BENIGN PROSTATIC HYPERPLASIA

(BPH)
DEFINITION
Benign prostatic hyperplasia is stromal and epithelial proliferation in the prostate gland that
causes an increase in size of the prostate gland that may eventually result in voiding symptoms.
It is also known as benign prostatic hypertrophy.

EPIDIMIOLOGY
BPH commonly occurs in men over 50 years. By the age of 60 years 50% of men have
histological evidence of BPH and 15% have significant lower urinary tract symptoms. It is rare in
men who are younger than 40 years of age, however it can be found in approximately 70% of
men in their seventies and nearly all men in their nineties.

AETIOLOGY
The cause is unknown, but it is thought to result from an imbalance between male and female
hormones. Oestrogen which increases with age, increases the level of androgen receptors in the gland
causing prostate overgrowth.

HORMONES
1. Testosterone vs Oestrogen
 With advancing age, serum testosterone levels significantly drop but levels of
oestrogenic steroids do not decrease equally.
 According to this theory the prostrate enlarges because of increased oestrogenic effects.
2. It is also likely that the secretion of intermediate peptide growth factors plays a part in
development of BPH.

PATHOLOGY
BPH affects both glandular epithelium and connective tissue stroma to variable degrees. It
affects the submucous group of glands in the transitional zone forming a nodular enlargement.
BPH affects the peri-urethral layer of the prostrate. The prostate has four lobes, lateral lobes,
median lobe and posterior lobe. These vary in size and are separated by stroma. Usually the median lobe
and lateral lobes are affected. Enlargement of the lateral lobes compresses the urethra; enlargement of
the median lobe obstructs urine outflow by plugging the urethral orifice.

The voiding dysfunction that results from prostate enlargement and bladder outlet obstruction (BOO) is
termed as lower urinary tract symptoms (LUTs).

NB: Not all men with BPH have LUTs, not all men with LUTs have BPH

CLINICAL FEATURES
SYMPTOMS
Obstructive (voiding) symptoms
1) Hesitancy (worsened when the bladder is very full)

1
2) Straining to pass urine - the strain/push to initiate and maintain urine stream in order to
more fully empty the bladder
3) Prolonged micturition
4) Poor flow (unimproved by straining). Decreased force of stream- the loss of urinary force or
weak force of urine stream over time
5) Intermittent stream- stops and starts
6) Dribbling (including after micturition dribbling) - the loss of small amounts of urine due to
poor urinary stream
7) Sensation of poor bladder emptying (incomplete bladder emptying) - there is the feeling of
persistent residual urine regardless of the frequency
8) Episodes of near retention
9) Urinary retention

Irritative (storage or filling) symptoms

Severe Irritative symptoms are associated with detrusor instability. They include:
1) Frequency of micturition - need to micturate frequently during the day and night
(polyuria/nocturia), usually voiding only small amounts of urine with each episode
2) Nocturia – frequent micturition at night
3) Urgency - sudden urgent urge or need to urinate
4) Urge incontinence
5) Nocturnal incontinence (enuresis)

SIGNS
(i) Signs of chronic renal failure with
 Anaemia
 Dehydration
(ii) Abdominal examination
 It is usually normal
 In patients with chronic retention, a distended bladder is felt as a suprapubic mass,
tender and dull on percussion
(iii) External urethral meatus should be examined for stenosis
(iv) Feel the urethra for stenosis
(v) Palpate the epididymis for signs of inflammation
(vi) Feel for palpable kidneys
(vii) Do a digital rectal examination - In BPH:
 Rectal mucosa moves freely over the prostrate
 Surface is smooth and convex
 Central sulcus is not obliterated
(Viii) The nervous system
 Examine to exclude a neurological lesion
 Examine the perianal sensation and anal tone to detect an S2-S4 cauda equina lesion

2
Differential diagnoses
1) Idiopathic detrusor instability
2) Neuropathic bladder dysfunction as a result of:
 Stroke
 Alzheimer’s disease
 Parkinson’s disease
3) Degeneration of bladder smooth muscle giving rise to impaired voiding and detrusor
instability
4) Urodynamically proven bladder outlet obstruction resulting from:
 Bladder neck hypertrophy
 Bladder neck stenosis
 Prostatic cancer
 Urethral stricture
 Functional obstruction due to neuropathic conditions
5) For patients with lower urinary tract symptoms:
 Urinary tract infections
 Bladder stones
 Urethral stricture
 Neurogenic bladder
6) Diabetes mellitus
7) Tabes dorsalis
8) Disseminated (multiple) sclerosis

INVESTIGATIONS
1) BLOOD TESTS
a) Serum Prostatic Specific Antigen (PSA):
- If it’s above 4ng/ml, trans-rectal biopsies should be considered to rule our carcinoma
b) Renal function tests: urea, electrolytes and createnine
c) Haemoglobin levels
2) URINE TESTS
a) Glucose
b) Blood
c) Bacteriology- microscopy and culture
d) Cytology- If carcinoma in situ is thought possible
3) RADIOLOGICAL INVESTIGATIONS
a) Pelvic ultrasound- Reveals enlarged prostate and residual urine in the bladder
b) Intravenous urography (IVU) - If hydroureters or hydronephrosis is detected
c) Transurethral ultrasound scanning- It increases the rate of detection of associated early
prostatic cancer
4) CYSTOURETHROSCOPY
Inspection of the urethra, the prostrate and the urothelium of the bladder. Should be done
immediately prior to prostatectomy, whether being done transurethrally or by the open route to

