Benign Prostatic Hyperplasia

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Introduction

Benign prostatic hyperplasia, or BPH, is a common affliction of older men. Benign prostate hyperplasia is a histologic diagnosis, revaling epithelium and stroma.

 

Prostate enlargement frequently goes along with this.

 

 

 

The Case of...

a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.

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Causes and Risk Factors

 

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Pathophysiology

Development requires presence of androgens and increasing age. Microscopic evidence can be seen in the 4th decade. The increase in prostate volume with increasing age, as well as vsculae mechanisms that affect urethral obstruction.

 

Alpha-1 adrenergic receptor stimulation produces smooth muscle contraction.

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Signs and Symptoms

  • history
  • physical exam

History

Obstructive and irritative symptoms are most common and usually begin in their early 50s. They tend to worsen over time.

Obstructive symptoms include:

  • hesitancy
  • decreased size and force of stream
  • stream interruption
  • urinary retention
  • post-void dribbling
  • overflow incontinence

Irritative symptoms include:

  • urgency
  • frequency
  • nocturia
  • hematuria
  • urge incontinence

 

 

Assess severity, prior surgery, trauma, and current medications.

 

Complications can include:

  • hematuria
  • acutre urinary retention
  • obstructive uropathy
  • UTIs
  • bladder stones

Objective symptom assessment: IPSS or AUASS - can be useful for

 

A voiding diary and sexual function questionnaire can be helpful, though optional, for determining course of action.

Physical Exam

Physical exam must include DRE for size, symmetry, nodularity, and texture of prostate.

Small: 10-30c: no more than 1 finger width either side of midline.

Medium: 1-2 finger widths...

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Urinalysis should be done for hematuria.

Culture and sensitivity should be done to rule out infectious causes.

 

PSA...

 

 

Optional testing includes:

  • renal function tests
  • urine cytology, especially if irritative symptoms predominate
  • uroflow
  • post-void residual volume by ultrasound

Cystoscopy and biopsy are not indicated, except in certain circumstances.

Diagnostic Imaging

Cytourethroscopy, cytology, prostate ultrasound or biopsy, or IVP are NOT recommended for initial evaluation.

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Differential Diagnosis

Prostate cancer is an ominous item on the differential diagnosis.

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Treatments

Treatment should be considered to improve bothersome symptoms and quality of life.

 

identification and prevention of complications, and identification of men who could require surgery.

 

Lifestyle modifications

Watchful waiting, with lifestyle modifications, are used for mild symptoms, or those considered non-bothersome by patients.

 

Medications

Medical therapies can be helpful if symptoms are moderate or worse. A combination of alpha blocker and 5-alpha reductase inhibitor appears best (McConnell et al, 2003). Alpha blockers are best for rapid response, while 5-alpha reductase inhibitors are best for long term prostate disease.

 

alpha receptor antagonists: relax smooth muscle around the prostate and bladder neck

 

5-alpha reductase inhibitor

Phytotherapies such as saw palmetto berry extract are considered safe, but require more studies before being recommended as standard therapy.

 

 

Transurethral resection of the prostate (TURP)

Absolute indications include intractable urinary retention and renal failure.

Relative indications include:

Complications of TURP include impotence, incontinence, ejaculatory difficulties, and decreased libido.

 

Other surgical approaches include TUIP (transurethral incision of the prostate), others.

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Consequences and Course

Predictors of progresion include:

Late complications include:

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Resources and References

Canadian Urological Association. BPH Guideline update 2010.

McConnell et al. 2003. NEJM.

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Topic Development

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