Benign Prostatic Hypertrophy

1. 2008 Benign Prostatic Hypertrophy

2. Causes of symptoms • Hyperplasia of epithelial and stromal components of prostate • Progressive obstruction of urinary outflow • Increased activity of detrusor muscle • Causes • Frequency, nocturia • Poor flow , intermittent stream • Hesitation, terminal dribbling

3. Prevalence • Men > 50 = 41% have symptoms of LUTS • Only 18% have a diagnosis • Only 10% aware of drugs or surgery that will help it

4. Risk factors • Age • ? obesity

5. Differential diagnosis • Poorly controlled diabetes • Neurological disorders • Urinary tract infections • Abacterial prostatitis • Overactive bladder • Drugs – diuretics, anticholinergics, antidepressants • Lifestyle factors – caffeine, alcohol, xs fluids

6. Abnormal symptoms • The presence of the following symptoms indicates referral to urologist for futher assessment • Urinary incontinence • Retention • Dysuria • Haematuria • Acute change in symptoms

7. Examination • Palpation of abdomen for • enlarged bladder • enlarged kidneys • constipation • Rectal examination for • Size and consistency of prostate gland

8. Investigations • Blood tests • Fbc esr • U&e’s • Fasting blood sugar • ? PSA – level rises with increasing volume of prostate gland • Urinalysis • Infection • haematuria

9. Investigations • Additional tests as appropriate by GP • Ultrasound for residual urine volume • Urinary diaries

10. Specialist investigations • Reasons for doing them • Patient reassurance • Patient explanation • Objective assessment of symptoms • Diagnostic precision • Ranking of treatment options • Prediction of treatment outcome

11. Specialist investigations • Uroflowmetry • max flow rate and volume of residual urine after voiding – low flow rate indicates need for TURP • Bladder pressure studies • pressure measurement during filling and emptying (cystometry) gives information on over/under activity of detrusor muscle and obstruction of bladder outlet. Predicts response to treatment. Use antimuscarinics for over activity and turp for bladder outlet obstruction

12. Specialist investigations • Urinary tract imaging • Ultrasound to estimate residual urine • Urethroscopy • Visual inspection of bladder and uerethra is used in dysuria or haematuria

13. Assesment • A validated questionnaire using international prostate symptom scale. • Completion gives total score of 35 • 1 – 7 mild • 8 – 19 moderate • 20 – 35 severe • Response to the quality of life questionnaire strong predictor or whether intervention is necessary

14. Scoring system • Ask 7 questions. Answers on scale 0 – 5 depending on severity of symptoms • For first 6 questions scores are • Not at all = 0 • < 1 in 5 = 1 • < half the time = 2 • About half the time = 3 • > half the time = 4 • Almost always = 5 • Q7 • Never = 0, once = 1, 2x = 2, 3x = 3, 4x = 4, 5x = 5

15. Questions In last month how often have you • Had sensation of not emptying bladder completely • Had urge to urinated < 2 hours after previously finished • Found you stopped and started again several times • Found it difficult to postpone urination • Had a weak stream (compared to when aged 30) • Had to push or strain to begin urination • How many times did you get out of bed per night to urinate

16. Quality of life • If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? • Delighted 0 • Pleased 1 • Mostly satisfied 2 • Mixed feelings 3 • Mostly dissatisfied 4 • Terrible 5

17. Management • Lifestyle modification • Reduce fluid intake • Stop diuretics if poss • Avoid xs night time fluid intake/caffeine /alcohol • Empty bladder before long trips/meetings

18. Management • Treat co morbid contributing conditions • Diabetes • uti

19. Management • Drug therapy • Alpha blockers • Improve bladder and prostate smooth muscle tone • More effective than 5 alpha reductase inhibitors • All work equally well • Tamsulosin and alfuzosin require no dose titration

20. Management • Drug therapy • 5 alpha reductase inhibitors • Reduce prostate volume • Reduces risk of prostate cancer, increases risk of high grade disease • Combined therapy • Men with large prostate > 40g or PSA >4 or moderate to severe symptoms combined therapy will prevent 2 episodes of clinical progression per 100men over 4yrs. Much less effective for men with smaller prostates

21. Management • Drug therapy • Storage problems • Men with symptoms of urinary urgency, frequency, small, urine volumes and nocturia in the absence of serious obstructive symptoms are categorised as over active bladder • Bladder training • Biofeedback • Antimuscarinic drugs ( oxybutinin, tolteridine) alone or in combination with treatment for obstructive symptoms

22. Management • Surgery • TURP • Greatest improvement in symptoms • 5% severe haemorrhage risk • Requires GA • Alternative energy sources for TURP • Ultrasound • Laser • microwave

23. Management • Surgery • Adverse effects of surgery • Loss of ejaculation • Erectile dysfunction • Retrograde ejaculation • Incontinence • Stricture formation • Urinary retention