Prostatic Hyperplasia Benign Disease

DESCRIPTION

Benign adenomatous growth of prostate which may result in bladder outlet obstruction

System(s) affected: Reproductive, Renal/Urologic
Genetics: Genetic factors may be involved. Risk higher if father had clinical BPH in his 50's.
Incidence/Prevalence in USA:
- Universal pathologic phenomenon seen in older men
- No hard evidence suggesting racial predisposition
Predominant age:
- Rarely seen in men < 40
- Seen in 50% of men > 50; 80% of men > 70
Predominant sex: Male only

SIGNS AND SYMPTOMS

Prostate size correlates poorly with symptoms

Obstructive symptoms: Due to mechanical obstruction and/or detrusor muscle decompensation
- Decrease force or caliber of stream
- Hesitancy
- Post-void dribbling
- Sensation of incomplete bladder emptying
- Overflow incontinence
- Inability to voluntarily stop stream
- Urinary retention
Irritative symptoms: Due to incomplete bladder emptying and/or detrusor muscle instability
- Frequency
- Nocturia
- Urgency
- Urge incontinence
Other symptoms and signs:
- Gross hematuria
- Observation of weak stream
- Distended bladder (> 150 cc in order to detect by percussion)
- Increased post-void residual (> 100 cc)
- Prostate enlarged (normal 20 gram prostate - size of horse chestnut)
- Clinical clues suggesting renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies, etc.)
- American Urological Association (AUA) symptom index score > 7

CAUSES

Exact etiology unknown, but evidence suggests BPH arises from a systemic hormonal alteration which may or may not act in combination with growth factors stimulating stromal or glandular hyperplasia

RISK FACTORS

Intact testes (BPH rare in eunuchs)
Aging (thus, rare in men < 40 years old)
Dietary and environmental may be implicated

LABORATORY

BPH is a pathologic diagnosis - lab data is only suggestive
Urinalysis: pyuria, pH changes due to chronic residual urine
Elevated serum creatinine (if obstructive uropathy present)
Urine culture positive (sometimes due to chronic residual urine)
Prostate specific antigen (PSA) may be elevated but usually < 10 ng/mL (10 µg/L)
Increased post-void residual (> 100 mL)
Acute urinary retention, transurethral instrumentation may elevate the PSA

Drugs that may alter lab results: Finasteride (Proscar) may lower the PSA
Disorders that may alter lab results: Acute urinary retention, prostatitis, urinary tract instrumentation or prostatic infarction may elevate the PSA

PATHOLOGICAL FINDINGS

Confirmation obtained by biopsy, resection or extirpation surgery. 5 types: Stromal (fibrous), fibromuscular, muscular ("leiomyoma"), fibroadenoma, fibromyoadenoma.

SPECIAL TESTS

Transrectal prostate ultrasound gives volumetric estimate of gland
Needle biopsy (to rule out cancer)
Have patient complete IPSS (see below)
- Mild symptoms (score 0-7): Offer watchful waiting only
- Moderate symptoms (score 8-19) to severe symptoms (score 20-35): Offer treatment options

IMAGING

IVP - increased post-void residual, large prostatic impression on bladder, trabeculated bladder, bladder diverticula, upper tract dilation, bladder stones
CT scan or MRI of pelvis - enlarged prostate
Ultrasound - increase postvoid residual, prostate or hydronephrosis

DIAGNOSTIC PROCEDURES

Uroflow - volume voided per unit time. Peak flow < 10 mL/sec suggests obstruction (accurate when voided volume is > 200 mL).
Pressure-flow curve (urine flow versus voiding pressures) - decreased urine flow and increased pressure indicates obstruction
Cystoscopy shows occlusive prostatic lobes, bladder trabeculation. Indicated if diagnosis is in doubt or helps guide the surgical approach (if surgery is an option)
Post-void residual by catheterization or bladder ultrasound

APPROPRIATE HEALTH CARE

Inpatient or outpatient treatment required, either for surgery or medical treatment. Inpatient emergent treatment required to manage fluid and electrolyte abnormalities of obstructive uropathy.

GENERAL MEASURES

Avoid large boluses of oral or IV fluids
Avoid prolonged periods of not voiding
Avoid sympathomimetic or anticholinergic medications (e.g., cold/flu preparations)
Urethral catheterization if in retention

SURGICAL MEASURES

Surgery (indicators to determine necessity)
- Urinary retention due to prostatic obstruction
- Intractable symptoms due to prostatic obstruction (gauged by AUA symptom index; score at least > 8)
- Obstructive uropathy
- Recurrent or persistent urinary tract infections due to prostatic obstruction
- Recurrent gross hematuria due to enlarged prostate
- Medical therapy indicated when surgery indicators not met.
Surgical procedures - minimally invasive
- Interstitial laser coagulation (ILC)
- High frequency focused ultrasound (HIFU)
- Transurethral needle ablation (TUNA)
- Transurethral microwave thermotherapy (TUMT)
- Water-induced thermotherapy (WIT)
- Prostate stenting
- Transurethral balloon dilation (TUDP)
- Transurethral ethanol ablation of prostate
Surgical procedures - more invasive
- TURP
- Open prostatectomy
- Transurethral laser ablation, laser-induced prostatectomy or laser enucleation of prostate
- Transurethral vaporization of prostate

ACTIVITY

No restriction

DIET

Avoid caffeinated or alcoholic beverages, excessively spiced foods

PATIENT EDUCATION

The Prostate Book, published by Krames Communications, 312 90th St, Daly City, CA 94015-1898
National Kidney & Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893, (301)468-6345

PREVENTION/AVOIDANCE

Appears to be part of the aging process

POSSIBLE COMPLICATIONS

Bladder stones
Prostatitis
Renal failure
Hematuria

EXPECTED COURSE AND PROGNOSIS

Symptoms improve or stabilize in 70-80% of patients; 20-30% require treatment because of worsening symptoms
11-33% men with BPH have occult prostate cancer

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric:N/A
Geriatric: Much more prevalent in elderly men
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

IPSS = International Prostate Symptom Score
IVP = intravenous pyelogram
AUA = American Urological Association

Clinical Investigations

ROLE OF HOMOEOPATHY

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