Benign Prostate Hyperplasia (BPH)

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Example Management | References

Definition

Benign Prostate Hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland commonly seen in older men. It can cause urinary symptoms due to the compression of the urethra and bladder outflow obstruction.

Aetiology

The exact cause of BPH is not well understood, but it is believed to be related to hormonal changes as men age, particularly the role of dihydrotestosterone (DHT), a metabolite of testosterone, which accumulates in the prostate and promotes growth.

Pathophysiology

BPH involves the proliferation of prostate stromal and epithelial cells, leading to the enlargement of the prostate gland. This growth primarily occurs in the transition zone around the urethra, causing compression and obstruction of urinary flow. The obstruction can lead to increased resistance to urinary flow, bladder muscle hypertrophy, and eventually bladder dysfunction.

Risk Factors

• Age: BPH is more common in men over 50.
• Family history: Genetic predisposition can play a role.
• Hormonal changes: Increased DHT and oestrogen levels.
• Lifestyle factors: Obesity, lack of physical activity, and a diet high in animal fats.
• Chronic conditions: Diabetes and heart disease.

Signs and Symptoms

• Increased frequency of urination, especially at night (nocturia).
• Difficulty starting and stopping urination (hesitancy and terminal dribbling).
• Weak urine stream.
• Sensation of incomplete bladder emptying.
• Straining to urinate.
• Urgency and occasional incontinence.

Investigations

• Clinical history and physical examination, including digital rectal examination (DRE).
• Urinalysis: To rule out infection or haematuria.
• Serum Prostate-Specific Antigen (PSA) test: To screen for prostate cancer.
• Uroflowmetry: To measure the flow rate of urine.
• Post-void residual volume (PVR): To assess bladder emptying.
• Ultrasound: To evaluate prostate size and bladder condition.

Management

Primary Care Management

• Lifestyle modifications: Advise on fluid management, reducing caffeine and alcohol intake, and bladder training exercises.
• Medications: Alpha-blockers (e.g., tamsulosin) to relax prostate muscles, and 5-alpha-reductase inhibitors (e.g., finasteride) to shrink the prostate.
• Monitoring: Regular follow-up to assess symptom progression and treatment effectiveness.
• Patient education: Inform about the nature of the condition and treatment options.
• Referral to a specialist (urologist) if symptoms are severe or not responsive to initial treatment.

Specialist Management

• Advanced medications: Combination therapy with alpha-blockers and 5-alpha-reductase inhibitors.
• Minimally invasive procedures: Transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA).
• Surgical interventions: Transurethral resection of the prostate (TURP), laser therapy, or open prostatectomy for larger prostates.
• Management of complications: Address acute urinary retention, recurrent urinary tract infections, or bladder stones.
• Close monitoring: Regular follow-up to manage symptoms and detect any complications.

Example Management for Benign Prostate Hyperplasia

A patient presenting with symptoms of BPH, such as increased frequency of urination and weak urine stream, should first be evaluated with a clinical history and physical examination, including a digital rectal examination (DRE). Initial management may include lifestyle modifications, such as reducing caffeine and alcohol intake, and prescribing alpha-blockers like tamsulosin 400 mcg once daily to relax the prostate muscles. If symptoms persist, a 5-alpha-reductase inhibitor like finasteride 5 mg once daily may be added. Referral to a urologist is recommended if symptoms are severe or unresponsive to initial treatment, with options for minimally invasive procedures or surgical intervention if necessary. Regular follow-up is essential to monitor the response to treatment and manage any complications.

References

1. NICE. (2024). Lower Urinary Tract Symptoms in Men: Management. Retrieved from NICE
2. NHS. (2023). Benign Prostatic Hyperplasia (BPH). Retrieved from NHS
3. American Urological Association. (2021). Benign Prostatic Hyperplasia (BPH): Clinical Management Guidelines. Retrieved from AUA
4. McVary, K. T., et al. (2011). Update on AUA guideline on the management of benign prostatic hyperplasia. The Journal of Urology.

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