BENIGN PROSTATIC

HYPERTROPHY
2008
Causes of symptoms
Hyperplasia of epithelial and stromal
components of prostate
Progressive obstruction of urinary outflow
Increased activity of detrusor muscle
Causes
Frequency, nocturia
Poor flow , intermittent stream
Hesitation, terminal dribbling
Prevalence
Men > 50 = 41% have symptoms
of LUTS
Only 18% have a diagnosis
Only 10% aware of drugs or
surgery that will help it


Risk factors
Age
? obesity
Differential diagnosis
Poorly controlled diabetes
Neurological disorders
Urinary tract infections
Abacterial prostatitis
Overactive bladder
Drugs diuretics, anticholinergics,
antidepressants
Lifestyle factors caffeine, alcohol, xs fluids

Abnormal symptoms
The presence of the following symptoms
indicates referral to urologist for futher
assessment
Urinary incontinence
Retention
Dysuria
Haematuria
Acute change in symptoms
Examination
Palpation of abdomen for
enlarged bladder
enlarged kidneys
constipation
Rectal examination for
Size and consistency of prostate gland
Investigations
Blood tests
Fbc esr
U&es
Fasting blood sugar
? PSA level rises with increasing volume of
prostate gland
Urinalysis
Infection
haematuria
Investigations
Additional tests as appropriate by
GP
Ultrasound for residual urine
volume
Urinary diaries
Specialist investigations
Reasons for doing them
Patient reassurance
Patient explanation
Objective assessment of symptoms
Diagnostic precision
Ranking of treatment options
Prediction of treatment outcome
Specialist investigations
Uroflowmetry
max flow rate and volume of residual urine after
voiding low flow rate indicates need for TURP
Bladder pressure studies
pressure measurement during filling and
emptying (cystometry) gives information on
over/under activity of detrusor muscle and
obstruction of bladder outlet. Predicts response to
treatment. Use antimuscarinics for over activity
and turp for bladder outlet obstruction
Specialist investigations
Urinary tract imaging
Ultrasound to estimate residual urine
Urethroscopy
Visual inspection of bladder and uerethra is used
in dysuria or haematuria
Assesment
A validated questionnaire using international
prostate symptom scale.
Completion gives total score of 35
1 7 mild
8 19 moderate
20 35 severe
Response to the quality of life questionnaire
strong predictor or whether intervention is
necessary
Scoring system
Ask 7 questions. Answers on scale 0 5 depending
on severity of symptoms
For first 6 questions scores are
Not at all = 0
< 1 in 5 = 1
< half the time = 2
About half the time = 3
> half the time = 4
Almost always = 5
Q7
Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5
Questions
In last month how often have you
1. Had sensation of not emptying bladder completely
2. Had urge to urinated < 2 hours after previously
finished
3. Found you stopped and started again several times
4. Found it difficult to postpone urination
5. Had a weak stream (compared to when aged 30)
6. Had to push or strain to begin urination
7. How many times did you get out of bed per night to
urinate

Quality of life
If you were to spend the rest of your life with
your urinary condition the way it is now, how
would you feel about that?
Delighted 0
Pleased 1
Mostly satisfied 2
Mixed feelings 3
Mostly dissatisfied 4
Terrible 5
Management
Lifestyle modification
Reduce fluid intake
Stop diuretics if poss
Avoid xs night time fluid intake/caffeine
/alcohol
Empty bladder before long
trips/meetings
Management
Treat co morbid contributing
conditions
Diabetes
uti
Management
Drug therapy
Alpha blockers
Improve bladder and prostate smooth
muscle tone
More effective than 5 alpha reductase
inhibitors
All work equally well
Tamsulosin and alfuzosin require no dose
titration

Management
Drug therapy
5 alpha reductase inhibitors
Reduce prostate volume
Reduces risk of prostate cancer, increases risk of
high grade disease
Combined therapy
Men with large prostate > 40g or PSA >4 or
moderate to severe symptoms combined therapy
will prevent 2 episodes of clinical progression per
100men over 4yrs. Much less effective for men with
smaller prostates
Management
Drug therapy
Storage problems
Men with symptoms of urinary urgency, frequency,
small, urine volumes and nocturia in the absence of
serious obstructive symptoms are categorised as
over active bladder
Bladder training
Biofeedback
Antimuscarinic drugs ( oxybutinin, tolteridine) alone
or in combination with treatment for obstructive
symptoms
Management
Surgery
TURP
Greatest improvement in symptoms
5% severe haemorrhage risk
Requires GA
Alternative energy sources for TURP
Ultrasound
Laser
microwave
Management
Surgery
Adverse effects of surgery
Loss of ejaculation
Erectile dysfunction
Retrograde ejaculation
Incontinence
Stricture formation
Urinary retention