Benign prostatic hyperplasia

D: Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland, the most frequent cause of LUTS in adult males.

A: Precise unknown but thought to be related to hormonal changes, in particular ^^ fluctuating levels of androgens and oestrogens.

A/R: A diet rich in soya and vegetables may reduce the risk and there is a negative association with cirrhosis.

_E Common, 70% of men aged 70 years have histological BPH, with 50% of these experiencing significant symptoms, West > Far East, Afrocarribean > Caucasian.

Obstructive symptoms: Hesitancy, poor or intermittent stream, terminal dribbling and incomplete emptying.

Irritative/storage symptoms: Frequency, urgency, urge incontinence and nocturia.

Acute retention: Sudden inability to pass urine, associated with severe pain. Chronic retention: Painless, there is often frequency with passage of small volumes of urine, especially at night.

On digital rectal examination, the prostate is often enlarged; however, there is poor correlation between the size and symptoms and if nodular, prostate carcinoma should be suspected.

Acute retention: Suprapubic pain and a distented palpable bladder. Chronic retention: A large distended painless bladder (residual volumes > 1L) and there may be signs of renal failure.

Micro: From middle age, hyperplasia of the para-urethral glands with associated smooth muscle and fibrous tissue growth occurs, surrounded by a false capsule of compressed peripheral zone glandular tissue.

Bloods: U&Es for impaired renal function, PSA. Midstream urine: For microscopy, culture and sensitivity. Imaging: Ultrasound imaging of the renal tract to check for dilatation of the upper urinary tract. Bladder scanning to measure pre- and postvoiding volumes. TRUS to measure prostate size and guide biopsies. Flexible cystoscopy to visualise the bladder outlet and bladder changes (e.g. trabeculation). Other: Urinary flow studies (flowmetry).

Depends on the severity of symptoms and the presence of complications. Emergency: In acute retention, urinary catheterisation.

Conservative: If mild, 'watchful waiting' may be appropriate with symptom monitoring using the IPSS questionnaire.

Medical: Selective a-blockers relax smooth muscle of the internal (bladder neck) sphincter and the prostate capsule (e.g. alfuzosin, tamsulosin). 5a-reduc-tase inhibitors act by inhibiting conversion of testosterone to dihydrotestoster-one (e.g. finasteride), reduce prostate size by ~ 20%, but may take time to show improvement.

Surgery: TURP involves electrocautery-mediated resection from within the prostatic urethra. Open prostatectomy (retropubic or suprapubic approaches) is usually reserved for very large glands (> 60 g).

Recurrent urinary infections, acute or chronic urinary retention, urinary stasis and bladder diverticulae or stone development, obstructive renal failure, post-obstructive diuresis.

From TURP: Retrograde ejaculation (common), haemorrhage (primary, reactionary or secondary 2-10%), clot retention, more rarely incontinence, TUR syndrome (seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid), urinary infection, erectile dysfunction; late: urethral stricture.

Mild symptoms may be improved by medical therapies but those with marked symptoms usually obtain significant relief from surgical intervention.

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