16 BPH
An overview on BPH (Benign Prostatic Hyperplasia) Written by Jasim Siddiqui, MBBS, Urology Registrar at Our Lady of Lourdes Hospital & Mr Ronan Long, MB, BCh, BAO, MCh, MMed SCI, FRCS(Urol), Consultant Urologist at Our Lady of Lourdes Hospital, Louth County Hospital and Mater Private Outreach Clinic Drogheda.
A transrectal or abdominal ultrasound & cystoscopy is considered in assessing Prostate size, shape & morphology, which play an important role in decision-making for the treatment and differential diagnosis of male LUTS/BPH. Role of PSA in BPH
Definition: BPH (benign prostatic hyperplasia) refers to the non-malignant growth or hyperplasia of prostate tissue. A benign prostatic enlargement (BPE) can cause bladder Outflow Obstruction (BOO) and is a common cause of lower urinary tract symptoms (LUTS)in men. Epidemiology: The prevalence of histological BPH increases with age, affecting approximately 42% of men between the ages of 51 and 60 years and 82% of men between the ages of 71 and 80 years.1 The global lifetime prevalence of BPH is around 25%.2 Aetiology & Pathophysiology: Hyperplasia in the prostate is stimulated by androgens. The main androgen is dihydrotestosterone, which is converted from testosterone by the enzyme 5-alpha reductase. Lower urinary tract symptoms resulting from hyperplasia are mainly due to 2 components: a static component related to an increase in benign prostatic tissue mainly at the transitional zone, narrowing the urethral lumen and a dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors.3 The aetiology is multifactorial with advancing age, endogenous androgens and prostate volume increasing the risk of developing symptoms. Black men appear to have a higher risk and Asian men have a lower risk.4 Potential
causal risk factors include Obesity, smoking, male pattern baldness, family history of BPH & metabolic syndrome. Progression from pathologic BPH to clinical BPH (i.e., the presence of symptoms) may require additional factors such as prostatitis, vascular effects, and changes in the glandular capsule.5 Making the Diagnosis: The diagnosis of benign prostatic hyperplasia (BPH) can often be suggested based on the history alone. In men above the age of 50, history and symptoms suggestive of BPH include possible voiding and storage symptoms. Voiding symptoms include hesitancy, intermittency, weak stream, straining, incomplete emptying & post void dribbling. Storage symptoms include urinary frequency, nocturia, and urgency. A small proportion of men present with the inability to pass urine and is associated with suprapubic pain and a palpable bladder, which is a complication of untreated BPH. This is a urological emergency and the bladder requires immediate drainage. Men presenting under the age of 50 with voiding LUTS are unlikely to have BPH. Examination: Examination for BPH begins with abdominal, digital rectal examination(DRE) and a focused neurological examination. The DRE should assess perianal sensation, anal tone, prostate size and for any prostatic irregularity. A prostate nodule on DRE should
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prompt PSA levels. Decreased anal sphincter tone or the lack of a bulbocavernosus muscle reflex may indicate an underlying neurological disorder. Investigations: All patients should have a urine dipstick and/or culture and sensitivity to rule out a UTI or haematuria. NICE guidelines recommend that all patients with LUTS suggestive of renal impairment should have a serum creatinine and eGFR. If renal impairment is present, an ultrasound scan should be requested to assess for hydronephrosis and post-void residual. Patients should be advised to record a frequency/volume chart voiding diary for a few days, which is a useful tool to objectify symptoms and detect polyuria.6 Assessment of the severity of the patient’s symptoms and the impact on their quality of life is done using the IPSS (International Prostate Symptom Score), a selfadministered questionnaire with 8 questions.7 (Image 1 on page 17) Investigations may include a urinary flow rate and post-void residual estimation. Post-void residuals greater than 200ml may indicate a less favourable response to treatment. Urodynamic or Pressure flow studies provide the most complete means of determining the presence of outlet obstruction, but its use is optional.7
PSA has a useful role in the assessment of LUTS by acting as a surrogate marker in benign disease for an enlarged prostate. The weight of evidence suggests that men with a PSA >1.4ng/ml should be considered at increased risk of disease progression of BPH.8,9 A note of caution should remain that a PSA test cannot replace a DRE and should not be done in its absence. The presence of BPH symptoms does not predispose to prostate carcinoma and therefore it is not essential in men with BPH unless an abnormal prostate is felt on DRE or the patient is specifically concerned about or has a family history of prostate carcinoma [10]. The NICE guidelines also recommend that a PSA test is offered only after full counselling. One must also exclude a UTI prior to a PSA test and not perform the test within a month of a proven UTI. Approach To Treatment: The aim of treating BPH with LUTS is to relieve symptoms and improve quality of life, as well as to attempt to prevent progression of disease and the development of complications. These aims need to be balanced against the potential side-effects of treatment. Therefore, watchful waiting is an option recommended for many men. Watchful waiting is the recommended strategy for patients with BPH who have mild symptoms (International Prostate Symptom Score ≤7) and for those with moderate-to-severe symptoms (IPSS score ≥8) who are not bothered by their symptoms and are not experiencing complications of BPH. In patients
