Benign prostatic hyperplasia

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Introduction:

Benign Prostatic Hyperplasia is a non-cancerous enlargement of the prostate causing clinical symptoms.

Increase in size impacts on the urethra and partially or completely obstructs urine outflow.

Benign prostatic hyperplasia is a common cause of lower urinary tract
obstruction among elderly males.

Pathological enlargement occurs usually after the age of 40.

Symptoms are due to mechanical obstruction (static cause) or spasm of the smooth muscles in the prostate and around the bladder neck.

Symptoms and Clinical features of benign prostatic hyperplasia

Lower Urinary Tract Symptoms (LUTS);

  1. Filling/Storage Symptoms
    • Daytime frequency
    • Urgency
    • Urgency incontinence
    • Nocturia
  2. Voiding/Emptying Symptoms
    • Poor stream
    • Excessive straining
    • Hesitancy
    • Intermittency
    • Terminal dribblinAcute retention of urine.
  3. Postmicturition Symptoms
    • Feeling of incomplete emptying of the bladder
    • Post-micturition dribbling of urine
  4. Other Symptoms
    • Haematuria
    • Swelling of the lower abdomen

Signs of benign prostatic hyperplasia

Mass in the lower abdomen

  • Digital Rectal Examination (DRE) – Anatomic enlargement of the prostate, firm, smooth surfaced, with median groove and lateral sulci present.
  • Signs of progressive renal failure in severe longstanding obstruction

Investigations

  • Full blood count and ESR
  • Urinalysis, urine microscopy, culture and sensitivity
  • Serum electrolytes, urea, and creatinine
  • Prostate Specific Antigen (PSA)
  • Transrectal ultrasound (TRUS)
  • Abdominal ultrasound
  • X-rays-Chest, Abdomen (KUB)
  • Uroflowmetry
  • Cystoscopy

Differential Diagnosis

  • Prostate Cancer
  • Bladder Cancer
  • Bladder neck stenosis/ contracture
  • Bladder neck dysnerrgia
  • Urinary Tract Infection
  • Urethral stricture
  • External sphincter dysnerrgia
  • Bladder calculus
  • Prostatitis.
  • Neurological Diseases.
  • Bladder wall diseases, especially chronic schistosomiasis and tuberculosis of the bladder.

Complications of benign prostatic hyperplasia

  1. Urinary retention
  2. Recurrent Urinary Tract Infection
  3. Bladder calculus
  4. chronic renal insufficiency & Acute renal failure
  5. Haematuria
  6. Obstructive uropathy

Treatment for benign prostatic hyperplasia

Treatment Objectives

To relieve obstruction and treat complication

Non-drug treatment

In severe symptoms (IPSS >19) and associated complications

  • Surgical Operation
    • Open prostatectomy
    • Transurethral resection of the prostate
    • Transurethral incision of the bladder neck
    • Transurethral Vaporization of the Prostate
    • Transurethral laser surgery

Non-medical minimally invasive alternatives

  • Urethral catheterization (Size 16 or 14 FG)
  • Prostatic urethral stents.
  • Balloon dilatation of the prostatic urethra
  • Transurethral or transrectal hypothermia
  • Transurethral thermotherapy
  • Interstitial therapies

Drug Treatment

In mild to moderate symptoms
(IPSS <19)

α-1 adrenergic blockers

  • Alfuzosin 10mg nocte (preferable in reproductive age)

5-α-reductase inhibitors

  • Finasteride-5mg daily

Adverse Reactions

 α -1 adrenergic blockers

  • Retrograde ejaculation, dizziness, hypotension and syncopal attacks.
  • So this should be taken at bedtime

5- α -reductase inhibitors

  • Loss of libido, erectile dysfunction, gynaecomastia.

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