Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.
Lower Urinary Tract Symptoms
There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:
- Hesitancy – difficult starting and maintaining the flow of urine
- Weak flow
- Urgency – a sudden pressing urge to pass urine
- Frequency – needing to pass urine often, usually with small amounts
- Intermittency – flow that starts, stops and varies in rate
- Straining to pass urine
- Terminal dribbling – dribbling after finishing urination
- Incomplete emptying – not being able to fully empty the bladder, with chronic retention
- Nocturia – having to wake to pass urine multiple times at night
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms.
Assessment
The initial assessment of men presenting with LUTS involves:
- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
- Abdominal examination to assess for a palpable bladder and other abnormalities
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
- Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Prostate-specific antigen (PSA) testing is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.
Common causes of a raised PSA are:
- Prostate cancer
- Benign prostatic hyperplasia
- Prostatitis
- Urinary tract infections
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
Prostate Examination
- A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
- A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
TOM TIP: When you first start performing any intimate examination, there is a temptation to rush. It is natural to want to reduce the discomfort of the patient and get it over with quickly. It is important to take your time and adequately assess the prostate, feeling for any abnormal area, asymmetry or tenderness. If you rush, you are more likely to miss something. The same is true of breast, vaginal and testicular examinations.
Management
Patients with mild and manageable symptoms may not require interventions.
The medical options are:
- Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
- 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate. They may be used together where patients have significant symptoms and enlargement of the prostate.
5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.
The surgical options are:
- Transurethral resection of the prostate (TURP)
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- Holmium laser enucleation of the prostate (HoLEP)
- Open prostatectomy via an abdominal or perineal incision
TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure. The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
Transurethral Resection of the Prostate
Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
Major complications:
- Bleeding
- Infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
- Urethral strictures
- Failure to resolve symptoms
Other Surgical Options
Transurethral electrovaporisation of the prostate (TEVAP / TUVP) involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP) also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
Open prostatectomy involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate. Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.