http://www.fpnotebook.com/

Benign Prostatic HyperplasiaAka: Benign Prostatic Hypertrophy, Prostatic Hyperplasia, BPH

Epidemiology
1. Incidence of BPH increases with age
  1. Men aged 60 years: 50%
  2. Men aged 80 years: 88%
2. Incidence of symptomatic onset is related to ethnicity
  1. African american men: onset at age 60 years
  2. Caucasian men: onset at age 65 years
Pathophysiology
1. Prostate size increases with age
  1. Birth: few grams
  2. Age 20 to 55 years: 20 grams
  3. Age over 55 years: Increased growth
2. Prostatic hyperplasia begins centrally (periurethral)
  1. Prostatic hyperplasia compresses urethra
  2. Results in urinary flow obstruction
3. Prostate growth is hormonally regulated
  1. Testosterone converted to Dihydrotestosterone
  2. Dihydrotestosterone stimulates prostate growth
  3. Estrogen also stimulates prostate growth
Provocative factors (for Urinary Retention)
1. See Medication Causes of Urinary Retention
2. Urinary Tract Infection
3. Overhydration
4. Caffeine and other Diuretics
5. Comorbid conditions
6. Post-operative pelvic floor muscle spasm
  1. Herniorrhaphy
  2. Hydrocelectomy
  3. Perirectal Abscess
  4. Rectal trauma or perineal trauma
7. Natural Products
  1. Ephedra or Ma Huang
  2. Country Mallow
  3. Heartleaf
  4. Bitter Orange
Symptoms
1. See International Prostate Symptom Score
2. Obstructive uropathy symptoms
  1. Weak urine stream with decreased caliber
  2. Hesitancy starting urine stream
  3. Incomplete voiding sensation
  4. Urinary Retention
    1. Double voiding (returning to urinate shortly after)
    2. Straining to empty bladder
  5. Postvoid or terminal dribbling
3. Irritative symptoms
  1. Dysuria
  2. Urinary frequency
  3. Urinary urgency
4. Increased urine Residual Volume symptoms
  1. Nocturia
  2. Overflow Incontinence
  3. Bladder palpable on exam
Signs
1. Digital Rectal Exam
  1. Findings suggestive of Prostate Cancer
    1. Asymmetry
    2. Induration
    3. Nodularity
    4. Diffuse firmness
  2. Findings suggestive of Benign Prostatic Hyperplasia
    1. Symmetric prostatic enlargement
    2. Smooth
    3. Firm but elastic
2. Abdominal and genitourinary exam
  1. Suprapubic swelling of distended bladder
  2. Signs of urethral stricture
    1. Penile induration
    2. Penile nodularity
  3. Balanoposthitis - meatal stenosis (Diabetes Mellitus)
Differential Diagnosis
1. See Urinary Retention
2. Medication Causes of Urinary Retention
Labs
1. Urinalysis: Urinary Tract Infection and Hematuria
  1. Urine Dipstick
  2. Urine microscopy
2. Prostate Specific Antigen (PSA)
3. Renal Function Tests (Assess for Postrenal Azotemia)
  1. Serum Creatinine
  2. Blood Urea Nitrogen (BUN)
Diagnostics
1. See Urodynamics
2. Transabdominal ultrasound
  1. Assess post-void residual
3. Other studies to consider
  1. Transrectal ultrasound (prostate size evaluation)
  2. Intravenous pyelogram (assess urinary obstruction)
Management: Conservative Measures for mild symptoms
1. Limit night-time water consumption
2. Reduce caffeine intake
3. Avoid provocative medications
  1. See risk factors above
  2. Avoid anticholinergics (e.g. Antihistamines)
4. Observe for complications with annual examination
5. Alternative Medications
  1. Soy products (Isoflavone Genistein)
    1. Tofu contains high concentrations of Genistein
    2. Trinovin (OTC Genistein derived from red clover)
      1. Reduced BPH symptoms at 40-80 mg qd (small trial)
    3. References
      1. Lowe (2000) Patient Care 34:191
  2. Saw Palmetto 160 mg PO bid
    1. As effective as Finasteride (Proscar)
Management: Medication
1. Alpha Adrenergic Antagonists (long-acting)
  1. Preferred over 5a-Reductase Inhibitors (Finasteride)
  2. Non-Selective agents (antihypertensives)
    1. Terazosin (Hytrin) ($42/month)
    2. Doxazosin (Cardura) ($30/month)
    3. Prazosin (Minipress) (least expensive)
  3. Selective agents (no Blood Pressure effect)
    1. Tamsulosin (Flomax) ($40-$78)
2. Testosterone conversion (5a-reductase) inhibitor
  1. Efficacy: See Finasteride
    1. Less effective than alpha blockade or surgery
    2. Most effective in men with large prostate
    3. Finasteride effective in reducing Gross Hematuria due to BPH (80%)
  2. Agents
    1. Dutasteride (Duagen)
    2. Finasteride (Proscar) ($63/month)
      1. See Finasteride regarding increased Prostate Cancer risk
Management: Surgery
1. Indications
  1. Failed medical therapy
  2. Refractory Urinary Retention
  3. Recurrent Urinary Tract Infections
  4. Persistant Hematuria
  5. Bladder stones
  6. Renal Insufficiency
2. Invasive Procedures
  1. Transurethral Resection of the Prostate (TURP)
  2. Open Prostatectomy (rarely used for BPH alone)
    1. Very large prostate size
    2. Large median prostate lobe protruding into bladder
    3. Urethral diverticulum
3. Minimally invasive procedures
  1. Transurethral Incision of the Prostate (TUIP)
  2. Transurethral Laser Induced Prostatectomy (TULIP)
    1. Ultrasound-guided Nd-Yag laser
    2. Shorter procedure and fewer complications than TURP
    3. No tissue samples for histopathology testing
  3. Transurethral Microwave Thermotherapy (TUMT)
    1. Microwave probe heats to over 45 C)
    2. Safe, effective method for Urinary Retention relief
  4. Transurethral Vaporization of the Prostate (TUVP)
  5. Transurethral Electrovaporization Prostate (TVP)
  6. Transurethral Needle Ablation of Prostate (TUNA)
  7. Hot Water Ballon Thermoablation
    1. Experimental procedure with good outcomes
    2. Minimal discomfort
  8. Urethral stent
    1. Risk of infection and re-blockage
    2. Indications
      1. BPH patients with high surgical risk
      2. Short life expectancy
  9. Transurethral Balloon Dilation
    1. Rarely used due to high rate of symptom recurrence
Complications
1. BPH is not related to Prostate Cancer development
2. Obstructive complications
  1. Postrenal Azotemia
  2. Hydronephrosis
  3. Bladder decompensation
    1. Overflow Incontinence
    2. Bladder hypertrophy
  4. Urosepsis
References
1. Dornbland (1992) Adult Ambulatory Care, p. 249-52
2. Cooner (1994) Prostate Disease, AAFP, p. 9-15
3. Corica (2000) Urology 56:76
4. Donovan (2000) J Urol 164:65
5. Dull (2002) Am Fam Physician 66(1):77
6. Guthrie (1997) Postgrad Med 101(5):141
7. Macchia (Feb, 1997) Consultant, p.336-45
8. Oesterling (1995) N Engl J Med 332(2):99

