BENIGN PROSTATE HYPERPLASIA

Introduction

BPH: Benign and diffuse hyperplasia of prostate

Androgen-dependent

Anatomy review

Prostate lies immediately inferior to the bladder, posterior to the pubic symphysis and anterior to the rectum. It is a gland, consisting of a median lobe (Central lobe) and two lateral lobes (Peripheral lobe), that surrounds the neck of the bladder and the urethra in the male

Diameter of 2 x 4 x 3 cm, and weighing about 15-20 g, and enclosed in a fibrous capsule containing smooth muscle fibers in its inner layer

The gland secretes a thin, opalescent, slightly alkaline fluid that forms part of the seminal fluid. No endocrine function

(Gray's Atlas of Anatomy)

Epidemiology

Men > 50 years: 40% and > 70 years: 80%

Idiopathic: no precise etiology but contributing factors: Hormonal activity (DTH) / age / ethnicity (rare in Asia)

*BPH is NOT a prostate cancer risk factor

Physiopathology

BPH developed at the central zone/transitional zone of the prostate and never at the peripheral zone

Proliferation of glandular cells, smooth muscle, stroma

But no parallelism between functional symptoms and prostate size

Diagnosis

1. Clinical manifestation

Men > 50 years

Contribute factors (Medication): Anticholinergic, α-Stimulator

Obstruction sign

Dysuria syndrome (in voiding phase)

• Hesitancy (delay initiation), weak stream and chopped
• Urination push: abdominal contraction
• Terminal drops: slow and gradual completion

Post voiding residue (After voiding phase)

• Sensation of incomplete bladder emptying
• Drops laggards

Irritative signs

• Do not predominant (Can also be: prostatitis or bladder tumor)
• Burning urination / urge incontinence / urinary frequency / nocturia

AUA Symptom Index

Auto-assessment of functional symptoms and impact on life quality

Harrison's Principals of Internal Medicine

• Mild: AUA0-7
• Moderate: AUA 8-19
• Severe: AUA 20-35

2. Physical examination

Rectal touch must be done to confirm diagnosis

• Increase volume of prostate
• Smooth, regular shape, firm and elastic
• Painless

*May not precise with patient with obesity

Differential diagnosis in rectal touch

• Prostatitis: Pain*/ warm/ tense/ fever
• Prostatic cancer: Solidary nodule/ irregular shape/ painless /asymmetric

Search distended bladder (Palpation): Urinary retention

3. Investigation

Biology

Dipstick test +/- Urinalysis are the only recommendation for first episode

Urinalysis is proceed if dipstick is positive to rule out Prostatitis

*No others investigation are recommended for diagnosis, unless the diagnosis is not certain: Obesity, BPH only expense in the central zone

PSA for screening prostate cancer if patient in > 50 years

Creatinine/urea: Renal function test (depend on patient)

Urinary cytology ± bladder endoscopy: detecting bladder cancer

Imagery

Transparietal and endorectal ultrasound of the urinary tract (kidney, bladder and prostate)

Indication: Previous assessment are unclear, diagnosis uncertain, before surgical procedure

Purpose: Volume of prostate, post-voiding residue, bladder stone, alteration of the upper urinary tract

Uretrocystoscopy

Indication: Hematuria or irritative signs presented

Purpose: Detect bladder tumor

Complication

Acute urinary retention

Chronic urinary retention (Post-voiding residue > 100ml):

• Overflow incontinence
• Painless bladder Globe
• Upper urinary tract alteration (i.e. Chronic kidney disease by obstruction)

Infection: prostatitis, urinary infection repeatedly

Bladder stone

Differential diagnosis

Dysuria

• Prostate cancer
• Urethral stenosis or urethral meatus stenosis
• Neurological bladder syndrome: diabetes, Parkinson's
• Iatrogenic: anticholinergic, alpha stimulator

Irritative signs

• Infection: Prostatitis
• Bladder Tumor
• Neurogenic bladder syndrome