3
exclude:
- Urethral stricture
- Bladder carcinoma
- The occasional non-opaque vesical calculus

TREATMENT
INDICATIONS FOR TREATMENT
1. Acute retention (accounts for 25% of prostatectomies)
2. Chronic retention and renal impairment (accounts for 15% of prostatectomies) evidenced
by:
- A residual urine of ≥200mls
- Hydroureter or hydronephrosis revealed by urography
- Uraemic manifestations

3. Complications of bladder neck obstruction:

- Infections
- Stones
- Diverticulum formation
4. Haemorrhage- Occasionally venous bleeding from a ruptured vein overlying the prostrate will
require prostatectomy to be performed

METHODS OF TREATMENT
NON-OPERATIVE METHODS
a) Conservative ‘watchful waiting’- Give general advice about fluid intake, use of
anticholinergic drugs in men with mild symptoms, with no complications. Watchful waiting
involves follow up 1 to 2 times yearly.
b) Use of prostatic stents in men with retention who are unfit or have dementia
c) Balloon dilatation of the prostrate (experimental)
d) Use of indwelling catheter in unfit men of those with dementia
e) Drugs in men with mild symptoms
 α adrenergic blocking agents
1-

 5α reductase inhibitor
f) Injection of the prostrate with phenol
- It makes the prostrate undergo slow necrosis and fibrosis
- It is fit for patients who are too old or too sick

DRUGS USED
There are two components to the bladder outlet obstruction resulting from BPH:
1) Mechanical
Refers to the urethral compression resulting from the enlarged prostrate
2) Dynamic
Refers to the smooth muscle in the urethra and prostatic stroma that contracts and further
4
 obstructs the bladder
The smooth muscles at the bladder outlet are under α- adrenergic innervation

The first line therapy is an α1- blocker, which targets the dynamic components whereby they
inhibit the contraction of smooth muscles in the prostrate. Alpha adrenergic blockers relax the
smooth muscle of prostate and provide a larger urethral opening in the prostate stroma, urethra
and bladder neck. These drugs include: Terazosin; Doxazosin; Tamsulosin; Alfuzosin and
Phenoxybenzamine.

Terazosin and Doxazosin are selective for α-adrenoceptors, which are found in the prostrate as
well as in the CNS. They both significantly lower the blood pressure especially in men with
hypertension. Common side effects with these two drugs are dizziness, and orthostatic
hypotension. Both medications should be titrated up over 1-2 weeks to their target dose.

Tamsulosin is a selective α1-receptor antagonist with preferential selectivity for α1A -

adrenoceptor subtype which is predominantly found in the prostrate. Its effect on blood
pressure is clinically insignificant. It does not require titration hence can be started at its
effective dose. Its common side effects are rhinitis and retrograde ejaculation.

Drugs used as 2nd line treatment include

1. Finasteride
This is a 5α reductase inhibitor that blocks the conversion of testosterone to
dihydrotestosterone. It is effective in decreasing the risk of urinary retention and haematuria in
men with very large prostate gland. 5α-reductase inhibitors- Finasteride, Dutasteride- shrink
the prostate gland, prevent progression of LUTs and reduce the risk of urinary retention.
2. Aromatase inhibitors- inhibit oestrogen effect
3. Saw palmetto
Derived from the American dwarf palm tree and sold in America as a herbal supplement. Its
precise mechanism of action in not known.

NB: Combination therapy of Alpha adrenergic blockers and 5-Alpha Reductase inhibitor can be used to
provide rapid relief and target the underlying disease process.

2. SURGICAL METHOD (PROSTATECTOMY)

It is surgical removal of the prostrate
METHODS OF PROSTATECTOMY
i. Transurethral resection of the prostrate (TURP)
It has largely replaced other methods unless diverticulectomy or removal of large calculi (stone)
necessitates open operation
ii. Retropubic prostatectomy (RPP)
iii. Transvesical prostatectomy (TVP)
iv. Perineal prostatectomy - It has been abandoned

5
v. Open prostatectomy- for patients with very large prostates (≥ 75g), patents with
concomitant bladder stone or bladder diverticula and patients who cannot be positioned for
TURP
COMPLICATIONS OF PROSTATECTOMY
1. LOCAL COMPLICATIONS
 Haemorrhage
 Perforation of the bladder on the prostate capsule at the time of transurethral surgery
 Sepsis
 Urinary incontinence
 Retrograde ejaculation (dry orgasm)
 Erectile dysfunction (Impotence)
 Urethral stricture
 Bladder neck contracture
 Injury to the rectum (rare)
2. GENERAL COMPLICATIONS
 Pulmonary atelectasis
 Pneumonia
 Myocardial infarction
 Congestive cardiac failure
 Deep venous thrombosis
 Water intoxication
 Osteitis pubis(rare)
3. OTHER NEWER TREATMENTS
a) Microwave treatment
 Hyperthermia( 40-45 degree Celsius)
 Thermotherapy(temperatures above 50 degrees Celsius)
b) Laser treatment - used to cut/destroy prostate tissue

COMPLICATIONS of BPH
1. Urine retention

2. Hydronephrosis / Hydroureter
3. Recurrent urinary tract infections
4. Calculi formation (Bladder calculi)
5. Haematuria
6. Acute renal failure/renal insufficiency/uraemia
7. Cystitis
8. Urine reflux
9. Thickening of the bladder muscles
These are related to bladder outlet obstruction (BOO) secondary to BPH