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TeuvoTammela
JukkapekkaJousimaa

Benign Prostatic Hyperplasia

Essentials

  • The diagnosis of benign prostatic hyperplasia is based on symptoms and basic investigations. Other causes of voiding disturbances (prostate cancer in particular) are excluded.
  • Conditions requiring surgical management are recognized.
  • Follow-up alone or drug therapy are good options in patients with mild to moderate symptoms and no complications of urinary tract stricture.

Symptoms

  • Storage symptoms
    • Extraordinary voiding frequency
    • Nocturia
    • Urinary urgency
    • Urge incontinence
  • Voiding symptoms
    • Difficulty in the initiation of voiding
    • Poor urine flow Poor Urine Flow
    • Need to strain while voiding
    • Discontinued voiding
    • Feeling of inadequate bladder emptying
    • Urinary retention Urinary Retention

Primary investigations

  • Symptom questionnaire
    • A commonly used questionnaire is IPSS . DAN-PSS-1 is an alternative.
    • The questionnaire is useful in the assessment of severity symptoms when decisions are made between follow-up, drug treatment and surgery.
  • Writing down details associated with voiding
  • DRE (digital rectal examination)
  • Urinalysis
  • Plasma creatinine
  • Plasma prostate-specific antigen (PSA)
  • Residual urine volume is determined by ultrasonography Determining the Volume of Residual Urine by Ultrasonography (video Residual Urine Volume (Ultrasonography)) or if ultrasonography is not available by catheterization. Ultrasonography is useful in the determination of prostatic size (calculated with the same equation as residual urine volume Determining the Volume of Residual Urine by Ultrasonography), shape, and eventual hydronephrosis.
  • Differential diagnosis, see table T1.

Differential diagnosis on benign prostatic hyperplasia

Condition or diseaseHistory or finding
Prostate cancerFinding in DRE, elevated plasma PSA concentration
Urinary bladder cancerHaematuria, abnormal cytological finding
Bladder calculiHaematuria, ultrasonography finding
Urethral strictureBox-shaped flow curve
Stricture of the bladder neckEarlier invasive treatment
Bladder neck dyssynergiaSmall prostate gland, disturbing symptoms associated with voiding
ProstatitisTender prostate gland
Overactive bladderUrgency with possible urge incontinence

Indications for specialist consultation

Indications for diagnostic investigations by the urologist

  • The patient is below 50 years of age.
  • DRE is suspicious (nodules or induration)
  • Plasma PSA is above 10 µg/l (above 3 µg/l in patients below 65 years of age). Determination of free PSA is recommended if total PSA is in the range 2.5-10 µg/l.
    • If the plasma total PSA concentration is in the range of 3-10 µg/l, measuring free/total PSA ratio is recommended. If this value is under 0.15, the probability of prostatic cancer is increased and a urologist should be consulted Prostate Cancer.
    • DRE before determination of plasma PSA level does not influence the result.
  • Rapidly developing symptoms
  • Haematuria (cystoscopy)
  • Diabetics who may have neuropathy
  • History of pelvic surgery or irradiation
  • Neurological disease or injury affecting the function of the urinary bladder
  • Necessary medication affecting the function of the urinary bladder
  • Lower abdominal pain as the main symptom
  • Discrepancy between symptoms and findings
  • The investigations performed by the urologist include
    • always
      • urine flow measurement
      • transrectal ultrasonography,
    • and if necessary also
      • cystometry and pressure-flow examination (recommended before deciding on surgery if the peak flow is >10 ml/s and also when there is a discrepancy between symptoms and findings or the patient has undergone surgery of the lower urinary tract)
      • urethrocystography
      • ultrasonography of the urinary tract
      • prostatic biopsies
      • cystoscopy.

Surgical treatment is indicated in the following cases:

  • Urinary retention, overflow incontinence or repeatedly more than 300 ml of residual urine
  • Severe symptoms not relieved by drug therapy
  • Severe narrowing based on measurement of flow rate
  • Dilatation of the upper urinary tract
  • Impairment of renal function
  • Recurrent macroscopic haematuria
  • Urinary tract infections
  • Bladder calculi
  • Severe or moderate symptoms in a patient who wants rapid relief or if satisfactory results have not been obtained with other treatments.

Conservative treatment

Follow-up

  • As the symptoms of BPH vary greatly and the course of the disease in an individual cannot be fully predicted, follow-up is a suitable approach in patients with mild symptoms. Also in moderate symptoms, follow-up can be the initial approach if the symptoms do not essentially affect the quality of life and complications have not developed.
  • Follow-up includes explaining to the patient the nature of the disease and carrying out basic investigations annually or when symptoms have changed. Opportunistic follow-up during other encounters in primary care is one method of screening.

