Editing Benign prostatic hypertrophy

== Pathophysiology ==

* Proposed to occur secondary to increasing oestrogenic stimulus over time
* Affects both glandular epithelium and connective tissue
* Typically affects submucosal glands in transitional zone, forming a nodular enlargement
* Complex relationship between BPH, BOO and LUTS
**
* '''Bladder outlet obstruction:'''
** Urodynamic concept - low flow rates in the presence of high voiding pressures
** Can result from:
*** BPH
*** Bladder neck stenosis
*** Bladder neck hypertrophy
*** Prostate cancer
*** Urethral strictures
*** Functional obstruction due to neuropathic conditions
** Consequences:
*** Decompensated bladder - less efficient detrusor contraction, residual urine
*** Irritable bladder with decrease in functional capacity
*** Acute/chronic urinary retention
*** Impaired bladder emptying
*** Haematuria (complication of BPH or otherwise)
*** Pain is not a symptom of BOO, other than AUR
* Anatomical effects of BPH:
** Urethra - lengthened prostatic urethra, but not narrowed
** Bladder - if BPH causes BOO, the musculature of the bladder hypertrophies to overcome the obstruction and appears trabeculated. Significant BPH is a/w increased blood flow, and the resultant veins at the base of the bladder are apt to cause haematuria.

== Presentation ==

* Important to acknowledge that BPH can coexist with other pathologies such neuropathic bladder, idiopathic detrusor overactivity and BOO
* See 'urologic symptoms' for a full description of LUTS
* Post-micturition dribbling is not a consequence of BOO and does not usually improve with prostatectomy
* Can use International Prostate Symptom Score for a semi-objective assessment
* Examination
** Loss of transverse suprapubic skin crease due to large bladder
** DRE: smooth posterior surface, which is convex and typically elastic. The rectal mucosa should be able to move over the prostate. An inability to get to prostate base implies a volume of at least 50mL.

== Investigations on initial presentation ==

* Urinalysis
* Urine MCS
* UEC
* PVR
* ?PSA - if an early diagnosis of prostate cancer would influence treatment - those under 70yo and positive family history
** If higher than age-adjusted cut-off, will need TRUS + biopsies
* ?urodynamics
* Upper tract imaging may not be necessary in men with straightforward symptoms
* Cystourethroscopy will normally be done at the time of TURP

== Natural history of BPH ==

* Quite variable
* Symptoms of BOO rarely get worse after 10 years

== Indications for treatment in men with BPH: ==

* Acute retention with no other cause
* Chronic retention and renal impairment
** PVR >200mL
** Raised blood urea
** Hydroureter/hydronephrosis
* Complications of BOO 
** Stone
** Infection
** Diverticulum
* Haemorrhage
* Elective prostatectomy for severe symptoms
** Increasing difficulty in micturition
** Hesitancy
** Poor stream (<10mL/s max flow rate)
** Frequency day and night (not a strong indication for prostatectomy alone)
** Failed a preliminary trial of medical therapy

== Management ==

* Non-operative
** Fluid restriction
** Reduction in caffeine
** Duodart - results in a 25% shrinking of prostate if taken for a year, and an average 20% improvement in symptom scores. And men often end up needing surgery anyway.
* Operative
** TURP - results in significant improvements in max flow rate and a 75% improvement in symptoms scores
** Very large prostates may require open prostatectomy or HOLEP (Holmium laser enucleation of the prostate)
** Risks:
*** Secondary haemorrhage occurs after discharge, often with clot retention. Needs readmission and washout.
*** Retrograde ejaculation - about 65% of men
*** Erectile impotence - about 5% of men, and usually those whose potency is waning regardless
*** Failure to improve symptoms - worse in those who only have mild symptoms, or those with weak bladder contraction anyway
*** Risk of reoperation - about 15% after 10 years


[[Category:Urology]]