Benign Prostatic Hyperplasia

Question 1

What is BPE?

Answer 1

Enlargment most commonly due to BPH.

Question 2

What is BPH?

Answer 2

A histological diagnosis and is characterised by non-cancerous hyperplasia of the glandular epithelial and stromal tissue of the prostate.

Question 3

Why might you see LUTS in BPH?

Answer 3

Because BPH is the most common cause of Bladder Outlet Obstruction

However 15-30% of men over 65 have LUTS regardless of BPH

Question 4

Pathophysiology

Answer 4

The exact mechanism is unknwon.

Androgens seem to play a role, particularly in the development of the gland in adolescence and then future development of BPH.

Prostate converts testosterone to dihydrotestostone DHT using the enzyme 5-alpha reductase.

DHT is more potent and accounts for 90% of androgen in the tissue.

The prostate retains the ability to respond to testosterone and thus levels of DHT also remain high throughout life.

Question 5

Risk factors

Answer 5

Age

FH

Afro-Caribbean ethnicity

Obesity

Question 6

Clinical features

Answer 6

LUTS with either voiding (hesitancy, weak strea, terminal dribbling or incomplete emptying) or storage (urinary frequency, nocturia, nocturnal enuresis or urge incontinence)

Other less common symptoms are haematuria and haematospermia

Question 7

Examinations

Answer 7

DRE is essential especially to distinguish between BPH and prostate cancer

Firm, smooth and symmetrical prostate is a reassuring sign

International Prostate Symptom Score should be done as well IPSS

Question 8

Explain IPSS

Answer 8

A screening tool used to evaluate and quantify LUTS

Question 9

Dx

Answer 9

Prostate cancer - may present with LUTS but is usually asymmetrical, craggy/nodular prostate + raised PSA

UTI

Overactive bladder

Bladder cancer

Question 10

Initial investigations

Answer 10

Urinary frequency and volume chart should also be done in LUTS

Bedside urinalysis to exclude UTI

Post-void bladder scan if there is any retention

PSA might be done if indicated from DRE, it can however be increased in BPH as well.

Question 11

Imaging

Answer 11

USS-KUB might be done to calculate the volume of the prostate alongside assessment of the rest of the urinary tract for urinary retention and hydronephrosis.

Urodynamic studies can also show bladder contractility, flow rate and storage capacity. Bladder outlet obstruction index (BOOI) can help diagnose obstructive voiding related to BPH

Question 12

On USS-KUB what is defined as an enlarged prostate?

Answer 12

>30ml

Question 13

Initial management

Answer 13

Since it is an incidental finding quite commonly patients just needs to be reassurd.

Ask patient to keep a symptom diary and provide a medication review

Give suitable lifestyle advice about moderate caffeine intake and alcohol intake.

Question 14

Indications of medical management

Answer 14

Most men with symptomatic BPH

Question 15

Medical management

Answer 15

First line is an alpha blocker like Tamsulosin
They act by relaxing the prostatic smooth muscle by blocking alpha-receptor leading to a reduction in the dynamic component.
They provide symptomatic benefit within a few days.

Question 16

Side effects of tamsulosin

Answer 16

Postural hypotension

Retrograde ejaculation

Floppy-Iris Syndrome

Question 17

What should be tried if the patient remains symptomatic despite alpha blocker?

Answer 17

5alpha-reductase inhibitors like Finasteride which prevent the conversion of testosterone to DHT leading to a decrease in prostatic volume.

Note that it can take up to 6 months to perceive any symptomatic benefit

Question 18

Indications of surgical management

Answer 18

Refractory through medical management or develop signficant sequale of BPH like high pressure retention

Question 19

Surgical approaches

Answer 19

TURP (most commonly used=

Holmium laser enucleation of the prostate (HoLEP)

PVP

TUVP

TUMT

Question 20

Explain TURP

Answer 20

This involves endoscopic removal of obstructive prostate tissue by using a diathermy loop to increase the urethral lumen size.

Complications include haemorrhage, sexual dysfunction, retrograde ejaculation and urethral strictures.

Question 21

Explain HoLEP

Answer 21

Holmium:YAG laser is used to heat and dissect section of the prostate into the bladder.

It is becoming more popular due to excellent outcomes and reduced post-op complications

It is only used in a limited fashion due to it being a technically challenging procuedure

Question 22

What is PVP, TUVP and TUMT?

Answer 22

PVP = Photoselective vaporisation of the Prostate

TUVP = Transurethral vaporisation of the prostate

TUMT = Transurethral microwave thermotherapy

Question 23

Complications of BPH

Answer 23

High-pressure retention with chronic or acute-on-chornic urinary retention leading to post AKI

Recurrent UTI

Significant haematuria

TURP syndrome

Question 24

What is TURP syndrome?

Answer 24

A rare but potentially life-threatening complication of TURP

TURP needs hypoosmolar irrigation during the procedure it can lead to significant fluid overload and hyponatraemia when the fluid enter the circulation through exposed venous beds.

Question 25

Clinical features of TURP syndrome

Answer 25

Confusion

Nausea

Agitation

Visual changes

This needs urgent management by carefully reducing the level of hyponatraemia.