Benign Prostatic Hyperplasia (BPH) - Short Notes

Definition

Epidemiology

• Age-related condition and common after 50 years.
• Histological BPH occurs in about 50% of men over 50 years and up to 90% of men in their 80s.
• Not all men with histological BPH develop symptoms.
  Goldman-Cecil Medicine, p. 1316.

Etiopathogenesis

• Requires aging and androgenic stimulation.
• Testosterone is converted to dihydrotestosterone (DHT) by 5-alpha-reductase.
• DHT promotes proliferation of prostatic stromal and epithelial cells.
• Two components of obstruction:
  1. Static component: enlargement of prostate tissue.
  2. Dynamic component: increased alpha-1 adrenergic smooth-muscle tone in prostate and bladder neck.

Pathology

• Nodular hyperplasia in the transition/periurethral zone.
• Stromal and glandular proliferation forms nodules.
• Enlarged lateral lobes and/or a median lobe may obstruct the urethra.
• In contrast, prostatic adenocarcinoma usually arises in the peripheral zone.

Clinical Features

• Hesitancy
• Poor urinary stream
• Intermittency
• Straining
• Terminal dribbling
• Prolonged micturition

• Frequency
• Urgency
• Nocturia
• Urge incontinence

• Feeling of incomplete emptying
• Post-void dribbling

Complications

• Acute urinary retention
• Recurrent urinary tract infection
• Bladder stones
• Hematuria
• Bladder diverticula and trabeculation
• Chronic retention with overflow incontinence
• Hydroureter, hydronephrosis, and renal impairment in advanced obstruction

Evaluation

• History including medication review and symptom severity using IPSS/AUA symptom score
• Physical examination: abdominal examination, external genital examination, digital rectal examination
• Urinalysis to exclude infection/hematuria
• Serum creatinine if renal impairment is suspected
• PSA when it will influence management or cancer assessment
• Ultrasound for prostate size, post-void residual urine, upper tract when indicated
• Uroflowmetry
• Cystoscopy or urodynamic studies in selected patients, especially before surgery or with diagnostic uncertainty.
  Sabiston Textbook of Surgery, p. 2824.

Management

1. Conservative

• Reassurance and watchful waiting
• Reduce evening fluids, caffeine, and alcohol
• Timed voiding and double voiding
• Review drugs that worsen symptoms, for example decongestants with sympathomimetic action

2. Medical treatment

• Alpha-1 blockers: tamsulosin, alfuzosin, silodosin
  • Rapidly relax smooth muscle in prostate/bladder neck.
  • Adverse effects: postural dizziness, ejaculatory dysfunction.
• 5-alpha-reductase inhibitors: finasteride, dutasteride
  • Reduce DHT and shrink the prostate.
  • Best for enlarged prostate, but effect takes months.
  • Adverse effects: reduced libido, erectile dysfunction, reduced ejaculate.
  • PSA falls by about 50%, which must be considered during interpretation.
• Combination therapy: alpha-blocker plus 5-alpha-reductase inhibitor for moderate/severe LUTS with enlarged prostate.
• Tadalafil may help LUTS with coexisting erectile dysfunction.
• Antimuscarinic or beta-3 agonist therapy may be considered when storage symptoms predominate, after checking residual urine.

3. Surgery/procedures

• Refractory or recurrent urinary retention
• Recurrent UTI
• Recurrent gross hematuria attributable to BPH
• Bladder stone or diverticulum
• Hydronephrosis or renal dysfunction due to obstruction
• Persistent bothersome symptoms despite medication

• TURP: standard operation for many moderate-sized prostates.
• Laser enucleation, such as HoLEP.
• Photoselective vaporization of prostate.
• Simple prostatectomy or enucleation for very large glands.
• Selected minimally invasive options: prostatic urethral lift, water-vapour thermal therapy.

Key Points

• BPH is benign and does not itself become cancer.
• Size of the prostate does not always correlate with symptom severity.
• Differentiate BPH from carcinoma prostate, urethral stricture, neurogenic bladder, UTI, and bladder stone.
• Recent AUA BPH guideline update emphasizes structured symptom assessment, urinalysis, and individualized medical or procedural treatment.