BPH

• Benign prostatic hyperplasia (BPH) or benign prostatic enlargement refers to the benign enlargement of the prostate gland and is a common condition in men as they age.
• Bladder outlet obstruction (BOO) and BPH are interchangeable terms which can lead to lower urinary tract symptoms (LUTS) by causing compression or narrowing of the prostatic urethra, limiting the outflow of urine.
• The prevalence of BPH increases after the age of 40, with a prevalence of 8% – 60% in those aged 90.
• BPH is a benign condition associated with the proliferation of the smooth muscles and the epithelial cells in the transition zone of the prostate; there is no potential for malignancy
• hormones testosterone and dihydrotestosterone are the most significant contributors to the condition. As a result, pharmacological therapy has been developed to target these hormones. 5-alpha reductase inhibitors prevent the conversion of testosterone to dihydrotestosterone
• Anatomy of prostate tissue:

  • Glandular - secretory ducts and acini
  • Stromal - collagen and smooth muscle
• The proliferation of cells in BPH results in increased prostate volume and stromal smooth muscle tone. This enlargement occurs primarily in the peri-urethral transition zone of the prostate
• Modifiable risk factors include hormones (testosterone, dihydrotestosterone, oestrogen), metabolic syndrome, diabetes, diet, physical activity, and inflammation.
• BPH can be asymptomatic and diagnosed incidentally on a rectal examination performed to investigate another condition (e.g. haemorrhoids, faecal incontinence, suspected anal or rectal cancer).
• Typical symptoms of BPH include:

  • Lower urinary tract symptoms (LUTS), such as a poor urinary stream
  • Acute urinary retention (painful)
  • Chronic urinary retention (painless low-pressure retention)
  • Renal impairment with bilateral hydronephrosis and chronic retention (painless high-pressure)
  • Haematuria
  • Recurrent urinary tract infection
  • Bladder stones
• Other important areas to cover in the history include:

  • Caffeine intake: coffee, tea, energy drinks etc.
  • Sexual history: to exclude prostatitis
  • Red flag symptoms for malignancy: fever, weight loss, enlarged lymph nodes, loss of appetite
  • Recent urinary catheterisation
• Voiding LUTS:

  • Weak or intermittent stream
  • Straining
  • Hesitancy
  • Terminal dribbling
  • Incomplete emptying
• LUTS storage systems:

  • Frequency
  • Urgency
  • Incontinence
  • Nocturia
• Post-micturition symptoms:

  • Post-micturition dribbling
• In the context of suspected BPH, an abdominal examination is required with palpation and percussion of the supra-pubic area to evaluate for residual urine. A bladder is only palpable when it contains 200ml or more of urine.
• Typical clinical findings of BPH on rectal examination are an enlarged and non-tender prostate with a rubbery consistency.

  • Median furrow (sulcus) is lost in enlarged prostate glands
• bedside investigations include:

  • International prostate symptom score (IPSS): measures the severity of LUTS
  • Uroflowmetry (flow rate & US bladder PVR): measures the volume of urine passed, the speed at which it is passed, and how long it takes to be passed
  • Bladder diary: assesses patient symptoms by monitoring fluid intake, frequency of urine passage, and urine leakage
  • Urodynamics: assesses bladder and urethral function at storing and releasing urine by measuring pressures.
  • Urinalysis: for evidence of a urinary tract infection
• • Full blood count: to assess haemoglobin for anaemia, possibly indicating bleeding and/or malignancy. An elevation in white cell count and CRP would indicate an infectious aetiology.
  • Urea & electrolytes: for assessment of renal function. If these are abnormal, an ultrasound of the kidneys is required. 
  • Prostate-specific antigen (PSA): elevated PSA may suggest prostate cancer (or prostatitis), although PSA is not specific for malignancy and can be elevated in several conditions (including BPH).
• The gold-standard investigation for diagnosing BPH is a rectal examination followed by uroflowmetry and post-void bladder scanning in conjunction with an IPSS questionnaire.
• Conservative management of BPH includes lifestyle modifications (weight loss, evening fluid restriction, and reducing caffeine intake).
• Medical management of BPH includes:

  • Alpha antagonists (e.g. tamsulosin, doxazosin, terazosin)
  • 5-alpha reductase inhibitors (e.g. finasteride)
• Tamsulosin is a selective alpha adrenergic receptor antagonist. Blocks smooth muscle receptors of the bladder and urethra, causing relaxation
• Most common surgical management = transurethral resection of the prostate (TURP)
• Common complications that may occur as a result of benign prostatic hyperplasia include:

  • Acute urinary retention
  • Chronic retention
  • Urinary tract infection (due to incomplete emptying)
  • Haematuria
  • Bladder calculi
• Surgical management is reserved for patients with symptoms impacting their quality of life, symptoms refractory to medical management, and those with complications that are absolute indications for surgery.

  Absolute indications for surgical management include:

  • Progression of symptoms despite maximal medical therapy
  • Refractory urinary retention
  • Recurrent urinary tract infections
  • Recurrent haematuria
  • Renal impairment
  • Bladder stones
• PSA restrictions:

  • no active or recent UTI within 6 weeks
  • no urological intervention within 6 weeks
  • no recent ejaculation or prostate stimulation within 48 hours
  • no vigorous exercise within 48 hours
• Tamsulosin takes a few days to work

  Side effects - postural hypotension, retrograde ejaculation
• Finasteride:

  • Reduces size of prostate
  • Takes 6 months to work
  • Need to do PSA 6 months after starting to get new PSA baseline (will be lower due to smaller prostate)
• Surgical options:

  • Transurethral resection of the prostate (TURP)
  • Laser
  • Urolift
  • Prostatectomy
• Transurethral resection of the prostate (TURP)

  • Endoscopic removal of obstructive prostate tissue using diathermy loop to increase urethral lumen size
  • Complications:
  • Retrograde ejaculation
  • Urinary infection
  • Clot retention
  • Urinary incontinence
  • Urethral stricture
  • Erectile dysfunction
• Laser:

  • Holmium laser enucleation of the prostate (HoLPE)
  • Greenlight laser photoselective vaporisation of the prostate (greenlight)
• Urolift:

  • Transurethral technique
  • Implants placed that compress lobes of prostate to open the urethra
• Patients with BPH who present with acute retention will be catheterised

  They are usually started on tamsulosin and return to a TWOC clinic >72 hours after