Benign prostatic hyperplasia

Question 1

Define BPH

Answer 1

benign enlargement of the prostate – often resulting in bladder outlet obstruction

Question 2

What clinical findings may be found?

Answer 2

Benign prostate enlargement

Bladder outflow obstruction

Question 3

In which part of the prostate does the hyperplasia originate?

Answer 3

o Initially begins in the peri-urethral transition zone

Question 4

Aetiology of BPH

Answer 4

o Shifts in age-related hormonal changes creating androgen/oestrogen imbalances
o Changes in epithelial-stromal interactions

Question 5

What could the progression from pathological to clinical BPH be due to?

Answer 5

prostatitis
vascular effects
capsular changes

Question 6

RFs for BPH

Answer 6

•	Age >50
•	FH
•	Non-Asian race
o	In particular, Afro-Caribbeans have an increased risk
•	Smoking
•	Male pattern baldness
o	Androgens
o	Functional androgen receptors
•	Metabolic syndrome
o	Obesity
o	Diabetes
o	Dyslipidaemia

Question 7

Epidemiology of BPH

Answer 7

• 30% of over 80 year olds have histological BPH
• 50% of over 80 year olds have urinary symptoms
• Uncommon in Asian

Question 8

Presenting symptoms of BPH

Answer 8

•	Storage/irritative symptoms -> FUND
o	Frequency
o	Urgency
o	Nocturia
o	Dysuria
•	Voiding/obstructive symptoms -> HITS
o	Hesitancy
o	Intermittency
o	Incomplete bladder emptying
o	Post-void dribbling
o	Weak urinary stream

Question 9

Name the steps leading to loss of detrusor efficacy

Answer 9

Increased pressures required to void -> bladder detrusor muscle hypertrophies + trabeculation (ridging) -> muscle fibres are replaced by collagen -> loss of detrusor efficacy

Question 10

Signs of BPH on examination

Answer 10

• Bladder enlargement
• DRE
o Smooth, enlarged, soft prostate, deepened sulcus
o Normal = 30cc = 4cm diameter and ping pong ball/walnut size

Question 11

Investigations for BPH

Answer 11

o	DRE
	Ping-pong ball = 4cm diameter = approx 33cc
o	Urinalysis
	Exclude infection
	Haematuria
o	PSA
o	IPSS (International Prostate Symptom Score)
	Patients score each item from 0-5 according to frequency on which they experience the symptoms (not at all to almost always)
•	Incomplete emptying
•	Frequency
•	Intermittency
•	Urgency
•	Weak stream
•	Straining
•	Nocturia
	Max score of 35
	Used to re-evaluate/monitor disease progression/treatment response
o	Volume charting

Question 12

Management of BPH

Answer 12

• Conservative (IPS score 0-7 with no significant bother)
o Reassure
 Watchful waiting
o Fluid intake advice
• Medical = lifelong
o Alpha-blockers = Tamsulosin, Alfuzosin
 Works by relaxing the prostate smooth muscle
 Taken once daily
 Work quickly (within 2 days)
o 5 alpha-reductase inhibitors = Finasteride, Dutasteride
 Works only on large prostates (30-40cc)
 Take 6 weeks-3 months to work
• Surgical
o TURP = Transurethral Resection of Prostate
 70-80% success rate
 1% have incontinency afterwards, either ST or LT
• 1 in 1000 have LT incontinency problems

Question 13

Complications of BPH

Answer 13

• BPH progression (20%)
• UTI
• Renal insufficiency
• Bladder stones
• Haematuria
• Sexual dysfunction
• Acute urinary retention (2.5% in 5 years)
• Overactive bladder

Question 14

Prognosis for BPH

Answer 14

• Majority will expect at least a moderate improvement
• Clinical progression occurs in 20%
o Increased risk with larger prostates and higher PSA