Benign Prostatic Hyperplasia

It is a benign enlargement of prostate which occurs after about 50 years (usually between 60-70 years)
Theories
It is involuntary hyperplasia due to disturbance of the ratio and quantity of circulating androgens and estrogens.
BPH is a benign neoplasm, also called as fibromyoadenoma.

Pathology

• BPH usually involves median and lateral lobes or one of them.
• It involves adenomatous zone of prostate, i.e. submucosal glands.
• Median lobe enlarges into the bladder.
• Lateral lobes narrow the urethra causing obstruction.
• Urethra gets elongated and narrowed.
• Bladder initially takes the pressure burden causing trabeculations, sacculations and later diverticula formation.
• Enlarged prostate compresses the prostatic venous plexus causing congestion, called as vesical piles leading to haematuria.
• Incrimination of BPH as the source of haematuria before excluding other causes is termed as “Decoy prostate”
• Kidney and ureter
• Back pressure causes hydroureter and hydronephrosis.
• Secondary ascending infection can cause acute or chronic pyelonephritis.
• Often severe obstruction can lead to obstructive uropathy with renal failure.
• BPH causes impotence.

Clinical Features

• Frequency occurs due to introversion of sensitive urethral mucosa into the bladder or due to cystitis and urethritis.
• Urgency
• Overflow and terminal driblling.
• Difficulty in micturation with weak stream and dribble.
• Pain in suprapubic region and in loin due to cystitis and hydronephrosis respectively.
• Acute retention of urine
• Retention with overflow
• Haematuria
• Renal failure
• Prostatism is a combination of symptoms like frequency both at day and night, poor stream, delay in starting and difficulty in micturation.
• Tenderness in suprapubic region, with palpable enlarged bladder due to chronic retention. Hydronephrotic kidney may be palpable.
• P/R examination shows enlarged prostate. It should be done when bladder is empty.
• Features of urinary infection like fever, chills, burning micturation.

Investigations

• Urine for microscopy and C/S
• Blood urea and serum creatinine
• USG abdomen- look for presence of residual urine
• Urodynamics
• Cystoscopy
• Acid phosphatase
• Prostate specific antigen (PSA)
• IVU
• Serum electrolytes

Management

• Patient with acute retention of urine requires urethral catheterization.
• If urethral catheterization fails, then suprapubic cystostomy is done.
• If patient presents with uraemia, then urethral catheterization is a must. That allows the kidney to function adequately and further obstructive damage is prevented.
• Serum electrolyte should be corrected properly in these patients.

Indications for surgery

• Prostatism (frequency, dysuria, urgency)
• Acute retention of urine.
• Chronic retention of urine with residual urine more than 200 ml.
• Complications like hydroureter, hydronephrosis, stone formation, recurrent infection, bladder changes.
• Haematuria

Surgeries

• Transurethral resection of prostate (TURP)

Using cystoscope with fluid like glycine irrigating continuously, enlarged prostate is identified and resected using a loop with a hand control. Resection is done using high frequency diathermy current.
After surgery, continuous bladder irrigation using NS is done using three way Foley’s catheter. Antibiotics should be given. Catheter is removed within 72 hours.

• Freyer’s suprapubic transvesical prostatectomy.Before TURP this was procedure of choice.

• Millin’s retropubic prostatectomy
• It is done without opening the bladder ( not commonly practiced)
• Young’s perineal prostatectomy through perineal approach.
• Laser treatment using holmium laser.
• High energy electromagnetic treatment.
• Placement of intraurethral stents at prostatic urethra.
• Placement of extraurethral stents which are inert.
• Transurethral balloon dilatation of the prostate.

Drugs used for BPH

1)Alpha 1 adrenergic blocking agents- which inhibit smooth muscle contraction of prostate. They reduce the bladder neck resistance so as to improve the urine flow

• Short acting drugs are prazocin and indoramin.
• Long acting drugs are terazocin and doxazosin.
• Selective alpha1A- adrenoceptor blocking agent: tamsulosin

2)5-alpha reductase inhibitor inhibits conversion of testosterone to dihydrotestosterone.

• It is effective in palpably enlarged prostate.
• Drug used is finasteride 5mg daily for 6-8 months.
• It is contraindicated in obstructive uropathy or carcinoma prostate.