Benign Prostatic Hyperplasia Flashcards
(14 cards)
Define benign prostatic hyperplasia
Slowly progressive nodular or diffuse hyperplasia of the periurethral (transitional) zone of the prostate gland
ie benign growth
Predominantly due to 2 components:
- Static: increase in benign prostatic tissue → narrowing of urethral lumen
- Dynamic: increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors.
Differentiate between area of growth in BPH versus prostate carcinoma
The inner transitional zone enlarges in BPH
- The transition zone (TZ) surrounds the urethra as it enters the prostate gland.
- It is small in young adults, but it grows throughout life, taking up a bigger percentage of the gland
The peripheral zone enlarges in prostate carcinoma
- Contains the majority of prostatic glandular tissue.
- The largest area of the peripheral zone is at the back of the gland, closest to the rectal wall.
- Hence on DRE can be felt
Explain the risk factors for benign prostatic hyperplasia
-
age over 50 years
- age-related hormonal changes create androgen/oestrogen imbalances.
- Changes in prostatic stromal-epithelial interactions that occur with ageing and increases in prostatic stem cell numbers
- positive family history
- non-Asian race
- cigarette smoking
Summarise the epidemiology of benign prostatic hyperplasia
COMMON:
- 42% of men 51-60 years
- 82% of men 71-80 years
- global lifetime prevalence of BPH is around 25%
More common in the west than the east
More common in Afro-Caribbeans
Recognise the presenting symptoms of benign prostatic hyperplasia
Can be divided into 2 categories:
Storage symptoms
- Frequency
- Urgency
- Nocturia
Voiding symptoms
- Weak stream
- Hesitancy
- Intermittency
- Straining
- Incomplete emptying
- Post-void dribbling
What is an acute complication of BPH?
Urinary retention
- Sudden inability to pass urine
- Associated with SEVERE PAIN
What is a symptom of a complication of BPH?
UTI
- Fever with dysuria
- Smell/odour
What are the symptoms of chronic retention?
- Painless
- Frequency - with passage of small volumes of urine
- Nocturia is a major feature
Recognise the signs of benign prostatic hyperplasia on physical examination
DRE -
- the prostate is usually smoothly enlarged with a palpable midline groove
- there is poor correlation between the size and the severity of the symptoms
Signs of Acute Retention
- Suprapubic pain
- Distended, palpable bladder
Signs of Chronic Retention
- A large distended painless bladder (volume > 1 L)
- Signs of renal failure
Identify appropriate investigations for benign prostatic hyperplasia
Urinalysis
- Check for UTI signs and blood
Bloods
- U&Es - check for impaired renal function
- PSA- increased PSA may suggest the presence of underlying prostate cancer or prostatitis.
Urinalysis
- MC&S
- normal in uncomplicated BPH; pyuria may indicate UTI
- haematuria might indicate cancer
- Uroflowmetry- measure of peak urinary flow rate. <15ml/s in moderate-to-severe BPH.
Imaging
Patients with chronic retention, history of urinary tract surgery, recurrent urinary tract infections or haematuria, presence of urolithiasis, or renal insufficiency.
-
US of urinary tract - check for:
- hydronephrosis
- mass
- urolithiasis
- post-void residual
- Bladder scanning to measure pre- and postvoiding volumes
- Transrectal Ultrasound Scan (TRUS) - allows assessment of bladder size and volume - +/- biopsy
-
Flexible Cystoscopy-
- indicated in patients for direct visualisation or intervention as indicated, following urinary tract imaging.
- may show mass/stone/stricture
International prostate symptom score
- Mild score: 0 to 7
- Moderate score: 8 to 19
- Severe score: 20 to 35
- Also includes an additional question on quality of life (bother score) scored from 0 to 6.
Generate a management plan for benign prostatic hyperplasia
In Emergency (acute urinary retention)
- Catheterisation
Conservative (if mild)
- Watchful waiting
- Lifestyle: avoid caffeine, alcohol to reduce urgency. Relax when voiding and control urgency by practising distracting exercises.
Medical – useful when waiting for surgery
-
Selective a-blockers (e.g. tamsulosin) are 1st line -
- relax the smooth muscle of the internal urinary sphincter and prostate capsule
- May cause ED and increased fall and fracture risk
-
5a-reductase inhibitors (e.g. finasteride)
- Larger prostate >30g/symptom progression on a-blockers
- inhibit the conversion of testosterone to dihydrotestosterone
- reduce prostate size by around 20%
- Excreted in semen so should use condom.
Surgery
- TURP: transurethral resection of prostate
- TUIP: transurethral incision of prostate – less destruction so less risk to sexual function but gives smaller benefit
- Open prostatectomy- significantly enlarged prostates (typically ≥80 grams)
Identify possible complications of benign prostatic hyperplasia
SHORT TERM
- BPH progression- 20% in 5 years
- urinary tract infection (UTI)
- renal insufficiency
- bladder stones- secondary to urinary stasis.
- haematuria- secondary to any urinary pathology and/or haematological disorders.
- sexual dysfunction- 5-8% with alpha blockade and 10-15% with 5-alpha-reductase inhibitor or surgical management.
LONG TERM
- acute or chronic urinary retention- significant reduction in urethral lumen diameter and increased sympathetic tone contribute to acute retention
- overactive bladder- treatment with alpha-blockers and antimuscarinic agents to aid symptoms
Summarise the prognosis for patients with benign prostatic hyperplasia
- The majority of patients with BPH can expect at least moderate improvement of their symptoms
- Lower urinary tract symptoms and medical/surgical therapy may affect sexual wellbeing including erectile function.
- Mild symptoms are usually well controlled medically
- Most patients get significant relief from surgery
