Benign Prostatic Hyperplasia
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Introduction
Benign prostatic hyperplasia, or BPH, is a common affliction of older men. Benign prostate hyperplasia is a histologic diagnosis, revaling epithelium and stroma.
Prostate enlargement frequently goes along with this.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Pathophysiology
Development requires presence of androgens and increasing age. Microscopic evidence can be seen in the 4th decade. The increase in prostate volume with increasing age, as well as vsculae mechanisms that affect urethral obstruction.
alpha-1 adrenergic receptor produces smooth muscle contraction
Signs and Symptoms
- history
- physical exam
History
Obstructive and irritative symptoms are most common and usually begin in their early 50s. They tend to worsen over time.
Obstructive symptoms include:
- hesitancy
- decreased size and force of stream
- stream interruption
- urinary retention
- post-void dribbling
- overflow incontinence
Irritative symptoms include:
- urgency
- frequency
- nocturia
- hematuria
- urge incontinence
Assess severity, prior surgery, trauma, and current medications
Complications can include:
- hematuria
- acutre urinary retention
- obstructive uropathy
- UTIs
- bladder stones
Objective symptom assessment: IPSS or AUASS - can be useful for
A voiding diary and sexual function questionnaire can be helpful, though optional, for determining course of action.
Physical Exam
Physical exam must include DRE for size, symmetry, nodularity, and texture of prostate.
Small: 10-30c: no more than 1 finger width either side of midline.
Medium: 1-2 finger widths...
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Urinalysis should be done for hematuria.
PSA level should be measured in the following circumstances:
- if life expectancy is over 10 years, or where CaP diagnosis would change management
- estimate of prostate volume for management of syptoms
- prediction of symptomatic progression
- to determine response to 5 alpha reductase inhibitor (should see 50% decrease after 6 months)
normal PSA is below 4.0 µg/ml, though patient's age and rate of PSA change should be considered.
PSA above 10 µg/ml is considered abnormal. It is difficult to know what to do for levels between 4-10 µg/ml.
C&S.
Optional testing includes:
- renal function tests
- urine cytology, especially if irritative symptoms predominate
- uroflow
- post-void residual volume by ultrasound
Cystoscopy and biopsy are not indicated, except in certain circumstances.
Diagnostic Imaging
Cytourethroscopy, cytology, prostate ultrasound or biopsy, or IVP are NOT recommended for initial evaluation.
Differential Diagnosis
Prostate cancer is an ominous item on the differential diagnosis.
Treatments
Treatment should include that of bothersome symptoms, improvement of quality of life, identification and prevention of complications, and identification of men who could require surgery.
Lifestyle modifications
Watchful waiting, with lifestyle modifications, are used for mild symptoms, or those considered non-bothersome by patients.
- fluid restriction (including alcohol and caffeine)
- avoidance of medications such as antihistamines, diuretics, antidepressants, and decongestants
- pelvic floor exercises
- bladder retraining (organized voiding)
- avoidance/treatment of constipation
Medications
Medical therapies can be helpful if symptoms are moderate or worse. A combination of alpha blocker and 5-alpha reductase inhibitor appears best (McConnell et al, 2003). Alpha blockers are best for rapid response, while 5-alpha reductase inhibitors are best for long term prostate disease.
alpha receptor antagonists: relax smooth muscle around the prostate and bladder neck
- terazosin (Hydrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Xatral)
- equal clinical effectiveness
- choice should include patient comorbidities, tolerance, and side effects
- fastest clinical response
- no impact on natural history of disease
- can cause orthostatic hypotension
5-alpha reductase inhibitor
- finasteride (Proscar), dutasteride (Avodart)
- reduce symptoms (30% from baseline)
- reducing prostate size (20-30%); should drop PSA by 50% after 6 months
- improve urinary stream (1-2 ml/sec)
- delayed time; up to 6 months for effect
Phytotherapies such as saw palmetto berry extract are considered safe, but require more studies before being recommended as standard therapy.
Transurethral resection of the prostate (TURP)
Absolute indications include failed medical therapy, intractable urinary retention, and renal insufficiency. Relative indications include
- medical therapy failure
- recurrent prostate bleeding
- recurrent urinary retention
- recurrent UTIs
- bladder calculi
Complications include impotence, incontinence, ejaculatory difficulties, and decreased libido.
Other surgical approaches include TUIP (transurethral incision of the prostate), others.
Consequences and Course
Predictors of progresion include:
- increasing age
- baseline PSA 1.4 ng/ml
- prostate volume >30 cc
- symptom severity
Late complications include:
- hydronephrosis
- loss of renal concentrating ability
- systemic acidosis
- renal failure
Resources and References
Canadian Urological Association. BPH Guideline update 2010.
McConnell et al. 2003. NEJM.
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