Benign prostate hyperplasia

Question 1

What is benign prostate hyperplasia (BPH)?

Answer 1

BPH is the enlargement of the prostate in men.

Prostate enlargement is a natural occurrence over time => dihydrotestosterone may be responsible

Question 2

What is the underling pathology of BPH?

Answer 2

Microscopically, benign nodular or diffuse proliferation of musculofibrosis and glandular layers of the prostate.

The inner (transitional zone) enlarges in contrast to peripheral layer expansion seen in prostate carcinoma.

Enlarged gland obstructs the urethra, therefore bladder outflow.

Question 3

Who is it most common in?

Answer 3

Most common in >60year old men

Question 4

What are the clinical features of BPH?

Answer 4

Lower urinary tract symptoms
=> nocturia

=> frequency

=> urgency

=> post-micturition dribbling

=> poor stream / flow

=> hesitancy

=> overflow incontinence

=> haematuria (due to rupture of prostatic vein, bacteruria, stones)

=> bladder stones

=> UTI

Question 5

How do you examine and investigate this?

Answer 5

Abdominal exam: bladder enlargement

Digital rectal exam: benign prostate feels smooth

Mid stream urine for culture

Bloods:
=> Serum prostate specific antigen (PSA) — prior to digital rectum exam, post digital exam PSA always high

=> renal function test (U&E)

Trans-rectal ultrasound ± biopsy

Measurement of urinary flow rate

Question 6

What lifestyle advice can you give in BPH?

Answer 6

1. Avoid caffeine, alcohol to reduce urgency/nocturia
2. Relax when voiding
3. Void 2x in a row to empty the bladder
4. Control urgency by practicing distraction methods i.e. breathing exercises
5. Train the bladder by holding on to increase time between voiding

Question 7

When can drugs be given in BPH?

Answer 7

Drugs are useful in mild-moderate disease and whilst awaiting surgery.

Question 8

What are some of the drugs given in BPH?

What are their mechanism of action?

What are their side effects?

Answer 8

1. Alpha blockers i.e. Tamsulosin 400mcg, alfuzosin, doxazosin = first line treatment
   ii. Reduces smooth muscle tone i.e. prostate and bladder
   iii. Side effects: drowsiness, depression, dizziness, low BP, dry mouth, ejaculatory failure, extra-pyramidal signs, nasal congestion, increase weight
2. 5-alpha reductase inhibitor e.g. finasteride 5mg can be added or used alone
   ii. Reduces conversion of testosterone to the more potent version androgen dihydrotestosterone.
   iii. Side effects: impotency, reduced libido, reduce prostate size over 3-6 months and reduces long term retention risk
   * Excreted in semen so wear condom => females should not handle this drug

Question 9

What are the 5 surgical options available for BPH?

Answer 9

1. Transurethral resection of prostate (TURP) => beware impotency, bleeding, clot retention. May be repeated in 8 years
2. Transurethral incision of the prostrate (TUIP) =>less destruction than TURP, less risk to sexual function. May be the best option for smaller enlarged prostates
3. Transurethral laser induced prostatectomy
   (as good as TURP)
4. Robotic prostatectomy (less traumatic & minimally invasive)
5. Retropubic prostatectomy (open operation if prostate very large ; outdated)