Benign Prostatic Hyperplasia

Essentials of Diagnosis

• Obstructive or irritative voiding symptoms

• May have enlarged prostate on rectal examination

• Absence of urinary tract infection, neurologic disorder, urethral stricture disease, prostatic or bladder malignancy

General Considerations

• Smooth, firm, elastic enlargement of the prostate

Etiology

• Multifactorial

• Endocrine: dihydrotestosterone (DHT)

• Aging

Demographics

• The most common benign tumor in men

• Incidence is age related

• Prevalence

  • ~20% in men aged 41–50

  • ~50% in men aged 51–60

  • > 90% in men aged 80 and older

• Symptoms are also age related

  • At age 55, ~25% of men report obstructive voiding symptoms

  • At age 75 years, 50% of men report a decrease in the force and caliber of the urinary stream

Symptoms and Signs

• Can be divided into obstructive and irritative complaints

• Obstructive symptoms

  • Hesitancy

  • Decreased force and caliber of stream

  • Sensation of incomplete bladder emptying

  • Double voiding (urinating a second time within 2 h)

  • Straining to urinate

  • Postvoid dribbling

• Irritative symptoms

  • Urgency

  • Frequency

  • Nocturia

• American Urological Association (AUA) Symptom Index (Table 23–3) should be calculated for all patients starting therapy

• Seven questions quantitate the severity of obstructive or irritative complaints on a scale of 0–5. Thus, the score can range from 0 to 35

Differential Diagnosis

• Prostate cancer

• Urinary tract infection

• Neurogenic bladder

• Urethral stricture

Laboratory Findings

• Urinalysis should be performed to exclude infection or hematuria

• Serum prostate-specific antigen (PSA) should be considered

Imaging

• CT or renal ultrasound is recommended only in the presence of

  • Concomitant urinary tract disease

  • Complications from benign prostatic hyperplasia (ie, hematuria, urinary tract infection, chronic kidney disease, history of stone disease)

Diagnostic Procedures

• History to exclude other possible causes of symptoms

• Physical examination, digital rectal examination (DRE), and a focused neurologic examination

• DRE: note size and consistency of the prostate

• Examine lower abdomen for a distended bladder

• If possibility of cancer, further evaluation is needed by serum PSA, transrectal ultrasound, and biopsy

Medications

• Alpha-blockers

  • Prazosin, 1 mg orally each night at bedtime for 3 nights, increasing to 1 mg twice daily orally and then titrating up to 5 mg twice daily orally if necessary

  • Terazosin, 1 mg once daily orally for 3 days, increasing to 2 mg once daily orally for 11 days, then 5–10 mg once daily if necessary

  • Doxazosin, 1 mg once daily orally for 7 days, increasing to 2 mg once daily orally for 7 days, then 4–8 mg once daily orally if necessary

  • Tamsulosin

    • 0.4 mg once daily orally after meal, increased to 0.8 mg once daily orally if necessary

    • Caution: Patients who receive tamsulosin within 14 days before cataract surgery have an increased risk of developing the intraoperative complication of floppy iris syndrome and postoperative ophthalmic complications

  • Alfuzosin, 10 mg once daily orally; no dose titration needed

• 5-alpha-reductase inhibitors

  • Finasteride, 5 mg once daily orally; 6 months of therapy required for maximum effects on prostate size (20% reduction) and symptomatic improvement

  • Dutasteride, 0.5 mg once daily orally

• Phosphodiesterase-5 inhibitor

  • Tadalafil approved by the FDA to treat the symptoms and signs of benign prostatic hyperplasia

  • Also approved for use in men with both urinary symptoms and erectile dysfunction

• Saw palmetto is of no benefit

• Combination therapy

  • α-Blocker and 5α-reductase inhibitor (eg, long-term combination therapy with doxazosin and finasteride)

    • Safe and reduces risk of overall clinical progression of BPH significantly more than either drug alone

    • Reduces the long-term risk of acute urinary retention and the need for invasive therapy

    • Entails the risks of additional side effects and the cost of two medications

Surgery

• Indications

  • Refractory urinary retention (failing at least one attempt at catheter removal)

  • Large bladder diverticula

  • Recurrent urinary tract infection

  • Recurrent gross hematuria

  • Bladder stones

  • Kidney failure

• Transurethral resection of the prostate (TURP)

  • Gold standard surgical treatment of BPH

  • Often requires a 1- to 2-day hospital stay

  • Over 95% of prostate surgeries can be performed endoscopically (through the urethra)

  • Risks include retrograde ejaculation (75%), erectile dysfunction (< 5%), and urinary incontinence (< 1%)

  • Potential complications of surgery

    • Bleeding

    • Urethral stricture or bladder neck contracture

    • Perforation of the prostate capsule with extravasation

    • Transurethral resection syndrome—a hypervolemic, hyponatremic state resulting from the absorption of the hypotonic irrigating solution

• Transurethral incision of the prostate (TUIP)

  • Removes the zone of the prostate around the urethra leaving the peripheral portion of the prostate and prostate capsule

  • Lower rate of retrograde ejaculation reported (25%)

• Consider simple prostatectomy when

  • Prostate is too large to remove endoscopically (> 100 g)

  • Concomitant bladder diverticulum

  • Bladder stone is present

  • Dorsal lithotomy positioning is not possible

• Minimally invasive approaches

  • Interstitial laser therapy usually under cystoscopic control

  • Holmium laser enucleation of the prostate (HoLEP)

    • Technique of enucleating the adenomatous lobes intact and morcellating the tissue within the bladder

    • Advantages compared with other methods include ability to treat all prostate sizes, low re-treatment rates, few complications, and shorter duration of catheterization

  • Advantages of laser surgery include

    • Outpatient surgery

    • Minimal blood loss

    • Rare occurrence of transurethral resection syndrome

    • Ability to treat patients while they are receiving anticoagulation therapy

  • Disadvantages of laser surgery include

    • Lack of tissue for pathologic examination

    • Longer postoperative catheterization time

    • Variable effectiveness

    • More frequent irritative voiding complaints

    • Expense of laser fibers and generators

  • Transurethral needle ablation of the prostate (TUNA)

    • Achieves similar improvement compared to TURP

  • Transurethral electrovaporization and KTP laser photovaporization of the prostate

  • Hyperthermia—microwave thermotherapy

  • Implant to open prostatic urethra (UroLift^®)

    • The implant retracts the enlarged lobes of the prostate in symptomatic men 50 years and older with an enlarged prostate (less than 80 g)

    • Evidence suggests that the technique improves symptoms and voiding flow while having minimal impact on erectile or ejaculatory function

  • Water vapor thermal therapy (Rezum^®)

    • Minimally invasive

    • FDA-approved

    • Uses a transurethral device to deliver steam into the prostatic tissue and thermally destroy it

    • 3-year data shows improvement in symptoms and voiding flows with minimal impact on erectile or ejaculatory function compared with medical therapy

Therapeutic Procedures

• With watchful waiting, ~10% progress to urinary retention, and half demonstrate marked improvement or resolution of symptoms

Follow-Up

• Follow AUA Symptom Index for benign prostatic hyperplasia (Table 23–3)

When to Refer

• Progression to urinary retention

• Patient dissatisfaction with medical therapy