urology,

Benign Prostatic Hyperplasia

May 10, 2020

Key facts

  • Non-malignant enlargement of the prostate gland
  • Commonly seen in older men
  • Commonest cause of lower urinary tract symptoms (LUTS) in older men

Risk factors

  • Age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH
  • Ethnicity: black > white > Asian

Symptoms

BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into: FUN WISE Dribble: Frequency, Urgency, Nocturia, Weak stream, Intermittent urinary flow, Straining, Empting incompletion

  • Storage symptoms (irritative): Frequency, urgency, nocturia
  • Voiding symptoms (obstructive): Weak stream, intermittent urinary flow, straining, emptying incompletion
  • Post-micturition: dribbling
  • Complications: urinary tract infection, retention, obstructive uropathy

Signs

  • On DRE: smooth enlarged prostate

Investigation

  • International Prostate Symptom Score (IPSS) to assess severity
  • DRE and PSA to rule out malignancy
  • Renal function
  • Urine analysis in all patient
  • Urodynamics: Urine flowmetry and pressure
  • If concern over malignancy
    • Transrectal ultrasound ± guided biopsy

Management

Conservative

  • Watchful waiting

    Medical management

    Recommended for those with LUTS and affecting QoL

  • Alpha-1 antagonists e.g. tamsulosin, alfuzosin, doxazosin
    • decrease smooth muscle tone (prostate and bladder)
    • considered first-line, improve symptoms in around 70% of men
    • SE: dizziness, postural hypotension, dry mouth, depression
  • 5 alpha-reductase inhibitors e.g. finasteride
    • Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
    • Unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50%
    • SE:erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

      Surgical management

  • Indication: Failed medical therapy, worsening QoL
  • Transurethral Resection of Prostate (TURP)- gold standard
  • Open retropubic prostectomy- for large gland
  • Transurethral incision in the prostate (TUIP)- causes less destruction and reduced sexual dysfunction
  • Laser Prostectomy
  • Microwave thermotherpay ablation of the prostate