Benign Prostatic Hyperplasia

Written by Ramita Kaur Shahi

Last Reviewed: September 2019

Review Due: September 2020

 

DEFINITION

'a non-cancerous enlargement of the middle portion of the prostate gland, with formation of discrete nodules in the periurethral region of the prostate'

 

AETIOLOGY

Unknown but may be due to hormonal changes that occur as males grow older. 

 

Risk Factors:

Aging

Family history

Diabetes

Obesity  

Heart disease

Use of beta blockers

SIGNS AND SYMPTOMS

Difficulty starting and stopping stream

Increased frequency of urination

Inability to empty the bladder completely

Weak urine stream

Bladder hypertrophy and distension

Overflow dribbling

Nocturia

Dysuria

Urinary tract infection

 

PATHOPHYSIOLOGY

Testosterone is converted to Dihydrotestosterone (DHT) by type 2 5-alpha-reductase located in the stromal cells of the prostate gland. 

 

DHT has a higher affinity than testosterone for androgen receptors (AR) in the stromal and epithelial cells of the prostate gland. 

 

Binding of DHT to AR activates the transcription of genes that result in increased production of several growth factors and their receptors. This results in increased stromal cell proliferation, decreased epithelial cell death and formation of well-defined nodules (hallmark of BPH). These nodules then compress the walls of the urethra into a slit-like orifice.

 

Investigations

laboratory

 

Urine dipstick 

White cells would suggest infection potentially precipitated by BPH 

U&Es  

Baseline kidney function

Prostate Specific Antigen (PSA)

 Elevated with enlarged prostate

 

Urinary flow test

Measures strength and amount of urine flow

 

Post-void bladder scan 

Measures ability of the bladder to empty completely

 

24-hour voiding diary

Record frequency and amount of urine. Helpful if more than 1/3 of daily urine output occurs at night

 

May be considered:

Transrectal ultrasound

Prostate biopsy

Urodynamic and pressure flow studies

Cystoscopy

Other investigations

 

TREATMENT

Treatment of BPH depends on:

Size of prostate

Age

Comorbidities

Severity of symptoms

 

For some, symptoms may be tolerable or ease without treatment.

For mild to moderate symptoms, where conservative management has been unsuccessful.

 

 

 

 

Alpha blockers (Alfuzosin, Doxazosin, Tamsulosin, Terazosin)

Relaxes smooth muscles of the bladder and prostate, allowing smoother passage of urine.

5-alpha reductase inhibitors (Finasteride)

Inhibits conversion of testosterone to DHT, thus reducing the proliferation of stromal and epithelial cells of the prostate. 

Offered when patient is symptomatic with prostate larger than 30g or PSA > 1.4 ng/ml.

Anticholinergics 

To manage symptoms of overactive bladder.

Oral desmopressin

If nocturnal polyuria present with other medical causes excluded and other treatments fail.

 

 

 

Transurethral resection of the prostate (TURP)

Lighted scope inserted into the urethra and all of outer part of prostate removed.

Transurethral incision of the prostate (TUIP)

Lighted scope inserted into the urethra and one or two small cuts made in the prostate. Offered if prostate is smaller than 30g.

Medical treatment

Surgical treatment

EPIDEMIOLOGY

Incidence in the UK ranges from 150 to 420 cases per 1,000,000 people.

 

 
 

BPH tends to affect men above the age of 50. Approximately 43% of men above the age of 65 and 90% of men in their seventies and eighties have urinary symptoms due to BPH.

 

REFERENCES

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