Benign Prostatic Hyperplasia

Related Subjects: |Urothelial tumour s |Haematuria |Acute Urinary Retention |Anuria and Oliguria |Bladder cancer |Renal cell carcinoma |Benign Prostatic Hyperplasia |IgA nephropathy |Prostate Cancer |Henoch-Schonlein purpura |Glomerulonephritis

🔵 Benign Prostatic Hyperplasia (BPH) is usually confined to the peri-urethral glands in the centre of the prostate. 📏 Importantly, prostate size does not always correlate with the degree of urinary obstruction.

📌 About

• Prostate size alone is not a reliable predictor of urinary outlet obstruction 🚫.

🧬 Pathology

• Represents hyperplasia (increase in cell number) rather than hypertrophy.
• Confined mainly to the peri-urethral (transition) zone.
• Prostate size ≠ severity of symptoms.

👨 Clinical

• Common in men >50 yrs; prevalence: Black > White > Asian.
• Voiding symptoms: weak stream, hesitancy, terminal dribbling 🚽.
• Storage symptoms: frequency, urgency, nocturia ⏰.
• Incomplete emptying → chronic retention with large bladder.
• Exam: smooth enlarged prostate, palpable bladder.

⚠️ Complications

• Acute urinary retention (can be worsened by drugs ❗ e.g. anticholinergics, antihistamines, antidepressants).
• Recurrent UTIs 🦠.
• Hydroureter, hydronephrosis, renal failure 🩸.
• Bladder calculi & infection.

🔍 Investigations

• Urinalysis (MSU if positive); haematuria → investigate for malignancy 🔎.
• Bloods: U&E, FBC, PSA (interpret carefully: ↑ with BPH, infection, cancer, recent catheterisation).
• KUB X-ray: consider if stone suspected.
• Post-void residual bladder volume (USS or catheter).
• 24-hr voiding diary: frequency & volume.
• Abdominal USS: kidney size, hydronephrosis, bladder wall.
• Flexible cystoscopy: if haematuria, obstruction, or diagnostic uncertainty.
• Urodynamics: in neurogenic bladder suspicion or failed prior prostate surgery.

💡 General Lifestyle Advice

• Limit alcohol 🍺, caffeine ☕, and evening fluids.
• Avoid decongestants/antihistamines as they worsen retention.
• Bladder training: urinate regularly (every 4–6 hrs). Double voiding can help.
• Maintain healthy weight & stay active 🏃 — reduces risk of retention.
• Keep warm 🧥 — cold triggers retention.

💊 Medical Management

• Alpha-blockers (Tamsulosin, Alfuzosin): relax smooth muscle → symptom relief. SE: postural hypotension, dizziness.
• 5-α reductase inhibitors (Finasteride, Dutasteride): shrink prostate (↓DHT). Takes 3–6 months; SE: retrograde ejaculation, ↓ libido.
• Combination therapy: in large prostates or severe symptoms.
• Anticholinergics (e.g. Oxybutynin): for storage symptoms; caution in frail elderly (delirium risk).
• Mirabegron: β3 agonist alternative for OAB; SE: hypertension.

🧴 Catheterisation & TWOC

• Acute retention: catheterise + start Tamsulosin → trial without catheter (TWOC) after 1–2 days.
• If fails: intermittent self-catheterisation or long-term catheter (urethral/suprapubic).
• Severe chronic retention (>1 L) → often requires long-term catheterisation.

📤 Indications for Urology Referral

• Suspicion of malignancy (hard nodular prostate, raised PSA).
• Obstructive uropathy: AKI, ↑ urea/creatinine.
• Large bladder, recurrent retention, or hydronephrosis.
• Rapidly worsening LUTS or failure of medical therapy.

🔪 Surgery: TURP

• Transurethral Resection of the Prostate (TURP): removes obstructive tissue via resectoscope.
• Benefits: strong urine flow & rapid relief.
• Complications: bleeding, TURP syndrome (dilutional hyponatraemia), clot retention, stricture, retrograde ejaculation, incontinence.
• Very large prostates → may need open prostatectomy.

Case 1 – Mild symptoms

58-year-old with daytime frequency and nocturia ×2. DRE normal, PSA ok, Post void residual 40 mL. Try lifestyle changes (less evening fluids, cut caffeine/alcohol). If still troublesome, start an alpha-blocker and review in 4–6 weeks.

Case 2 – Moderate symptoms, enlarged prostate

66-year-old with mixed LUTS (IPSS 18), smooth enlarged prostate, PSA 2.4 µg/L, volume ~45 mL, PVR 120 mL. Start tamsulosin and add a 5-alpha-reductase inhibitor (works over months). Consider bladder drug (e.g., mirabegron) only if PVR is low and storage symptoms persist.

Case 3 – Acute urinary retention

74-year-old unable to pass urine after a heavy night. Catheterise (record volume), start an alpha-blocker, check for UTI/culprit meds. Plan a trial without catheter in 2–7 days. If it fails or there are complications, refer for surgery (e.g., TURP/HoLEP) based on prostate size and fitness.