Introduction

  • This occurs most commonly in men over 60
  • 24% of those ages 40-64, and 40% of those over 65 will have the condition.
  • It is very rare in Asian men
  • It does not occur in eunuchs
  • Microscopically there is hyperplasia of both the connective (stromal)tissue, and of the glandular (epithelial)tissue, however, it is the connective tissue
  • Nearly All men will develop BPH if they live long enough. About ½ of all men will have macroscopic enlargement, and one half of these will have symptoms.
  • The prostate naturally grows throughout life – it grows in response to dihyrotestosterone – a breakdown product of testosterone.
 

Presentation

  • Frequency of urination (notably nocturia) is the most common early symptom
  • Hesitation in initiating urination.
  • Reduced force of the urinary stream
  • Post-void dribbling
  • Retention of urine resulting in overflow incontinence.
  • A benign prostate will always feel smooth
  • Size is relevant but is not always associated to the severity of the symptoms.
 

Investigations

  • PSA
  • PR (DRE – digital rectal examination)
  • Symptom score
  • Rectal ultrasound
  • Cystoscopy
  • Urine flow analysis
 

Management

  • Patients with mild symptoms should perhaps not be given treatment if they feel they can cope, due to the adverse effects many of the treatments. Sometimes symptoms after treatment may be worse than symptoms before treatment!
  • Patients with moderate symptoms should be treated with drugs:
    • α-blockers – alfuzosin, doxazosin, tamsulosin – these reduce smooth muscle contractions of the bladder and urethra – they generally reduce the muscle tension in these regions. This allows for easier passing of urine.
    • 5α- reductase – finasteride – these reduce the conversion of testosterone to dihyrotestosterone and thus help to shrink the size of the prostate. These take 4-6 months to have an effect.
    • Combination therapy – this is a combination of the two drugs above, and most patients who are on drugs for BPH are given this.
  • Patients with more severe symptoms should be considered for surgery. These symptoms may include renal damage, and upper UT dilation.
    • TURP – transurethral resection of the prostate – this is where part of the prostate is cut out via the urethra. It can be done under general or local anaesthetic. About 14% of patients will become impotent, and 20% of patients will need further surgery within 10 years.
    • TUIP – transurethral incision of the prostate – this is the best option for those with small glands. It removes less of the prostate than TURP and as a result, greatly reduces the chance of sexual dysfunction.  
  • In cases of acute retention, or retention with overflow, the immediate priority is to relieve discomfort and pain, and often catheterisation is a good idea. The urethral catheterization is not possible, then subra-pubic catheterization may be carried out. This involves sticking a tube through the abdominal wall directly into the bladder. It is often done in cases where the patient needs to be catheterized for a prolonged period.

 

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