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CASE 2 REFLECTION

In this reflection I will focus on the pathophysiology of Benign Prostatic Hyperplasia, its
clinical presentation, management, and complications that may occur.

Anatomy of Prostate

The prostate is a male reproductive organ, the size of a walnut that lies distal to the urinary
bladder. It consists of several zones enclosed within a capsule, namely the anterior
fibromuscular stroma, transition, central and peripheral zones. BPH involves the transition
zone, which surrounds the urethra, the prostatic urethra.1

Pathophysiology of Prostate 2,3

BPH is a disease where cells in the transition zone of the prostate undergo proliferation,
leading to enlargement. The enlarged prostate invades on the prostatic urethra and thereby
obstructs bladder outflow.

BPH is considered to be a result of the action of androgens on the prostate. Here, type II 5
alpha reductase enzymes catalyze the conversion of testosterone into Dihydrotestosterone
(DHT). Which is a more potent androgen. DHT then acts on the prostatic cellular nuclei and
stimulates their hyperplasia. Thus, leading to BPH.

Clinical Presentation 4,5

The usual demographic of patients presenting with BPH are males over the age of 50. Due
to the nature of the condition, that is, obstruction of the prostatic urethra BPH patients
usually present with lower urinary tract symptoms (LUTS). These can be divided into two
categories:

 Storage LUTS
o Increased frequency
o Urgency
o Incontinence
o Nocturia
 Voiding LUTS
o Decreased stream
o Hesitancy
o Incomplete emptying
o Dribbling
 Incontinence dribbling as the bladder fills
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 Terminal dribbling
 Post micturition dribbling

On per rectal examination the prostate is found to be enlarged symmetrically, with a smooth
non tender surface that is firm and rubbery in texture. In contrast a malignant prostate is
asymmetrical, nodular, and hard to palpation.

Investigations

A Urinalysis is carried out in all patients with LUTS, and a Prostate Specific Antigen (PSA)
serum level test may be indicated in certain patients.5 That is if the patient is over 50 years
old and has a family history of BPH.6

Urinalysis will help to rule out any urinary tract infections (UTI), that may be a complication of
BPH and or even the cause of the LUTS themselves.

Low levels of PSA are found in all male patients, and these levels may increase with age. A
significant increase raises concerns of prostate cancer. However, raised PSA levels are also
seen in other conditions such as BPH, prostatitis and even a UTI.

A PSA level of over 1.5 ng/ml is suggestive of BPH, while those over 4 ng/ml is suggestive of
prostate cancer. Moreover, increased free serum PSA is indicative of BPH, whereas in
cancer these levels tend to be increased. BPH can be further distinguished from prostate
cancer by a digital rectal examination as mentioned above, and ultrasound scan of the
abdomen to show urinary retention post micturition.4,5

Management

Management of BPH is dependent on International Prostate Symptom Scoring (IPSS). The

IPSS is a questionnaire that assesses the severity of a patients’ LUTS and impact on their
quality of life. Scoring is as follows:

 Score 0-7: Mildly symptomatic

 Score 8-19: Moderately symptomatic
 Score 20 – 35: Severely symptomatic

Mildly symptomatic patients would be initially managed with active surveillance and lifestyle
changes. These include pelvic muscle and bladder training, reduced fluid intake at night and
maintaining a healthy lifestyle. Patients maybe also encouraged to use containment products
such as pads, catheters, or waterproof pants. They may also be referred to a continence
nurse, physiotherapist, or urologist.
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Moderate to severely symptomatic patients are usually managed pharmacologically with

alpha blockers such as tamsulosin.7

Alpha blockers help to relax the muscles of the bladder neck and prostate, thereby allowing
for the passage of urine.8

The patient should then be followed up every 4 – 6 weeks and then on a 6 - 12 monthly
basis. If symptoms fail to improve patients are started on 5 alpha reductase inhibitors such
as Finasteride. These work by inhibiting the conversion of testosterone to DHT. If symptoms
continue to worsen referral to urology should be considered. Patients may need to undergo
urethral catheterization to ease voiding symptoms. At this stage surgical intervention, such
as Transurethral Resection of the Prostate (TURP) will be considered.7

Complications 9

BPH is a secondary cause of bladder outlet obstruction (BOO) syndrome, which leads to
chronic urinary retention. Complications include UTIs, bladder calculi and in extreme cases
even renal failure.

(Word count: 715)

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Bibliography

1. Benign Prostatic Hyperplasia (BPH): Practice Essentials, Background, Anatomy

[Internet]. Emedicine.medscape.com. 2022 [cited 20 March 2022]. Available from:
https://emedicine.medscape.com/article/437359-overview#a3

2. Benign Prostatic Hyperplasia [Internet]. Teachmesurgery. 2022 [cited 20 March

2022]. Available from: https://teachmesurgery.com/urology/prostate/benign-prostatic-
hyperplasia/

3. Benign Prostatic Hyperplasia (BPH): Practice Essentials, Background, Anatomy

[Internet]. Emedicine.medscape.com. 2022 [cited 19 March 2022]. Available from:
https://emedicine.medscape.com/article/437359-overview#a4

4. NHS trust B. Lower Urinary Tract Symptoms [Internet]. Bsuh.nhs.uk. 2022 [cited 22
March 2022]. Available from:
https://www.bsuh.nhs.uk/wp-content/uploads/sites/5/2016/09/LUTS-leaflet.pdf

5. Benign prostatic hyperplasia - Knowledge @ AMBOSS [Internet]. Amboss.com. 2022

[cited 27 March 2022]. Available from:
https://www.amboss.com/us/knowledge/Benign_prostatic_hyperplasia/

6. Management of Male Lower Urinary Tract Symptoms in Primary Care [Internet].

Westessexccg.nhs.uk. 2022 [cited 24 March 2022]. Available from:
https://westessexccg.nhs.uk/your-health/medicines-optimisation-and-pharmacy/
clinical-guidelines-and-prescribing-formularies/07-obstetrics-gynaecology-urinary-
tract-disorders/98-managment-of-lower-urinary-tract-symptoms-in-men/file

7. Scenario: Voiding symptoms | Management | LUTS in men | CKS | NICE [Internet].

Cks.nice.org.uk. 2022 [cited 22 March 2022]. Available from:
https://cks.nice.org.uk/topics/luts-in-men/management/voiding-symptoms/

8. UpToDate [Internet]. Uptodate.com. 2022 [cited 21 March 2022]. Available from:

https://www.uptodate.com/contents/benign-prostatic-hyperplasia-bph-beyond-the-
basics#:~:text=Alpha%20blockers%20%E2%80%94%20These%20medications
%20relax,%2C%20and%20silodosin%20(Rapaflo).
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9. Benign Prostatic Hyperplasia (BPH): Practice Essentials, Background, Anatomy

[Internet]. Emedicine.medscape.com. 2022 [cited 23 March 2022]. Available from:
https://emedicine.medscape.com/article/437359-overview#a6