Benign Prostatic Hyperplasia

Definition
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate.


Anatomy

Anatomy of the prostate and urethra

Blood supply to prostate: two main branches: urethral and capsular

Epidemiology
Histologic BPH 20% in men aged 41-50 , to 50% in men 51-60% and to over 90% in men older than 80. although clinical evidence of disease occurs less commonly.
55 year, approximately 25% of men report obstructive voiding symptoms (clinical BPH). at age of 75y, 50% of men complain of clinical BPH.

Risk Factors

• Increased risk of BPH with higher free prostate-specific antigen (PSA) levels, heart disease, and use of β-blockers
• Decreased risk with cigarette smoking, higher physical activity
• Intact testes (BPH rare in eunuchs)
• No evidence of increased or decreased risk with smoking, alcohol, or any dietary factors
• Low androgen levels from cirrhosis/chronic alcoholism can reduce the risk of BPH.

Genetics

• Males who had 1st-degree relative with BPH are at increased risk.

• Race has some influence on risk for BPH severe enough to require surgery.

• Black men less than 65 years old may need treatment more often than white men.

Pathophysiology
As the prostate enlarges, the surrounding capsule prevents it from radially expanding, potentially resulting in urethral compression.
However, obstruction-induced bladder dysfunction contributes significantly to LUTS.
The bladder wall becomes thickened, trabeculated, and irritable when it is forced to hypertrophy and increase its own contractile force.
This increased sensitivity (detrusor instability), even with small volumes of urine in the bladder, is believed to contribute to urinary frequency and LUTS.
The bladder may gradually weaken and lose the ability to empty completely, leading to increased residual urine volume and, possibly, acute or chronic urinary retention.

Aetiology
BPH develops in the periurethral or transition zone of the prostate.
Hyperplastic nodules of stromal and epithelial components increase glandular components.

Commonly Associated Conditions : LUTS:

• Irritative symptoms: Frequency, urgency, dysuria, nocturia
• Obstructive symptoms: Poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence

Presentation

History

Symptom scores such as American Urological Association (AUA). It consists of 7 questions, each of which is scored on a scale of 0 (not present) to 5 (almost always present). Symptoms are classified as mild (total score 0–7), moderate (total score 8–19) and severe (total score 20–35): Frequency Nocturia Weak urinary stream Hesitancy Intermittence Incomplete emptying Urgency Gross hematuria History of type 2 diabetes, which can cause nocturia and is a risk factor for BPH Symptoms of neurologic disease that would suggest a neurogenic bladder Sexual dysfunction, which is correlated with LUTS History of urethral trauma, urethritis, or urethral instrumentation that could lead to urethral stricture Family history of BPH and prostate cancer Treatment with drugs that can impair bladder function (anticholinergic drugs) or increase outflow resistance (sympathomimetic drugs)

Physical Exam

Digital rectal exam finding of enlarged prostate, but size does not always correlate with symptoms Percussion to detect distended bladder, particularly if post-void Signs of renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies) Anal sphincter tone or lack of it may indicate an underlying neurological disorder.

Differential diagnosis

Obstructive	Prostate cancer Urethral stricture or valves Bladder neck contracture (usually secondary to prostate surgery) Prostatitis
Neurologic	Spinal cord injury Stroke Parkinsonism Multiple sclerosis
Medical	Poorly controlled diabetes mellitus Congestive heart failure (CHF)
Pharmacologic	Diuretics Sympathomimetics (e.g., cold medications) Anticholinergics
Other	Bladder carcinoma Overactive bladder Bladder calculi Urinary tract infection

Investigation

PSA	Prostate-specific Antigen: may be elevated, but usually <10 ng/mL (10 µg/L). Acute urinary retention, prostatitis, urinary tract instrumentation, or prostatic infarction may elevate PSA.
Urinalysis	Urine using dipstick methods and/or via centrifuged sediment evaluation to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. Pyuria if stones or infection present, pH changes due to chronic residual urine
Urine culture	positive (sometimes due to chronic residual urine)
BUN	Blood urea nitrogen and creatinine (if concerns for uremia)
Uroflow	Volume voided per unit time (peak flow <10 mL/sec is abnormal)
Post-void residual	Either with catheterization or bladder ultrasound (>100 mL demonstrates incomplete emptying)
Ultrasound	abdominal, renal, transrectal ulstrasonography and intravenous urography are useful for helping determine bladder and prostate size and the degree of hydronephrosis
Pressure-flow studies	Using urine flow vs voiding pressures: Best test to determine etiology of voiding symptoms Obstructive pattern shows high voiding pressures with low flow rate
Cystoscopy	Demonstrates presence, configuration, and site of obstructive tissue Helps to show stricture, stones May help determine best minimally invasive therapeutic option Not recommended in initial evaluation unless other factors such as hematuria are present

