Prostate

Question 1

BPH pathophysiology

Answer 1

• Benign hyperplasia

• Affects inner (transitional) layer of prostate
- causes urethral compression

• DHT produced from testosterone in stromal cells by 5α-reducatase enzyme.
• DHT-induced GFs → ↑ stromal cells and ↓ epithelial cell death.

Question 2

Presentation of BPH

Answer 2

• Storage Symptoms

• Nocturia
• Frequency
• Urgency
• Overflow incontinence

• Voiding Symptoms

• Hesitancy
• Straining
• Poor stream/flow + terminal dribbling
• urinary tenesmus
• Incomplete emptying
• Bladder stones secondary to stasis)
• UTI secondary to stasis)

Question 3

Examination of BPH

Answer 3

PR:

• Smoothly enlarged prostate
• Definable median sulcus

• Bladder not usually palpable unless acute-on-chronic obstruction

Question 4

Investigations of BPH

Answer 4

• International Prostate Symptom Score (IPSS) questionnaire - quantification of LUTS

• Voiding diary
• urinary frequency and volume chart
• Blood: U+E, PSA (after PR)
• DRE
• Urine: dip, MC+S
• post-void bladder scan - chronic retention

• Imaging
- Transrectal US ± biopsy
• Urodynamics: pressure / flow cytometry

Question 5

Conservative and medical mx of BPH

Answer 5

Conservative:
• ↓ caffeine, EtOH
• Bladder training
• Medication review

Medical:
• Useful in mild disease and while awaiting TURP

1st: α-blockers
- Tamsulosin, doxazosin
- Relax prostate smooth muscle

2nd: 5α-reductase inhibitors - Finasteride

Question 6

S/E of alpha blockers

Answer 6

Drowsiness
↓BP
Depression, 
Weight gain 
extra-pyramidal signs

Question 7

5α-reductase inhibitors

Answer 7

• Inhibit conversion of testosterone → DHT

- Preferred if significantly enlarged prostate.

Question 8

Surgical Mx of BPH

Answer 8

• TURP
- resection of lateral and middle lobes

• Transurethral incision of prostate (TUIP)

• Tranurethral Electro -vaporisation of Prostate
- Electric current → tissue vaporisation

• Laser prostatectomy
- ↓ ED and retrograde ejaculation

• Open retropubic prostatectomy
- Used for very large prostates

Question 9

Early TURP Complications

Answer 9

• Haemorrhage
• Infection
• Clot retention: requires bladder irrigation

Question 10

Risk factors for BPH

Answer 10

Age
Afro - Caribbean
Obesity
FHx

Question 11

Complications of BPH

Answer 11

High-pressure retention

Question 12

TURP syndrome

Answer 12

Use of hypoosmolar irrigation during the procedure can result in fluid overload and hyponatremia

Presents with:

• confusion
• nausea
• agitation
• visual changes

Question 13

Risk factors for developing TURP syndrome

Answer 13

Prolonged operating time

Large volume of prostate resected

Hypo - osmolar irrigation fluid

Question 14

Late complications of TURP

Answer 14

• Retrograde ejaculation: common
• Erectile dysfunction
• Incontinence
• Urethral stricture