Drug treatment Naftopidil for the Treatment of Lower Urinary Tract Symptoms Compatible with Benign Prostatic Hyperplasia

  • Although the effectiveness of drug treatment is not as good as that of surgery it is often sufficient for reducing or alleviating the symptoms.
  • When deciding on the treatment, cost-effectiveness should also be evaluated, i.e. when would invasive therapy, which usually gives complete cure, cost less and be more convenient for the patient than drug therapy continuing for years.
  • Patients on drug treatment should be followed up regularly at 6-12-month intervals to detect complications resulting from urethral obstruction.
  • The size of the prostate and total plasma PSA determine the selection of the therapy. If the prostate is not markedly enlarged on palpation or in ultrasonography (< 30 ml) and PSA is < 1.5 µg/l the first choice is an alpha1-blocker (e.g. tamsulosin or alfuzosin). If the prostate is markedly enlarged or PSA is > 1.5 µg/l either 5-alpha-reductase inhibitor (finasteride, dutasteride)5-Alpha-Reductase Inhibitors (5ARI) for Benign Prostatic Hyperplasia or an alpha1-blocker can be used.
  • A combination of 5-alpha-reductase inhibitor and alpha1-blocker alleviates symptoms more effectively than either drug alone Combination of Doxazosin and Finasteride Compared with Either Drug Alone or Placebo for Benign Prostatic Hyperplasia.

Alpha-blockers Terazosin for Benign Prostatic Hyperplasia

  • Tamsulosin Tamsulosin for Benign Prostatic Hyperplasia, alfuzosin
  • Alpha1-blockers decrease symptoms, increase peak urinary flow and reduce the volume of residual urine.
  • The effect of alpha1-blockers is seen rapidly and continues for several years.
  • The patients should be followed up initially at 1-3-month intervals.
  • The side effects include dizziness, postural hypotension, and missing of ejaculation, which is more rare with alfuzosin than with tamsulosin.

5-alpha-reductase inhibitors (5ARI)

  • The dose of finasteride is 5 mg × 1 and that of dutasteride is 0.5 mg × 1.
  • The symptoms are alleviated, the urine flow is increased, and the obstruction is decreased 5-Alpha-Reductase Inhibitors (5ARI) for Benign Prostatic Hyperplasia.
  • The effect is at its best in patients with large prostates.
  • The effect starts slowly, sometimes as late as 6 months after the onset of treatment. If no effect is observed in 6 months the indications for surgery should be reconsidered.
  • The drug decreases prostatic size but the prostate returns to its original size a few months after discontinuation of treatment.
  • Impotence may occur as an adverse effect.
  • Although treatment with 5ARIs decreases plasma PSA level by about 50% this makes follow-up no more difficult than with alpha-blockers: an increasing PSA concentration is an indication for investigation by a urologist.

Phosphodiesterase-5 inhibitors

  • Particularly the long-acting tadalafil at a dose of 5 mg daily has been shown to alleviate symptoms associated with urination significantly better than placebo. The more short-acting sildenafil and vardenafil can also be used.
  • These drugs are particularly suitable for patients with mild to moderate urination symptoms and concomitant need of treatment for erectile dysfunction.

Plant extracts (phytotherapy) Pygeum Africanum for Benign Prostatic Hyperplasia, Serenoa Repens for Benign Prostatic Hyperplasia, Phytotherapy for Benign Prostatic Hyperplasia

  • Plant extracts are prepared from e.g. pumpkin seeds and berries of American saw palmetto (Serenoa repens).
  • Their efficacy has not been verified in randomized controlled trials.

Surgical and other invasive treatments

Catheter

  • Percutaneous cystostomy is indicated in patients with urinary retention waiting for surgery; see Catheterization of the Urinary Bladder and Suprapubic Cystostomy.
  • Repeated catheterization is to be preferred particularly if the patient can perform it himself.
  • A silicon catheter with the balloon filled with hypertonic (5%) saline or glyserol can be used, but percutaneous cystostomy is preferred.

Treatment after TURP

  • Urine bacterial culture should be taken routinely 4-6 weeks after the operation to detect bacteriuria, and always if a urinary tract infection is suspected (pyuria and haematuria may occur as long as 3 months after the operation).
  • If bacterial growth is detected, antimicrobials are indicated.
  • Stress incontinence may be alleviated within 1 year: exercises of pelvic floor muscles may help Conservative Management for Postprostatectomy Urinary Incontinence.
  • Anticholinergic drugs (oxybutynin, tolterodine, fesoterodine, trospium chloride, solifenacin or darifenacin) or a beta-3-selective sympathomimetic drug (mirabegron) can be used for the treatment of urge incontinence and nocturia.

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