Management
The American Urological Association (AUA) Guideline

Initial evaluation	History, exam, urinalysis, PSA IPSS/AUA Symptom Index: which inquires about incomplete emptying how often have you had the sensation of not emptying your bladder completely after you have finished urinating? Frequency how often have you had to urinate again less than 2 hours after you finished urinating? Intermitency how often have you stopped and started again several times when urinating? Urgency how often have you found it difficult to postpone urination? Weak stream how often have you had a weak urinary stream? Strain how often have you had to push or strain to begin urination? Nocturia ow many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? Each graded from 0-5 (0=not at all, 5= almost always) over the past month Bother score: The IPSS uses the same 7 questions as the AUA-SI, with the addition of the following disease-specific QOL question: How would you feel if you were to spend the rest of your life with your urinary condition just the way it is now? (0=delighted, 6=terrible)
Lifestyle	decrease fluid intake before bedtime Moderate the consumption of alcohol and caffeine-containing products Follow timed voiding schedules.
First line med	α-adrenergic antagonists Nonselective, reduce prostatic smooth muscle tone, improving urinary flow: Terazosin (Hytrin): 1–10 mg/d p.o. Doxazosin (Cardura): 1–8 mg/d p.o. Selective, may produce fewer side effects. Generally more expensive: Tamsulosin (Flomax): 0.4 mg/d p.o. Alfuzosin (Uroxatral): 10 mg/d p.o. 5-α-reductase inhibitors reduce prostatic volume (useful if demonstrable prostatic enlargement): Finasteride (Proscar): 5 mg/d p.o. Dutasteride (Avodart): 0.5 mg/d p.o. Also useful in controlling prostatic bleeding Combination therapy of α-blocker plus 5-α-reductase inhibitor is superior to monotherapy Anticholinergic agents may be combined with α-blockers for relief of persistent storage symptoms. Contraindications: α-blockers can cause orthostatic hypotension; less risk with tamsulosin and alfuzosin. See specific recommendations for α-blocker use with phosphodiesterase type-5 inhibitors (for erectile dysfunction).
Precaution in elderly	Drugs to be avoided include anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, narcotics, and skeletal muscle relaxants when possible.
Alternative	Phytotherapy (emerging therapy, not recommended) Saw palmetto (Serenoa repens) has shown mild improvement of peak flow rates and appears to work by blocking 5-α-reductase
Surgical	Indications for surgery: Urinary retention due to prostatic obstruction, recurrent Intractable symptoms due to prostatic obstruction AUA sx score >8 and bother) Obstructive uropathy (renal insufficiency) Recurrent or persistent UTIs due to prostatic obstruction Recurrent gross hematuria due to enlarged prostate Bladder calculi Transurethral resection of the prostate. Gold standard Definition Minimally invasive procedure performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. Indication BPH refractory to medication Media Pre-op During the weeks before surgery, stop aspirin, ibuprofen, naproxen , vitamin E, clopidogrel , warfarin (Coumadin),. On the day of surgery:fasting from midnight. Procedure General anesthesia (asleep, pain-free) or spinal anesthesia (awake, sedated, pain-free). The procedure takes about 1 hour. The surgeon will insert a tube-like tool called a cystoscope (or endoscope) through the urethra. The surgeon then inserts a special cutting tool through the cystoscope to remove part of your prostate gland piece by piece with an electric current. Outcome Reduces symptoms in 88% of BPH patients. Mortality rates are 0.2%, but they can be as high as 10% in patients over 80 years of age. Following surgery, inadequate relief of BPH symptoms occurs in 20–25% of patients, and 15–20% require another operation within 10 years. Urinary incontinence affects 2–4%, and 5–10% of TURP patients become impotent. Post-op hospital stay for 1 to 3 days. Foley catheter to remove urine. The urine will look bloody at first. It will clear with time. A bladder irrigation solution may be attached to the catheter to continuously flush the catheter. Initial recovery period ~1 week Meds: B&O suppository (Belladonna and Opium). This medication has the dual purpose of providing pain relief and reducing the ureteral and bladder spasms that follow TURP surgery. It is a strong medication