Benign Prostatic Hyperplasia

Question 1

What are the risk factors for BPH?

Answer 1

Age > 50 and positive family history for BPH and ethnicity

Question 2

What are the symptoms of BPH?

Answer 2

Voiding symptoms - Weak/intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
Storage symptoms - Urgency, frequency, incontinence, noturia

Question 3

What are the complications for BPH?

Answer 3

UTIs, bladder stones, sexual dysfunctionretention or obstructive uropathy

Question 4

What is the pathophysiology of BPH?

Answer 4

Increased ratio of stromal to epithelial cells. This occurs as the prostate has two growth phases, the second one starts at 25 years old and continues.

Question 5

What are the investigations for BPH?

Answer 5

• Urine dipstick,
• UEs - Look for chronic retention
• DRE,
• PSA,
• Urine frequency and volume chart (records 3 days),
• International prostate symptom score
• If you suspect retention the do bladder scan

Question 6

What is the first line management of BPH?

Answer 6

• Alpha 1 antagonists such as tamsulosin or alfuzosin

Question 7

What is the second line management of BPH?

Answer 7

5 alpha reductase inhibitors such as finasteride. Should be considered in larger prostates > 30g on imaging

Question 8

What is the mechanism of alpha-1 antagonists and their side effects

Answer 8

It causes smooth muscle relaxation which can treat immediate symptoms. Side effects include: dizziness, postural hypotension, dry mouth and depression

Question 9

What is the mechanism of action of 5-alpha reductase inhibitors and side effects?

Answer 9

It blocks the conversion of testosterone to dihydrotestosterone. Slows disease progression but can take up to 6 months to work.
Side effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

Question 10

When should you put a patient on both an alpha blocker and a 5-alpha-reducatse inhibitor?

Answer 10

In patients with larger prostates who experience symptom progression on monotherapy.
Or if they have a high IPSS score

Question 11

What medication can be used for BPH if they also have erectile dysfunction?

Answer 11

Tadalafil

Question 12

When should patients with BPH be referred for surgery?

Answer 12

• If they have severe complications such as recurrent UTIs/retention
• Not responding to medication or has intolerable side effects

Question 13

What are the different surgical options for BPH?

Answer 13

• TURP,
• Prostatectomy
• Transurethral vaporisation of the prostate
• HoLEP

Question 14

What are the major complications of TURP?

Answer 14

• Bleeding,
• Infection,
• Urinary incontinence,
• Erectile dysfunction,
• Retrograde ejaculation,
• Urethral strictures,
• Failure to resolve symptoms

Question 15

What are the differential diagnosis for BPH?

Answer 15

• Prostate cancer,
• Prostatitis (will also present with perineal pain