Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia

Definition of Benign Prostatic Hyperplasia.
 Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostateFor most men, one of those changes is that the prostate gets bigger. It's a natural part of aging, but at some point, it can lead to a condition called BPH, or benign prostatic hyperplasia. Your prostate surrounds part of your urethra, the tube that carries urine and semen out of your penis

Factors affecting Benign prostate Hyperplasia or Enlargement:

• ageing
• testosterone
• genetic factors
• decreased cell death of epithelial and stromal cells
• increased activity of growth factors
• diet (red meat, fatty diet)

Pathophysiology of Benign Prostatic Hyperplasia

The pathopysiology of benign prostatic hyperplasia involve the influence of dihydrotestosterone (DHT) there is hyperplasia of fibromuscular and glandular prostatic tissue. The fibromyoadenoma develops in the peri-urethral and transitional zone of prostate. Thenormal periphery is compressed, forming a false capsule. The true capsule transmits the pressure of tissue expansion (especially of middle and lateral lobes) to the urethra, increasing the urinary outflow
resistance and producing lower urinary tract symptoms. Refer to the image below:

There is compensatory hypertrophy of detrusor smooth muscle to increase intravesical pressure and maintain urine flow. This leads to decreased compliance of the bladder wall, producing irritative symptoms.

The prolonged increased detrusor smooth muscle contractility leads to stretching of the muscles, with decreased ability to contract. This produces obstructive lower urinary symptoms. There may be acute retention, and decreased bladder contractility leads to increasing residual urine, and chronic retention.

The thickened bladder wall causes kinking of the terminal ureters. As a result there is failure of the uretero-vesical valves, vesico-ureteric reflux, bilateral hydroureters, and hydronephrosis. This in turn, leads to destruction of the renal papillae and parenchyma, with impaired renal function.

Generally there is no correlation between the size of the prostate and the degree of bladder outlet obstruction, the development or severity of lower urinary tract symptoms.

Complications of Benign Prostatic Hyperplasia

The complications of benign prostate enlargement is as outlined below:

• Recurrent Urinary Tract Infection

• 
  Haematuria

• 
  Urinary retention

• 
  Acute/chronic renal failure

Clinical Features of BPH

The clinical features of benign prostate enlargement is categorized into initial recognition phase, Intermediate symptoms, and late symptoms. the clinical features or the signs and symptoms like the causes and complications of benogn prostatic hyperplasia has a pattern which as a reader, I will recommend you to follow.

Initial Recognition (Screening Questions)

• Nocturia
• slow flow of urine
• bothersome bladder
• Initial Symptoms (irritative)
• frequency
• urgency
• nocturia
• urge incontinence

Intermediate symptoms (obstructive)

• weak (poor) urine stream (with prolonged micturition)
• feeling of incomplete bladder emptying
• straining on micturition
• intermittency
• hesitancy
• urinary retention
• acute/acute-on-chronic
• chronic retention with overflow incontinence and post urination
• dribbling

Late symptoms (complications)

• haematuria
• recurrent UTI
• renal failure (acute or chronic)

The International Prostate Symptoms Score (IPSS)

Developed by the American Urological Association and adopted by WHO in
1994. There are three assessments: obstructive and irritative symptoms
(which give the IPSS), as well as the quality of life due to BPH.

Obstructive symptoms:

• incomplete bladder emptying
• intermittency
• weak stream
• straining
• Irritative symptoms
• frequency
• urgency
• nocturia

These are scored from 0 to 5, to give a maximum possible score of 35.

Interpretation is 0-8 (mild), 9-19 (moderate), 20-35 (severe).

The quality of life due to BPH urinary symptoms is assessed and scored
from 0 – 6.

Past medical history in Prostate enlargement

• Diabetes mellitus, previous STI, previous operations, neurological
• disorders
• Drug history
• Diuretics, aspirin, antihypertensives
• Examination Findings
• General: anaemia, dehydration, oedema
• Abdominal: hernia, palpable kidneys, suprapubic masses
• External genitalia: urethral discharge, meatal stenosis, perineal
• swellings, indurations, fistulae, extravasation of urine, water-can
• scrotum

Focal CNS exam

DRE:   

    inspection;

     estimation of sphincter tone;

     prostate:

         size,

         consistency,

         surface,

         tenderness,

         edges,

         symmetry,

         median sulcus,

         rectal mucosa mobility

Investigations in prostate enlargement

• Urine Examinations
• Urinalysis for pH, sugar, proteins, crystals
• Microscopy for RBC, WBC, casts, crystals, malignant cells
• C/S of MSSU and Expressed Prostatic Secretions
• Full Blood Count, Sickling
• BUE and Creatinine
• Prostatic Specific Antigen (PSA)
• Raised in CAP, BPH, prostatitis, infarct, prostatic biopsy (injury)

Indications for biopsy:
The indications for biopsy for patient with benign prostatic hyperplasia or prostate enlargement involve the following:

 concentration>4ng/ml; density >0.15ng/ml; velocity > 0.75ng/ml/year)

Where IPSS is less than 8 and Prostate Specific Antigen is normal, management is by

‘watchful waiting’, involving biannual review of IPSS, Digital Rectal Examination and PSA.

For moderate and severe symptoms, further tests are indicated.

Urine Flow Rate

Direct observation of urine flow or using flow meter (urine vol>150ml)

Peak Flow Rate > 15ml/sec is normal;

PFR <10ml/sec: bladder outlet obstruction, nephropathy from diabetic,
spinal cord lesions

Post-void Residual Urine

Transabdominal ultrasound

Sterile urethral catheterisation after urination


In summery we have learn about  the definition of benign prostatic hyperplasia commonly called prostate enlargement, the causes of BPH, the signs and symptoms of BPH, Complications as a result of prostate enlargement, investigations to do to confirm BPH, factors affecting prostate enlargement.

I believe we have solved the  problem to some of the frequently asked questions I usually receive in my mail which are outlined below:

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