60

It affects many men, nearly all men would develop it if they were to live long enough

Question 5

What is the pathogenesis of BPH?

Answer 5

Hyperplasia (increased no. of cells) of the glandular and connective tissue elements of the gland

Enlargement of the inner part of the prostate

Question 6

Which part of the prostate enlarges in BPH compared to prostatic cancer?

Answer 6

BPH: inner zone

Cancer: peripheral zones

Question 7

What are the clinical features of BPH?

Answer 7

Increased frequency of urination

Nocturia: needing to urinate through the night

Delay in initiating urination

Reduced force of urinary stream

Post-void dribbling

Urinary retention causing overflow incontinence

Question 8

Why does BHP cause problems with urination?

Answer 8

The urethra runs through the prostate, so if it is enlarged it obstructs the flow of urine

Question 9

What should the prostate feel like in BPH?

Answer 9

Smooth, if it is not consider cancer

Question 10

Investigations of BPH?

Answer 10

Blood:

• PSA
• U+E to see if BPH has caused any renal damage

USS: to check for renal damage caused by BPH

Digital rectal examination: is it smooth, how enlarged is it?

Trans-rectal USS: to rule out cancer

Biopsy: to rule out cancer

Cystoscopy

Question 11

What is PSA?

Answer 11

Prostate Specific Antigen

A glycoprotein that is expressed by the prostate

Question 12

If someone has a raised PSA, what could be the cause?

Answer 12

Old age, it’s raised in 80% of men aged 80

Prostate cancer

BPH

Infections: prostatitis

Sigmoidoscopy or anything that causes trauma to the prostate

Question 13

What should you feel for in a digital rectal examination of the prostate?

Answer 13

If it is enlarged
If it is excessively hard or soft
If it is smooth or if there are nodules/irregularities

Question 14

Why does BPH not occur in men who have had been castrated for medical reasons?

Answer 14

Removal of the testicles means no production of testosterone

No testosterone means no dihydrotestosterone

No dihydrotestosterone means no prostatic enlargement because it is this hormone that stimulates the prostate to grow

Question 15

What is dihydrotestosterone and what does it do?

Answer 15

It is the breakdown product of testosterone

It stimulates the prostate to grow

Question 16

What should you do if you have a patient with a raised PSA?

Answer 16

Do a digital rectal exam to assess condition of prostate

Refer to a specialist for a biopsy to rule out cancer

Question 17

Management of BPH?

Answer 17

In mild cases with few symptoms: watchful waiting

Lifestyle changes

• reduce caffeine and alcohol to reduce urgency + Nocturia
• train the bladder to hold on to urine, to reduce frequency

Medication

Catheterisation

Surgery

Question 18

What drugs are used to treat BPH?

Answer 18

Alpha adrenoreceptor antagonists (alpha blockers)

5-alpha reductase inhibitors

A combo of both!

Question 19

How do alpha blockers work?

Answer 19

Relax bladder smooth muscle to increase urine flow, reducing symptoms of obstruction

Question 20

How do 5-alpha reductase inhibitors work?

Answer 20

Block conversion of testosterone to dihydrotestosterone

So the dihydrotestosterone can’t stimulate prostate growth

Question 21

What surgical methods can be used to treat BPH?

Answer 21

TURP: transurethral resection of the prostate

TUIP: transurethral incision of the prostate

Prostatectomy

Question 22

What is TURP?

Answer 22

Transurethral resection of the prostate

Part of the prostate is cut out, via the urethra

Question 23

What is TUIP?

Answer 23

Transurethral incision of the prostate

Removes some of the prostate but not all of it

Question 24

Which of TURP and TUIP have worse side effects?

Answer 24

TURP: more of prostate is removed

There’s a 14% chance of becoming impotent with this operation