Epidemiology
The estimated prevalence of the disease from community-based studies is 40% for men in their 70s, and histological evidence of BPH in autopsy studies has been found in 60% to 80% of men aged 60 to 69 years. A third of men aged over 50 years will develop lower urinary tract symptoms (LUTS). Approximately 25% of these men have moderate to severe LUTS, which greatly affect their quality of life, and a quarter will need surgical intervention.
Aetiology
The aetiology of BPH is not completely understood. However, it is likely to be related to the effects of androgens. Other potential factors in the causation of benign prostatic hyperplasia include dietary fat, alcohol, genetic factors
Symptoms of BPH
Lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), is the most common diagnosis in men presenting with urinary symptoms in clinical practice.
Lower urinary tract symptoms are categorized into the following categories.
Voiding or obstructive symptoms, which include:
• slow stream
• hesitancy
• intermittency
• terminal dribble
Storage or irritative symptoms, which include
• increased daytime frequency
• nocturia
• urgency
• urinary incontinence
The complications of BPH include:
• acute urinary retention
• chronic retention with renal failure
• haematuria as a result of prostatic bleeding
• renal tract calculi secondary to stasis of urine
Diagnosis
Diagnosis of LUTS, benign prostatic hyperplasia and benign enlargement of the prostate is based on history, physical examination, rectal examination, and simple investigations to exclude urinary tract infection and renal damage. No specific symptoms clearly indicate benign prostatic obstruction. However, a working diagnosis of BPH can be made if there is a predominance of obstructive urinary symptoms, a benign feeling prostate, an absence of infection, and normal renal function. If there is any doubt as to the cause of the LUTS, a mixed picture of voiding and storage symptoms, or an abnormality on examination or initial investigations referral to a urologist is appropriate.
It is important to identify those patients with BPH in whom the disease is particularly likely to cause further problems. This so-called BPH progression can result in
• Increases in prostate volume
• Worsening of LUTS
• Increasing bother, interference, and quality of life
• Deterioration in urinary flow rate
• Episodes of acute urinary retention
• Need for surgical intervention
2 Key risk factors determine high risk of BPH progression
• prostate volume
• prostate specific antigen (PSA)
Prostate volume
Men with larger prostates have (larger than a golf ball)
• Greater rates of prostate growth
• 3x higher rate of moderate or severe symptoms
• Decreased flow rates
• 3x greater risk of acute urinary retention
• 4x greater risk of medical or surgical intervention
Prostate specific antigen (PSA)
Assuming cancer has been excluded. A higher baseline PSA (e.g. 3.3-4ng/ml) corresponds to
• Increased prostatic growth rate
• Increased risk of acute urinary retention
• Increased risk of surgical intervention
Treatment
Treatment of BPH falls under 3 general headings
• Conservative management
• Medical management ( alpha receptor antagonists, 5a reductase inhibitors)
• Surgical management ( TURP, open prostatectomy)
The British Association of Urological Surgeons have recently formulated primary care guidelines for the treatment of BPH (see figure 1):
Primary care assessment should include
• History and symptom score assessment
• Physical Examination and DRE
• Urinalysis/MSU
• PSA
The following findings warrant urological referral:
• PSA elevated for age
• Abnormal DRE
• Haematuria
• Abnormal renal function
• Palpable bladder
• Recurrent UTI
• Abnormal cytology
• Severe symptoms
Figure 1: Summary of the British Association of Urological Surgeons guidelines
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