BPH

Question 1

What is benign prostatic hyperplasia?

Answer 1

• Periurethral hyperplasia of stroma and epithelium in prostatic transition zone
• Prostatic smooth muscle cells + hyperplasia both involved

Question 2

Aetiology of BPH?

Answer 2

• Unknown (DHT required; converted from testosterone by 5a-reductase)
• possible role of impaired apoptosis, oestrogen, other GFs

Question 3

Epidemiology of BPH?

Answer 3

• Age related

- 25% require treatment

Question 4

How common is BPH?

Answer 4

Extremely common: 50% or 50y, 80% or 80y

Question 5

What causes the clinical features of BPH?

Answer 5

Outlet obstruction and compensatory changes in detrusor function

Question 6

What are the voiding symptoms of BPH?

Answer 6

• Straining
• Hesitancy
• Incomplete Emptying
• Terminal Dribbling

Question 7

What are the storage symptoms of BPH?

Answer 7

-frequency, urgency, nocturia, urgency incontinence

Question 8

What causes the storage symptoms of BPH?

Answer 8

thought to be due to detrusor overactivity and/or decreased complicance

Question 9

DRE findings of BPH?

Answer 9

-Prostate smooth, rubbery and enlarged (symmetrically)

Question 10

Complications of BPH?

Answer 10

• Retention
• Overflow incontinence
• Hydronephrosis
• Infection
• Gross haematuria
• Bladder stones

Question 11

Approximate prostate sizes by fruit?

Answer 11

Approximate Prostate Sizes
• 20 cc – chestnut 
• 25 cc – plum
• 50 cc – lemon
• 75 cc – orange
• 100 cc – grapefruit

Question 12

How may severity of BPH be assessed on history?

Answer 12

AUA Prostate Symptom Score
FUNWISE
Frequency
Urgency
Nocturia
Weak stream
Intermittency
Straining
Emptying, incomplete feeling of
Each symptom graded out of 5 0-7: Mildly symptomatic
8-19: Moderately symptomatic 20-35: Severely symptomatic

Question 13

History features to ascertain in BPH?

Answer 13

• LUTS and impact on QoL

e. g. AUA Sx index

Question 14

Ix in BPH workup?

Answer 14

• DRE
• Urinalysis (exclude UTI)
• Cr +/- renal U/S for hydronephrosis
• PSA to r/o Ca
• Uroflowmetry to measure flow rate
• PVR (optional)
• Cystoscopy prior to surgical intervention
• Biopsy if suspicious for malignancy

Question 15

What are the absolute indications for BPH surgery?

Answer 15

• Renal failure with obstructive uropathy

- Refractory urinary retention

Question 16

What are the relative indications for BPH surgery?

Answer 16

• Recurrent UTIs
• Recurrent haematuria refractory to medical treatment
• Renal insufficiency
• Bladder stones

Question 17

Conservative management BPH?

Answer 17

• Watchful waiting (50% spontaneously improve)

- Lifestyle modifications (e.g. evening fluid restriction, planned voiding)

Question 18

Medical management BPH?

Answer 18

• a-adrenergic antagonists: reduce stromal smooth muscle tone
• 5a-reductase inhibitors: block conversion of testosterone to DHT (reduce prostate size)
• Anticholinergics (for storage LUTS w/o elevated PVR)

Question 19

Surgical management BPH?

Answer 19

• TURP
• Laser ablation
• TUIP (prostate

Question 20

Minimally invasive surgical therapies?

Answer 20

• Microwave therapy
• TUNA
• Prostatic stent

Question 21

Who should avoid a-adrenergic antagonists?

Answer 21

Men awaiting cataract surgery should avoid due to risk of intraoperative floppy iris syndrome