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Benign prostatic hyperplasia

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Benign prostatic hyperplasia (BPH) is an idiopathic but common benign condition which affects older men. The prevalence increases with age and it affects 70% of males > 60 years. It is characterised by a slowly growing prostate which compresses the urethra and causes chronic lower urinary tract obstruction, causing lower urinary tract symptoms (LUTS). It can be managed with medicines or surgical removal.

Etiology

  • Multifactorial
  • Sensitization of the prostate to androgens and oestrogens
  • Higher oestrogen/testosterone ratio in elderly

Pathophysiology

  • BPH originates from the transitional zone of the prostate
  • BPH -> chronic bladder outlet obstruction -> LUTS
  • There is no increased risk for prostate cancer

Clinical features

  • Lower urinary tract symptoms like urinary urgency, frequency, incontinence, hesitancy, poor stream, etc.

Complications

Diagnosis

  • Diagnosis of BPH is clinical
    • Based on presence of LUTS in absence of other causes of LUTS
    • BPH does not require prostate biopsy
  • International prostate symptom score (IPSS)
    • A questionnaire used to screen for, diagnose, and follow up symptoms of BPH
    • Points given from answers, the sum ranges from 0 – 35
    • The sum gives the severity of symptoms
  • Urine analysis
    • If pyuria -> infection, which can cause similar symptoms
    • If haematuria -> can be tumor or ureter stone
  • PSA
    • To look for co-existing prostate cancer
  • Ultrasound
    • Can see stones, tumor, dilation of upper urinary tract
    • Can see prostate size
    • Can look for residual urine
    • Can see thickened bladder wall (detrusor hypertrophy)
  • DRE
    • Symmetrically enlarged
    • Smooth (no nodules)
    • Firm
    • Nontender
    • Rubbery texture
  • Uroflowmetry
    • Low peak flow, prolonged duration

Management

Behavioural modifications

  • Restrict fluid intake before bedtime to prevent nycturia
  • Reduce intake of diuretics like coffee, alcohol
  • Urinating in sitting position

Medical therapy

  • For voiding symptoms
    • Alpha-blockers
      • Tamsulosin, alfuzosin
      • Relax smooth muscle in bladder neck
      • Can cause hypotension, retrograde ejaculation
    • 5-alpha-reductase inhibitors
      • Finasteride, dutasteride
      • Decrease size of prostate
      • Takes 6 months for effect to set in
      • Can cause sexual dysfunction, gynecomastia
  • For storage symptoms
    • Antimuscarinics
      • Oxybutynin, darifenacin
      • Decrease detrusor tone, increase bladder capacity
      • Can cause constipation, dry mouth, cognitive dysfunction (in elderly)
    • β-3 agonists
      • Mirabegron (Betmiga®)
      • Decrease detrusor tone, increase bladder capacity
      • More expensive
      • Does not have side effects of antimuscarinics

Surgical therapy

  • Indications
    • Severe LUTS
    • BPH with complications
  • Transurethral resection of the prostate (TUR-P)
    • Gold standard for BPH
    • Done under spinal/general anaesthesia
    • Only if the prostate is not very large (< 80 g)
    • A cautery resectoscope is led through the urethral opening and into the area of the prostate
      • The resectoscope has a camera like a cystoscope but is thicker, and has a metallic loop on the end
      • The metallic loop is a monopolar cautery, which is used to resect the prostate from the inside of the urethra
    • The prostate capsule is not removed
    • The remaining cavity will be epithelialized after a few months
    • TUR syndrome is a possible complication
  • Simple prostatectomy
    • For large prostates (> 80g)
    • Only central and transitional zones are removed
      • Peripheral zone remains
    • Most commonly transvesically
      • Entry suprapubically
      • Operation is called transvesical adenectomy or Freyer prostatectomy
    • Can also be accessed through the perineum or the lower abdomen (retropubic)
  • Newer methods
    • Laser ablation
    • Radioablation
    • Thermal ablation
  • Radical prostatectomy is NOT used for BPH, only prostate cancer!