Urology: Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

Definitions

  • Benign Prostatic Hyperplasia (BPH) – Noncancerous Increase in Prostatic Cell Number
    • *Occurs in the Transitional Zone of the Prostate
  • Benign Prostatic Hypertrophy – Noncancerous Increase in Prostatic Cell Size
    • *Outdated Term No Longer Used
  • Benign Prostatic Enlargement (BPE) – Noncancerous Overall Enlargement of the Prostate
  • Benign Prostatic Obstruction (BPO) – Noncancerous Urethral Obstruction Due to Prostate Enlargement

Risk Factors

  • Older Ager
  • Diabetes
  • Heart Disease
  • Obesity
  • Higher Caffeine/Coffee Intake

Lower Urinary Tract Symptoms (LUTS)

  • Urinary Storage:
    • Urgency – Sudden Strong Urge to Void
    • Nocturia – Multiple Nighttime Voids
    • Frequency
    • Incontinence – Involuntary Leakage
  • Urinary Voiding:
    • Hesitancy – Difficulty Initiating Stream
    • Weak/Slow Stream
    • Intermittency – Intermittent Stream
    • Straining – Difficulty in Voiding Requiring Muscular Effort
    • Dysuria
  • Post-Void:
    • Retention/Incomplete Emptying
    • Post-Void Dribble

Diagnosis

  • Made by the Presence of Lower Urinary Tract Symptoms (LUTS) Without any Evidence of Other Causes
  • Biopsy Unnecessary for Diagnosis (Only Required if Concern for Cancer)

BPH 1

Prostate Hyperplasia 2

Treatment

Medical Treatment

  • Alpha-1-Receptor Antagonist
    • Ex: Tamsulosin (Flomax), Doxazosin, or Terazosin
    • First Line Medication to Relieve Symptoms
    • Mechanism: Relax Smooth Muscle
  • 5-Alpha-Reductase Inhibitor
    • Finasteride (Proscar/Propecia)
    • Mechanism: Inhibits Testosterone Conversion to Dihydrotestosterone
    • Prevents Growth – May Take Months to See Effects
    • Generally Used as a Combination Therapy with Alpha-1-Receptor Antagonist if Symptoms Moderate-Severe

Surgical Treatment

  • Indications for Surgical Treatment:
    • Failure of Medical Therapy (Urinary Retention or Moderate-Severe Symptoms)
    • Recurrent UTI
    • Recurrent Significant Hematuria
    • Recurrent Stones
    • Renal Failure Secondary to Hydronephrosis
  • Surgical Procedures:
    • Simple Prostatectomy
      • Open, Laparoscopic or Robotic
      • Generally Reserved Only for Large-Very Large Prostates
    • Transurethral Resection of the Prostate (TURP)
      • Most Common Procedure
    • Transurethral Vaporization of the Prostate (TUVP)
    • Transurethral Incision of the Prostate (TUIP)
    • Photo-Selective Vaporization of the Prostate (PVP/Laser-TURP)
    • Laser Enucleation of the Prostate
      • Holmium Laser Enucleation of the Prostate (HoLEP)
      • Thulium Laser Enucleation of the Prostate (ThuLEP)
    • Robotic Waterjet Ablation of the Prostate
    • Transurethral Microwave Therapy (TUMT)

Transurethral Resection of Prostate (TURP)

  • Procedure: Resectoscope Inserted Through the Urethra to Resect Excess Prostatic Tissue Piecemeal & Irrigation is Used to Clear the Field
  • Can Be Done Sharply or with Monopolar (M-TURP) or Bipolar (B-TURP) Electrocautery
  • Complications:
    • Ejaculatory Dysfunction (65-75%)
      • Retrograde Ejaculation into the Bladder (Dry Orgasm)
      • Due to Damage to the Nerves/Muscles Around the Bladder Neck
      • Not Harmful but Decreases Fertility
      • The Most Common Long-Term Complication
    • UTI (1.7-8.2%)
    • Erectile Dysfunction (10%)
    • Urethral Stricture (2.2-9.8%)
    • Bladder Neck Contracture (0.3-9.2%)
    • Urinary Incontinence (30-40%)
    • Bleeding
    • TURP Syndrome (< 1%)

TURP Syndrome

  • Definition: Fluid Overload with Dilutional Hyponatremia Due to Water Irrigation During TURP
  • Occurs 15 Minutes to 24 Hours After
  • Increased Risk for Longer Procedures (> 1 Hour) or Larger Resections
  • Presentation:
    • Neurologic Symptoms (Headache, Confusion, Cerebral Edema, & Seizures)
    • Visual Disturbance/Blindness
    • Respiratory Distress
    • Nausea & Vomiting
    • Acute Renal Failure
    • Hypertension
  • Treatment: Hypertonic Saline & Diuresis (Furosemide/Lasix)

References

  1. National Institute of Health. Wikimedia Commons. (License: Public Domain)
  2. Dhingra N, Bhagwat D. Benign prostatic hyperplasia: An overview of existing treatment. Indian J Pharmacol. 2011 Feb;43(1):6-12. (License: CC BY-2.0)