Benign Prostatic Hyperplasia
Basics
It is a common cause of lower urinary tract obstruction symptoms (LUTS) in adult men. The incidence of the disease increases with advancing age, especially in men over 50 years of age.
It occurs due to hyperplasia of the transition zone of the prostate. The hyperplasia involves the glandular and the stromal tissue of the prostate. The transition zone of the prostate surrounds the prostatic urethra, for this reason, as the hyperplasia progresses there will development of urinary obstruction symptoms. Out of interest, it is worth mentioning that prostate cancer commonly involves the outer peripheral zone, palpable during the digital rectal examination.
The enlarged prostate will cause bladder outlet obstruction and this results in detrusor muscle overactivity and there is also weakening of the bladder wall (results in urinary stasis, UTIs, urinary retention, and bladder stone formation). As the condition progresses, increased pressure within the bladder occurs. This increased “intracystic pressure” results in detrusor muscle hypertrophy and the formation of trabeculations and a pseudodiverticulum.
Etiology
The etiology is not yet fully understand, however, like most diseases there are several factors that are involved in the development of BPH. One of the most important factors is hormones.
- Androgens:
- There is increased androgen receptor sensitivity to the effects of androgenic hormones, which results in prostatic hyperplasia.
- Dihydrotestosterone (DHT) acts as a potent growth factor and this is the reason why 5-alpha-reductase inhibitors block the conversion of testosterone into DHT.
- Estrogens:
- Surprisingly, Estrogens also have an important role in prostatic hyperplasia. Estradiol is known to be a potent agent in prostatic hyperplasia.
- As men get older, the levels of testosterone decline but not the levels of estrogen remain mostly unchanged, this results in a higher estrogen: testosterone ratio.
Symptoms
There are two types of symptoms these patients will present with: Symptoms of Obstructive Prostatism and Irritative Prostatism.
- Obstructive Prostatism:
- Hesitancy – the patient feels that the bladder is full but struggles to start or maintain a urine stream.
- Straining
- Weak stream
- Terminal dribbling
- Urinary intermittency – this refers to a urine stream that is not continuous.
- Overflow incontinence – small amounts of urine leak (incontinence) because the maximum bladder capacity has been reached.
- A sensation of incomplete emptying
- Irritative Prostatism:
- Urinary frequency – sometimes defined as voiding more than seven times during the day and more than once per night (nocturia).
- Nocturia – the need to urinate at night.
- Urinary urgency – strong urge to urinate.
- Dysuria
- Others
- Hematuria
Diagnosis
The diagnosis of Benign Prostatic Hyperplasia (BPH) is done by using the symptoms of suggestive of urinary obstruction, and a digital rectal examination. In BPH, the surface of the prostate is smooth, firm, mobile with a sulcus and there is no pain. Patients who have Prostate Cancer may have a prostate that has a nodular surface, rocky-hard, fixed without a median sulcus and it is also not painful to palpation. A smooth, soft prostate that is very tender to palpation suggests acute prostatitis.
Diagnosis
Investigations that may be done, include:
- Prostatic Specific Antigen (PSA) – helps to rule out Prostate Cancer.
- Urea and Electrolyte – deranged urea, creatinine and electrolytes may occur due to obstruction of urine flow.
- Uroflowmetry – this is a test that includes an assessment of the following: volume of urine released from the body, the speed with which it is released, and how long the release takes to release the urine.
- Ultrasound of the abdomen and prostate.
- Cystoscope
Management
Non-Medical
Patients with minimal symptoms of lower urinary tract obstruction may benefit from behavioral modifications, these include:
- Bladder Training
- Fluid restriction
- Advice on keeing a voiding diary. In this diary the patient keeps track of the frequency of urination as welll as the volume urinated.
Medical
There are two important agents that can be used to reduce the patient’s obstructive symptoms. These include:
- Alpha blockers: These agents block the alpha-adrenoceptors, which causes relaxation of the smooth muscle of the neck of the bladder and prostate.
- Doxazosin (Cardura XL) 4-8mg PO OD at bed time.
- Tamsulosin Hydrochloride (Uromax or Flomax) 0.4 – 0.8mg PO OD.
- 5-Alpha-Reductase Inhibitors: This agent blocks the enzyme 5-Alpha-Reductase, decreasing the conversion of testosterone into dihydrotestosterone (DHT). This results in shrinkage of the prostate. Because it lowers the levels of DHT, it may cause sexual dysfunction.
- Finasteride 5mg PO OD for 6 months.
Surgical
- Indication for Surgical Treatment:
- Failed alpha-blocker treatment
- Recurrent UTI
- Recurrent haematuria
- Bladder diverticulum
- Bilateral utero-hydronephrosis
- large, post-void residual volume
- uroflowmetry < 15ml/seg
- chronic urinary retention with a palpable bladder
- Surgical Methods:
- Endoscopic:
- One can use an endoscopic procedure to resect the prostate. This is called a Transurethral Resection of the Prostate (TURP). This may be used when the prostate measures around 40mls.
- Open Simple Prostatectomy:
- When the procedure cannot be done endoscopically, for instance if the volume of the prostate is > 40mls, then part of the prostate is removed through different approaches (retropubic or trans-vesical approach)
- Endoscopic:
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