Benign Prostatic Hyperplasia ✅

Related Subjects: |Urothelial tumour s |Haematuria |Acute Urinary Retention |Anuria and Oliguria |Bladder cancer |Renal cell carcinoma |Benign Prostatic Hyperplasia |IgA nephropathy |Prostate Cancer |Henoch-Schonlein purpura |Glomerulonephritis

🔵 Benign Prostatic Hyperplasia (BPH) / Male LUTS usually affects the peri-urethral (transition) zone of the prostate. 📏 Importantly, prostate size does not always correlate with urinary obstruction.

📌 About

• Male LUTS may arise from BPH, detrusor overactivity, impaired contractility, or mixed mechanisms 🚻.
• Prostate size alone is not a reliable predictor of obstruction 🚫.
• Assessment guided by IPSS score, DRE, PSA, and symptom diary aligns with NICE CG97 guidance.

🧬 Pathology

• Represents hyperplasia (increase in cell number) rather than hypertrophy.
• Confined mainly to the peri-urethral (transition) zone.
• Chronic obstruction → detrusor hypertrophy → trabeculation → impaired emptying.

👨 Clinical Features

• Common in men >50 yrs; prevalence: Black > White > Asian.
• Voiding symptoms: weak stream, hesitancy, terminal dribbling 🚽.
• Storage symptoms: frequency, urgency, nocturia ⏰.
• Incomplete emptying → chronic retention with large bladder.
• Exam: smooth enlarged prostate, palpable bladder.

⚠️ Complications

• Acute urinary retention (may be worsened by drugs ❗ e.g., anticholinergics, antihistamines, antidepressants).
• Recurrent UTIs 🦠.
• Hydroureter, hydronephrosis, renal impairment 🩸.
• Bladder calculi & infection.

🔍 Investigations

• Symptom assessment: IPSS or AUASS score.
• Urinalysis (MSU if positive); haematuria → rule out malignancy 🔎.
• Bloods: U&E, FBC, PSA (interpret carefully: ↑ in BPH, infection, recent catheterisation).
• Post-void residual (PVR) via bladder scan or ultrasound; >150 mL may indicate impaired emptying.
• Frequency-volume chart (2–3 days) to assess LUTS patterns.
• Abdominal ultrasound: kidney size, hydronephrosis, bladder wall changes.
• Flexible cystoscopy if haematuria, obstruction, or uncertain diagnosis.
• Urodynamics: only in complex cases (neurogenic bladder or failed prior surgery).

💡 General Lifestyle Advice

• Limit alcohol 🍺, caffeine ☕, and evening fluids.
• Avoid decongestants/antihistamines as they worsen retention.
• Bladder training: urinate regularly (every 4–6 hrs), double voiding helps empty residual urine.
• Maintain healthy weight & stay active 🏃 – reduces retention risk.
• Keep warm 🧥 – cold exposure may trigger urinary retention.

💊 Medical Management (NICE CG97)

• Alpha-blockers (Tamsulosin, Alfuzosin): relax smooth muscle → rapid symptom relief (days–weeks). ⚠️ SE: postural hypotension, dizziness.
• 5-alpha reductase inhibitors (Finasteride, Dutasteride): shrink prostate gradually (3–6 months), reduce long-term risk of retention/surgery. ⚠️ SE: retrograde ejaculation, reduced libido.
• Combination therapy: alpha-blocker + 5-ARI for large prostates or severe symptoms.
• Anticholinergics (Oxybutynin): for storage symptoms; caution in elderly/frail (delirium risk).
• Mirabegron: β3 agonist alternative for overactive bladder; SE: hypertension.

🧴 Catheterisation & TWOC

• Acute retention: catheterise + start alpha-blocker → trial without catheter (TWOC) in 2–7 days.
• If TWOC fails: intermittent self-catheterisation or long-term catheter (urethral/suprapubic).
• Severe chronic retention (>800–1000 mL) may require long-term catheterisation.

📤 Indications for Urology Referral

• Suspicion of malignancy (hard nodular prostate, elevated PSA).
• Obstructive uropathy: AKI, raised urea/creatinine.
• Large bladder, recurrent retention, or hydronephrosis.
• Rapidly worsening LUTS or failure of medical therapy.

🔪 Surgical Options

• TURP: gold standard for moderate prostate size; removes obstructive tissue via resectoscope. SE: bleeding, TURP syndrome, clot retention, stricture, retrograde ejaculation, incontinence.
• HoLEP (Holmium Laser Enucleation): preferred for large prostates; less bleeding, durable results, shorter catheter time.
• Minimally invasive: UroLift, Rezūm (for select patients prioritising ejaculation preservation).
• Open prostatectomy: for very large prostates or complex anatomy.

Case 1 – Mild Symptoms

58-year-old with daytime frequency and nocturia ×2. DRE normal, PSA normal, PVR 40 mL. Implement lifestyle modifications. If symptoms persist, start an alpha-blocker and review in 4–6 weeks.

Case 2 – Moderate Symptoms, Enlarged Prostate

66-year-old, IPSS 18, smooth prostate, PSA 2.4 micrograms/L, volume ~45 mL, PVR 120 mL. Start tamsulosin and 5-alpha-reductase inhibitor. Consider mirabegron if storage symptoms persist and PVR is low.

Case 3 – Acute Urinary Retention

74-year-old unable to void. Catheterise, start alpha-blocker, check for UTI or culprit meds. Plan TWOC in 2–7 days. If failure or complications, refer for surgery (TURP/HoLEP) depending on prostate size and patient fitness.