Clinical Notes : Urology

107. Benign Prostatic Hyperplasia 

BPH is a common problem that affects the quality of life in approximately one third of men older than 50 years.

BPH is histologically evident in up to 90% of men by age 85 years.

 

Etiology :

Prostatic enlargement depends on the potent androgen dihydrotestosterone (DHT).

In the prostate gland, circulating testosterone is metabolised into DHT,

DHT binds to androgen receptors in the prostate's smooth muscle cells nuclei,resulting in BPH .

Thus, the prostate enlarges with age in a hormonally dependent manner. Notably, castrated males (ie, who are unable to make testosterone) do not develop BPH.

Presentation

When the prostate enlarges, it may act like a "clamp on a hose," constricting the flow of urine.

Nerves within the prostate and bladder may also play a role in causing the following common symptoms:

  • Urinary frequency

    • The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode

  • Urinary urgency

    • The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control

  • Hesitancy

    • Difficulty initiating the urinary stream; interrupted, weak stream

  • Incomplete bladder emptying

    • The feeling of persistent residual urine, regardless of the frequency of urination

  • Straining

    • The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder

  • Decreased force of stream

    • The subjective loss of force of the urinary stream over time

  • Dribbling

    • The loss of small amounts of urine due to a poor urinary stream

 

Diagnosis

The diagnosis of BPH can often be suggested on the basis of the history and physical examination alone.

Symptoms often attributed to BPH can be caused by other disease processes, most notably LUTS (lower urinary tract symptoms in men)

The goal of a systematic comprehensive history and physical and laboratory evaluation is to seek out any potential causes.

Question 1

Normal bladder function is to store approximately 300-500 ml of urine before emptying with adequate warning of a gentle urge sensation.

Is there another reversible cause for the urinary urgency and frequency ?

  • diabetes causing polyuria and polydipsia (check glucose)

  • urinary tract infection (check urinalysis)

  • habit of drinking excessive fluids (enqire about drinkling habits)

  • medications that cause diuresis, alter normal sphincter control or mimic other urinary symptoms. (check prescription and OTC medication)

 

Medication that can cause LUTS

 

Question 2

Normal prostate function (in addition to creation of fluid for seminal emission) is to allow free urinary flow and not obstruct.

Is the urgency and frequency due to incomplete voiding ?

  • A Post Void Residual (PVR) volume less than 50ml means there is very little chance of significant obstruction or neurogenic bladder

  • The OOH physician is unlikely to have access to ultrasound to check PVR, and will have to rely on clinical signs and history to exclude significant obstruction and neurogenic bladder.

  • There is no need for urodynamic testing unless the patient has an identified neurologic issue or is refractory to therapy.

  • A cystoscopy will not provide further information and should only be performed in patients with hematuria or who are refractory to therapy. One can consider a cystoscopy as an option in high risks patients (i.e. those with a history of smoking).

Question 3

Normal prostate function (in addition to creation of fluid for seminal emission) is to allow free urinary flow and not obstruct.

Are there signs of obstruction ?

  • Poor flow

    • suggests BPH

    • good flow can be described as a smooth, arc-shaped curve with high amplitude

    • poor flow can be described as weak, flat, asymmetric or interrupted with multiple peaks

  • Good flow​

    • suggests LUTS 

    • good flow can be described as a smooth, arc-shaped curve with high amplitude

LUTS associated with the bladder as opposed the prostate

 

Treatment

The treatment of OAB, LUTS and BPH all require

  • assessment of the prostate by DRE

  • discussion of pros and cons or PSA testing 

  • monitoring of the effects of treatment and consequent adjustment of treatment plan

  • This is outside the scope of the work of the OOH physician , and is best left for the patient's own GP at follow-up

 

Simplified treatment of the enlarged prostate (EP)

 

In the OOH setting management should focus on

  • treatment of acute presenting condition such as infection, pain 

  • recommendation of appropriate early life style changes 

  • evaluation of patient's fears and anxiety

  • reassurance and initial education about LUTS and BPH, emphasising the importance of further investigation and the high success rate of early appropriate management.

 
 

1.  McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al.

Management of Benign Prostatic Hyperplasia (BPH).

American Urological Association (Guideline, 2014)

View/Access

2.  Egan KB.

The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates

Urol Clin North Am. 2016 Aug. 43 (3):289-97.

View/Access

3.  Carballido J, Fourcade R, Pagliarulo A, et al.

Can benign prostatic hyperplasia be identified in the primary care setting using only simple tests? Results of the Diagnosis Improvement in Primary Care Trial.

Int J Clin Pract. 2011 Sep. 65(9):989-996.

View/Access

4.  Emberton M, Cornel EB, Bassi PF, Fourcade RO, Gómez JM, Castro R.

Benign prostatic hyperplasia as a progressive disease: a guide to the risk factors and options for medical management.

Int J Clin Pract. 2008 Jul. 62(7):1076-86.

View/Access

5.  Rosenberg MT, et al.

STEP: Simplified Treatment of the Enlarged Prostate.

Int J of Clin Pract 2010.; 64(4): 488-496.

View/Access

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (2018)

American Urological Association

Published 2018

View/Access

 

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