Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia (BPH), also known as prostate enlargement, is a noncancerous increase in the size of the prostate gland. It is predominantly seen in males over the age of 40. The condition can lead to symptoms such as frequent urination, difficulty starting urination, weak urine stream, inability to urinate, and loss of bladder control. Complications may include urinary tract infections, bladder stones, and chronic kidney problems.

Signs and Symptoms

BPH is the most common cause of lower urinary tract symptoms (LUTS), categorised into storage, voiding, and post-urination symptoms. Storage symptoms include frequent urination, nocturia (waking at night to urinate), urgency, and urge incontinence. Voiding symptoms encompass urinary hesitancy, intermittency, weak stream, straining to void, and a sensation of incomplete emptying. Post-urination symptoms may involve bladder pain or dysuria.

Causes

The exact cause of BPH remains unclear, but it is thought to involve hormonal changes, particularly involving androgens such as testosterone and dihydrotestosterone (DHT). Androgens are essential for BPH development but do not directly cause it. Castrated males do not develop BPH, highlighting the role of androgens. DHT, a potent androgen, promotes prostate cell growth, and its inhibition through medications like finasteride can reduce prostate size.

Diet and lifestyle factors may also influence BPH development. Studies suggest a possible link between high animal protein intake and BPH, while other research indicates a correlation with metabolic syndrome.

Pathophysiology

BPH involves hyperplasia of both glandular epithelial and stromal cells, with stromal hyperplasia being more predominant. Anatomically, the median and lateral lobes of the prostate are usually enlarged. Growth primarily occurs in the transition zone of the prostate, with rare instances of exceptional enlargement termed giant prostatic hyperplasia.

Diagnosis

Diagnosis is based on a history of LUTS, digital rectal examination, and exclusion of other conditions with similar symptoms. Validated questionnaires like the International Prostate Symptom Score (I-PSS) aid in diagnosis. Laboratory investigations, including urinalysis and blood tests for kidney function and prostate-specific antigen (PSA), are commonly performed.

Imaging techniques such as abdominal ultrasound and transrectal ultrasonography (TRUS) help evaluate prostate size and rule out other conditions. Uroflowmetry measures urine flow rate and total volume, while post-void residual volume assessment can indicate significant obstruction.

Treatment

Lifestyle Modifications

Lifestyle changes include increasing physical activity, reducing fluid intake before bedtime, moderating alcohol and caffeine consumption, and following a timed voiding schedule. Avoiding medications with anticholinergic properties is also advised.

Medications

Alpha blockers, such as tamsulosin and terazosin, relax smooth muscle in the prostate and bladder neck, improving urine flow. 5α-reductase inhibitors like finasteride reduce DHT production, shrinking the prostate. Phosphodiesterase inhibitors (PDE) may also be used, particularly in combination with other medications.

Self-Catheterisation

Intermittent urinary catheterisation is an option for relieving bladder retention in BPH patients. Self-catheterisation can help manage urinary retention, though it carries a risk of urinary tract infections.

Surgery

If medical treatments are ineffective, surgery may be performed. Transurethral resection of the prostate (TURP) is the gold standard, while other options include holmium laser ablation (HoLAP), photoselective vaporisation (PVP), and aquablation therapy.

Minimally Invasive Procedures

Minimally invasive procedures include prostatic artery embolisation, water vapour thermal therapy (Rezum), and prostatic urethral lift (UroLift). These outpatient procedures use local anaesthesia and aim to reduce prostate size and urinary symptoms with fewer risks.

Alternative Medicine

Herbal remedies like saw palmetto have been studied but found ineffective compared to placebos. Other studied herbs include beta-sitosterol, pygeum, pumpkin seeds, and stinging nettle root, but their efficacy varies.

Epidemiology

Globally, BPH affects about 210 million males. The risk of developing BPH increases with age, with a prevalence rate of 24% by the age of 80 years.

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Self-assessment MCQs (single best answer)

What is Benign Prostatic Hyperplasia (BPH)?

Which of the following is NOT a symptom of BPH?

Which diagnostic method involves assessing the prostate gland through the rectal wall?

Which substance is primarily associated with the development of BPH?

Which class of medications for BPH works by relaxing smooth muscle in the prostate and bladder neck?

What is the gold standard surgical treatment for BPH?

Which minimally invasive procedure uses water vapour to reduce prostate size?

Which laboratory test is used to rule out infections or other conditions like diabetes in BPH patients?

What is the role of 5-alpha reductase inhibitors in the treatment of BPH?

Which zone of the prostate is predominantly affected by BPH?