Benign Prostate Hyperplasia

Very common benign condition in men of increasing age caused by hyperplasia of the stromal and epithelial cells of the prostate

Aetiology

  • Affects up to 40% of men over 40, and 90% of men over 80
  • Considered a variation of normal physiology - caused by lifelong exposure to androgens

Pathophysiology

  • Microscopically there is hyperplasia of both the connective (stromal) tissue, and of the glandular (epithelial) tissue
  • Thought to be the result of a failure of apoptosis
  • Nearly all men will develop BPH if they live long enough
  • The prostate naturally grows throughout life - it grows in response to dihydrotestosterone (breakdown product of testosterone)
  • The majority of growth occurs in the transitional zone
  • BPH does not make prostate cancer more likely

Clinical presentation

  • May manifest symptomatically with lower urinary tract symptoms (LUTS)
    • 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
    • Incontinence may occur
  • Bladder outflow obstruction, as a result of BPH, is associated with:
    • Urinary retention
    • Recurrent UTI
    • Impaired renal function
    • Haematuria
  • Symptom score such as the IPSS (international prostate symptoms score) - scores classed as mild, moderate or severe

Investigations

  • Urine dipstick to exclude infection
  • PSA done prior to rectal examination can help with assessing potential for prostate cancer
  • Rectal exam to assess prostate size, shape and characteristics
    • BPH usually causes a smooth, symmetrical prostate enlargement

Management

  • Reassurance and monitoring if manageable symptoms

Pharmacological management

  • Alpha-blockers - relax smooth muscle, e.g. tamsulosin 400 mcg once daily
  • 5-alpha reductase inhibitors - block testosterone and actually help reduce the size of the prostate, e.g. finasteride

Surgical management

  • Transurethral resection of the prostate (TURP)
  • Transurethral electrovaporisation of the prostate (TUVP)
  • Holmium laser enucleation of the prostate (HoLEP)
  • Open prostatectomy via abdominal or perineal incision