Benign Prostatic Hyperplasia (BPH)

The prostate begins to increase in size after the age of 45 years in most men, and continue to grow for the rest of a man's life. The prostate gland becomes increasingly hyperplastic. By itself, BPH is not a cause for concern, however about 10% of men by age 50 will experience symptoms of BPH, while 50% of men above 80 years will.

BPH may be classified as microscopic or macroscopic (clinical). Information henceforth, will be limited to clinical BPH. Clinical BPH is that which manifest with lower urinary tract symptoms ( LUTS).

Aeitiology

Aging, testicular function and androgen levels are interwoven in the concept of BPH occurrence. Hormonal levels that support the persistence of dihydrotestestotone DHT increases the chances of BPH. The role of race and diet are not well established.

Pathology

BPH occurs in the T2 and periurethral region near the preprostatic urethra. The size of the prostate does not correlate directly with the degree of obstruction. Obstruction to urine flow is secondary to occlusion of the urethra due to contraction of the glandular and fibromuscular tissue plus that of the smooth muscle.

Clinical features

The symptoms formerly called prostatism, now known as LUTS are grouped into:

-Irritative: frequency, urgency, nocturia

-Obstructive: straining, hesitancy, intermittency, incomplete voiding

The irritative symptoms early and are features of other disorders such diabetes mellitus, urinary tract infection UTI, prostate cancer, etc

Other features include

-Acute Urinary retention

This is a sudden ceasation of micturaion associated with a fully distended painful bladder. Usually precipitated by alcohol, diuretics and prolonged postponement of micturation e.g. while commuting on public transport.

-Chronic retention

-Haematuria- microscopic or gross

-Recurrent UTI

-Renal failure

On examination, the general health status of the patient is reviewed as there may be concomitant health problems. A hernia (secondary to straining) may be present. The genitals are examined. A digital rectal examination (DRE) is done to evaluate the integrity of the prostate i.e. its size, shape consistency etc.

Investigation

Urine for analysis, microscopy, culture and sensitivity

Full blood count

Electrolytes

Prostate specific antigen- It is done to exclude early cancer. It is increased is BPH, prostate cancer, prostatitis , prostate surgery and infarct. Levels more than 4g/ml may necessitate a biopsy.

There are other urodynamic evaluate test that may be performed e.g. Max flow rate, pressure flow dynamics but these are beyond the scope of this medium.

Transrectal ultrasound scan (TRUS) with biopsy

Intravenous Urography (IVU)- to evaluate the intergrity of the urinary tract in whole.

Management

Watchful waiting: done after exclusion of prostate cancer in patients with minimal symptoms

Medical therapy: a-1 adrenergic blocker

Androgen suppression (not very efficacious and their side effects deter most patients)

Surgery- Minimally invasive

Transurethral resection of the prostate TURP

Open prostatectomy

The first two are however not employed if the patient has refractory retention, gross haematuria, bladder stones etc.

Which ever method is applied excellent results are expected when performed by experienced hand.

There may be a concomitant cancer of the prostate.