Benign Prostate Hyperplasia (BPH)

Benign Prostate Hyperplasia is periurethral hyperplasia of stroma and epithelium in the prostatic transitional zone. It affects most men > 50 years but only 10% present with problems.

Aetiology

• Hormonal; DHT required (converted from testosterone by 5 alpha-reductase), the effect of estrogens in increasing expression of DHT receptors.
• Possible role of apoptosis

Clinical Presentation

Symptoms’ severity depends on the degree of encroachment on the prostatic urethra.

• Obstructive symptoms – hesitancy, weak stream, incomplete voiding, terminal dribbling
• Irritative symptoms – frequency, urgency, nocturia, dysuria
• Acute/chronic retention of urine
• Hematuria – From ruptured dilated bladder neck veins.

Complications of obstructive uropathy

• Hydroureter with reflux of urine
• Hydronephrosis
• Pyelonephritis
• UTI
• Nephrolithiasis
• Overflow incontinence
• Hernia secondary to chronic straining

Investigations

• History, assessing lower urinary tract symptoms and impact on QoL. Includes administering IPSS/AUA questionnaire to assess severity.

Scoring: Mild (1-7), Moderate (8-19), Severe (20-35)

• P/E including DRE (prostate smooth and symmetrically enlarged, intact median sulcus, firm consistency with smooth rectal mucosa not attached to prostate)
• FHG: Anaemia, raised WBC due to systemic infection
• UECs: Assess renal function due to chronic obstruction
• U/A to r/o UTI
• PSA to r/o malignancy (Beware of PSA controversy)
• Ultrasonography: Renal, bladder, prostate
• Uroflowmetry. Normal peak flow rate >15ml/s
• Cystoscopy to r/o stones, strictures/bladder neck obstruction or cancer.

Management

Dependent upon the severity of symptoms.

1. Watchful waiting

Patients with mild/no symptoms, no complications and normal investigations.

Monitor annually with IPSS scoring, PSA and other invx.

1. Medical treatment

• Alpha blockers (Prazosin, Terazosin, Tamsulosin, Alfuzosin)

Relax internal sphincter and smooth muscle of prostate. Take 3 days to be effective.

S/E: Hypotension, Dizziness, Headache, Retrograde ejaculation.

• 5-alpha reductase inhibitors (Finasteride, dutasteride)

Reduce prostate size. Take 3-6 months to be effective.

S/E: Decreased libido, ejaculatory dysfunction, impotence, gynecomastia.

• Anticholinergics – used with caution

1. Surgical management

Indications include:

• Failed medical treatment
• Significant complications, e.g. renal insufficiency, recurrent UTI, bladder decompensation.
• Recurrent/persistent gross haematuria
• Bladder calculi secondary to BPH

Methods of performing prostatectomy include:

1. Trans-urethral resection of the prostate (TURP) – Minimally invasive.
2. Retropubic prostatectomy (Millin’s)
3. Transvesical prostatectomy (Freyer’s)
4. Perineal approach (Young prostatectomy)

Complications of surgery

• Risks of GA/Spinal anaesthesia
• Bleeding, infection /urosepsis
• Local injury causing incontinence, stricture/bladder neck stenosis
• Retrograde ejaculation
• TUR syndrome
• Failure of procedure/recurrence