Name
BENIGN PROSTATIC HYPERTROPHY
DESCRIPTION
DETAIL
CAUSES Exact etiology unknown, but evidence suggests BPH arises from a systemic hormonal alteration which may or may not act in combination with growth factors stimulating stromal or glandular hyperplasia. Environmental and hereditary factors influence development of clinical BPH. Lower incidence of BPH in Japanese and Chinese. -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS . Obstructive conditions: . Prostate cancer . Urethral stricture or valves . Bladder neck contracture (acquired or congenital) . Anterior or posterior urethral valves . Mullerian duct cysts . Inability of bladder neck or external sphincter to relax appropriately during voiding . Non-obstructive conditions: . Neurogenic bladder (detrusor denervation) . Myogenic cause (detrusor muscle failure) . Medications (parasympatholytics, sympathomimetics, etc.) . Psychogenic . Irritative conditions: . Neurogenic bladder . Inflammatory disorders (prostatitis, urethritis, radiation cystitis, interstitial cystitis, etc.) . Neoplasm (bladder carcinoma, especially carcinoma in situ) . Detrusor overactivity (OAB)LABORATORY β’ BPH is a pathologic diagnosis - lab data is only suggestive β’ Urinalysis: pyuria if stones or infection present, pH changes due to chronic residual urine β’ Elevated serum creatinine (if obstructive uropathy present) β’ Urine culture positive (sometimes due to chronic residual urine) β’ Prostate specific antigen (PSA) may be elevated but usually < 10 ng/mL (10 MICROGM/L) β’ Increased post-void residual (> 100 mL) β’ Acute urinary retention, transurethral instrumentation may elevate the PSA PROSTATE SPECIFIC ANTIGEN - HIGH IN PROSTATIC CANCER SPECIAL TESTS . Transrectal prostate ultrasound gives volumetric estimate of gland . Needle biopsy (to rule out cancer) . Have patient complete IPSS (International Prostate Symptom Score) . Mild symptoms (score 0-7): Offer watchful waiting only . Moderate symptoms (score 8-19) to severe symptoms (score 20-35): Offer treatment options IMAGING . Ultrasound - increase postvoid residual, prostate or hydronephrosis . CT scan or MRI of pelvis - enlarged prostate . IVP - increased post-void residual, large prostatic impression on bladder, trabeculated bladder, bladder diverticula, upper tract dilation, bladder stones DIAGNOSTIC PROCEDURES β’ Uroflow - volume voided per unit time. Peak fl ow < 10 mL/sec suggests obstruction (accurate when voided volume is > 150 mL). May be low if bladder contractility is impaired. β’ Pressure-flow curve (urine flow versus voiding pressures) - decreased urine flow and increased pressure indicates obstruction β’ Cystoscopy demonstrates presence, configuration and site of obstructive tissue - helps to show stricture, stones. May help determine best therapy option. β’ Post-void residual (PVR) by catheterization or bladder ultrasound; PVR >150 associated with increased risk of retention
TYPENOTES
RISK FACTORS: Intact testes (BPH rare in eunuchs), Aging (thus, rare in men < 40 years old), Dietary and environmental may be implicatedAPPROPRIATE HEALTH CARE Inpatient or outpatient treatment required, either for surgery or medical treatment. Inpatient emergent treatment required to manage fl uid and electrolyte abnormalities of obstructive uropathy. GENERAL MEASURES . Avoid large boluses of oral or IV fl uids or alcohol intake . Avoid prolonged periods of not voiding . Avoid sympathomimetic or anticholinergic medications (e.g., cold/flu preparations) . Urethral catheterization or clean intermittent catheterization if in retention SURGICAL MEASURES . Surgery (indicators to determine necessity). One of the following: . Urinary retention due to prostatic obstruction, recurrent . Intractable symptoms due to prostatic obstruction (gauged by AUA symptom index; score at least > 8) . Obstructive uropathy (renal insuffi ciency) . Recurrent or persistent urinary tract infections due to prostatic obstruction . Recurrent gross hematuria due to enlarged prostate . Bladder calculi . Medical therapy indicated when surgery indicators not met . Surgical procedures - minimally invasive . Interstitial laser coagulation (ILC) . High frequency focused ultrasound (HIFU) . Transurethral needle ablation (TUNA) . Transurethral microwave thermotherapy (TUMT) . Water-induced thermotherapy (WIT) . Prostate stenting . Transurethral balloon dilation (TUDP) . Transurethral ethanol ablation of prostate . Surgical procedures - more invasive . TURP . Open prostatectomy . Transurethral laser ablation, laser-induced prostatectomy or laser enucleation of prostate, HOLAP . Transurethral vaporization of prostate ACTIVITY No restriction DIET Avoid caffeinated or alcoholic beverages, excessively spiced foods DRUG(S) OF CHOICE β’ Indicated when no strong indication for surgery exists or patient declines surgery β’ Alpha adrenergic antagonist: terazosin (Hytrin) 1-10 mg/day, doxazosin (Cardura) 1-8 mg/day, tamsulosin (Flomax) 0.4-0.8 mg/day, alfuzosin (Uroxatral) 10 mg qd β’ Hormonal (anti-androgens) agents: fi nasteride (Proscar) a 5-alpha reductase inhibitor, 5 mg/day works best for larger prostates; dutasteride (Avodart) 0.5 mg/day, turosteride, fl utamide (Eulexin) and leuprolide (Lupron) are rarely used; phytotherapy (e.g., serenoa repens [saw palmetto], similar to fi nasteride in effi cacy) β’ Combination therapy of alpha blocker plus 5-alpha reductase inhibitor is superior to monotherapy ALTERNATIVE DRUGS β’ Saw palmetto (serenoa repens) - meta-analysis has shown statistically significant improvement in symptoms in men with lower urinary tract symptoms (LUTS) compared to placebo and equivalent with tamsulosin and finasteride. Most widely studied form is extract of Serenoa repens (Permixon). Mechanism of action not fully identified. β’ South African stargrass, a beta-sitosterol, improves IPSS score, decreases nocturia and frequency and increases flow rate PATIENT MONITORING β’ Symptom index (IPSS) monitored every 3-12 months β’ Digital rectal exam yearly β’ PSA yearly β’ Bladder scan post-void residual every 3-12 months PREVENTION/AVOIDANCE Appears to be part of the aging process POSSIBLE COMPLICATIONS β’ Urinary retention (acute or chronic) β’ Bladder stones β’ Prostatitis β’ Renal failure β’ Hematuria β’ Erectile dysfunction in men with lower urinary tract symptoms (LUTS) EXPECTED COURSE/PROGNOSIS β’ Symptoms improve or stabilize in 70-80% of patients; 20-30% require treatment because of worsening symptoms β’ 11-33% men with BPH have occult prostate cancer
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
BLOOD UREA, SERUM CREATININE, URINE ROUTINE, URINE CULTURE TEST, ULTRA SOUND WHOLE ABDOMEN - MALE, COMPLETE BLOOD COUNT, PROSTATE SPECIFIC ANTIGEN ( PSA )
[BENIGN PROSTATIC HYPERTROPHY]