that must be used only as prescribed. Bulk-forming laxative. Macrobid. This antibiotic helps prevent urinary tract infections. Pyridium. This medication offers symptomatic relief from pain, burning, urgency, frequency, and other urinary tract discomfort. Advices Refrain from alcoholic beverages. Avoid sexual activities for a few weeks. Avoid driving a car for a week or more. Keep domestic activities to a minimum. Avoid weight lifting or strenuous exercise. Check their temperature and report any fever to the physician. Practice good hygiene, especially of the hands and penis. Drink plenty of liquids Complications Risks for any surgery are: Blood clots in the legs that may travel to the lungs Breathing problems Infection, including in the surgical wound, lungs (pneumonia), or bladder or kidney Blood loss Heart attack or stroke during surgery Reactions to medications Additional risks are: Problems with urine control (incontinence) Loss of sperm fertility (infertility) Erection problems (impotence) Passing the semen into the bladder instead of out through the urethra (retrograde ejaculation) Urethral stricture (tightening of the urinary outlet from scar tissue) TURP syndrome:  Hyponatremia and water intoxication (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of fluid absorption from the open prostatic sinusiods during the procedure. This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma. Damage to internal organs and structures Open prostatectomy This procedure (invasive) is now reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery.
Other minimally invasive procedure (alternatives to TURP)	Interstitial laser coagulation. In this procedure, a laser beam inserted in the urethra via a catheter heats and destroys the extra prostate capsule tissue. Transurethral needle ablation (TUNA). This technique was approved by the FDA in 1996. It uses radio waves to heat and destroy the enlarged prostate through needles positioned in the gland. It is generally less effective than TURP for reducing symptoms and increasing urine flow. Transurethral electrovaporization. This procedure is a modified version of TURP, and uses a device that produces electronic waves to vaporize the enlarged prostate. Photoselective vaporization of the prostate (PVP). This procedure uses a strong laser beam to vaporize the tissue in a 20–50 minute outpatient operation. Transurethral incision of the prostate (TUIP). In this procedure, a small incision is made in the bladder, followed by a few cuts into the sphincter muscle to release some of the tension. Transurethral microwave thermotherapy (TUMT). TUMT uses microwave heat energy to shrink the enlarged prostate through a probe inserted into the penis to the level of the prostate. This outpatient procedure takes about one hour. The patient can go home the same day, and is able to resume normal activities within a day or two. TUMT does not lead to immediate improvement, and it usually takes up to four weeks for urinary problems to completely resolve. Water-induced thermotherapy (WIT). WIT is administered via a closed-loop catheter system, through which heated water is maintained at a constant temperature. WIT is usually performed using only a local anesthetic gel to anesthetize the penis, and is very well tolerated. The procedure is FDA approved. Balloon dilation. In this procedure, a balloon is inserted in the urethra up to where the restriction occurs. At that point, the balloon expands to push out the prostate tissue and widen the urinary path. Improvements with this technique may only last a few years.
Monitor/ Follow-up	Symptom index (IPSS) monitored every 3–12 months Digital rectal exam yearly PSA yearly: Should not be checked while patient is in retention, recently catheterized, or within a week of any surgical procedure to the prostate Consider monitoring postvoid residual if elevated

Complications
Urinary retention (acute or chronic)
Bladder stones
Prostatitis
Renal failure
Hematuria

Prognosis
Symptoms improve or stabilize in 70–80% of patients; 20–30% require treatment because of worsening symptoms.
25% of men with LUTS will have persistent storage symptoms after prostatectomy:

• LUTS can be divided into 3 groups: Filling/storage symptoms, voiding symptoms, and postmicturition symptoms
• Filling/storage symptoms include frequency, nocturia, urgency, and urge incontinence.

Of men with BPH, 11–33% have occult prostate cancer.