BPH: benign prostate enlargement

• Prostate cancer affects many men, responsible for 25% of all new malignancy in men, second most common cause of male cancer
• There is a poor relationship between Prostate specific antigen (PSA) level and the presence of cancer
• Investigation of prostate cancer

  Involves TRUS and biopsy, which in itself is potentially complex
• Clinical impression of the prostate

  Irregular prostates are more likely suggestive of cancer
• Prostate gland function


  • Contributes fluid for about 25% of the ejaculate
  • Includes citric acid, G Proteolytic enzymes, and Seminal plasmin to provide energy, facilitate sperm motility, and reduce bacteria
• Prostate specific antigen (PSA)

  A glycoprotein enzyme secreted by the epithelial membranes of prostate cells, rises with age and prostate gland size
• Screening men for elevated PSA is not currently recommended in Europe albeit it is the subject of intense debate
• Pathophysiology of prostate gland enlargement

  Primarily due to age, tissue remodeling, hormonal effects, metabolic effects, inflammation
• Age results in larger prostates and lower flow rates of urine, with men over 70 years experiencing greater reductions in flow
• Other factors contributing to LUTS exist and not only the prostate gland size
• Tissue remodeling in prostate gland enlargement

  Balance between cell growth and apoptosis is disrupted, abnormal growth patterns seen due to changes in signaling between stromal and epithelial cells
• BPH cells are hypertrophic and survive longer than normal, healthy prostate cells
• Cell growth


  Disrupted apoptosis
• Changes in signaling between stromal and epithelial cells


  May contribute to some abnormal growth patterns
• BPH cells


  • Are hypertrophic and survive longer than normal, healthy prostate cells
• Hormonal effects


  • Metabolic effects
• Metabolic syndrome components


  • Diabetes
  • Hypertension
• Metabolic syndrome


  Possibly contributes to BPH, with men in this situation showing faster rates of growth than those without
• Inflammation within the prostate

  Triggers cytokine release and resultant healing responses causing a proliferative environment to prevail
• Growth within the prostate

  Potentially leads to hypoxia within the tissue and subsequent angiogenesis mediated by VEGF and other growth factors
• Primary effects of an increase in size of the prostate are Lower Urinary Tract Symptoms (LUTS)
• Some men may not present with any symptoms
• Larger prostates need not always equal worsening LUTS
• Voiding symptoms


  • Hesitancy
  • Poor urinary flow
  • Incomplete bladder emptying
  • Terminal dribbling
• Storage symptoms


  • Urgency
  • Polyuria during the day and at night
• Bladder outflow obstruction (BOO)


  Can lead to acute or chronic urinary retention, renal failure, hypertension, chronic UTI, electrolyte imbalance
• International Prostate Symptom Score (IPSS) is used to guide severity of LUTS and how patients are being affected overall
• IPSS Score


  • 0–7: mild LUTS
  • 8–19: moderate LUTS
  • 20–35: severe LUTS
• NICE recommends investigative pathway for newly presenting patients including assessment of medical and drug history, physical examination, urine dipstick test, urine frequency chart, assessment of serum creatinine if renal impairment is suspected
• Management strategies


  Focus on controlling LUTS, minimising impact on quality of life, reducing issues such as readmission to hospital as a consequence of recurrent UTI
• Lifestyle issues


  • 'Watchful waiting'
  • Control fluid intake
  • Consider effects of medication on symptoms
• Patients likely to benefit from treatment

  • Patients with IPSS score <7
• Control of the condition

  1. Can be controlled by considering fluid intake

  2. Avoid drinking large amounts of fluid or consider how consumption affects symptoms

  3. Diaries can help control fluid intake
• Considerations for medication effects

  1. Parasympathomimetics exacerbate LUTS

  2. Foods and drinks containing active substances like spices or caffeine can affect symptoms
• Pharmacological management


  1. Reduce smooth muscle tone in the bladder or prostate

  2. Alter the size of the prostate to reduce resistance to urinary flow
• Alpha blockers


  • Tamsulosin
  • Doxazosin
  • Alfuzosin
  • Terazosin
• Alpha blockers


  • Improve IPSS score by improving urinary flow
  • NICE recommends for moderate to severe LUTS, reviewed after 6 weeks then annually thereafter
• Alpha blockers do not alter prostate size


  Issue lies in the fact that they do not alter prostate size
• Adverse effects of alpha blockers

  • Postural hypotension
  • Headache
  • Dizziness
  • Drowsiness
  • Sweating
• Tamsulosin is available over the counter