Benign Prostatic Hyperplasia (C1704272)
Definition (CSP)	enlargement or overgrowth of the prostate gland as a result of an increase in the number of its constituent cells.
Definition (MSH)	A disease caused by hyperplastic process of non-transformed prostatic cells.
Definition (NCI)	A non-cancerous nodular enlargement of the prostate gland. It is characterized by the presence of epithelial cell nodules, and stromal nodules containing fibrous and smooth muscle elements. It is the most common urologic disorder in men, causing blockage of urine flow.
Concepts	Pathologic Function (T046)
English	Benign Hyperplasia of Prostate, Benign Hyperplasia of the Prostate, Benign Prostate Hyperplasia, Benign Prostatic Hyperplasia, BPH, PROSTATIC HYPERPLASIA BENIGN <PROSTATISM>
Spanish	hiperplasia prostÃ¡tica benigna, hiperplasia prostatica benigna, hipertrofia prostÃ¡tica benigna, hipertrofia prostatica benigna
Credits	Derived from the NIH UMLS (Unified Medical Language System)

Urology Book

Miscellaneous

Examination Chapter related topics

Hematology and Oncology Chapter related topics

Infectious Disease Chapter related topics

Pathology and Laboratory Medicine Chapter related topics

Pharmacology Chapter related topics

Procedure Chapter related topics

Surgery Chapter related topics

http://www.fpnotebook.com/

Benign Prostatic HyperplasiaAka: Benign Prostatic Hypertrophy, Prostatic Hyperplasia, BPH

Benign Prostatic Hyperplasia (C1704272)

Navigation Tree