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Benign Prostatic Hyperplasia

Essentials

  • The size of the prostate usually increases with age.
  • Prostate < 20 ml in volume is normal and prostate > 40 ml in volume is clearly enlarged.
  • 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 obstruction.

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

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 a urologist consultation

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 and effective 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 http://www.dynamed.com/condition/benign-prostatic-hyperplasia-bph#WATCHFUL_WAITING 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 change. Opportunistic follow-up during other encounters in primary care is one follow-up method.

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

Alpha-blockers Terazosin for Benign Prostatic Hyperplasia

5-alpha-reductase inhibitors (5ARI)

  • The dose of finasteride is 5 mg once daily and that of dutasteride is 0.5 mg once daily.
  • The drugs affect the natural course of benign prostatic hyperplasia 5-Alpha-Reductase Inhibitors (5ARI) for Benign Prostatic Hyperplasia and significantly reduce the risk of urinary retention and need for invasive treatment, and, moreover, the treatment response is long-lasting. The drugs decrease prostatic size but the prostate returns to its original size a few months after discontinuation of treatment.
  • The drugs are well tolerated, and the only significant adverse effects are associated with sexual functions (reduced libido, ejaculatory and erectile dysfunction). These occur in about 5-19%.
  • The effect starts slowly, sometimes as late as 6 months after the onset of treatment. If no effect is observed in 6 months, the patient's situation and indications for possible surgery should be reconsidered.
  • 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 further urological investigations.

Phosphodiesterase-5 inhibitors

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

  • Transurethral resection of the prostate (TURP) Holmium Laser Prostatectomy Vs. Turp, Laser Prostatectomy for Benign Prostatic Obstruction, Transurethral Resection of the Prostate for Prostatic Hyperplasia
    • The best treatment for complicated prostatic hyperplasia and the best documented treatment for uncomplicated hyperplasia
    • Results very seldom in erectile dysfunction (though in most cases already before operation), but almost always in retrograde ejaculation.
    • Can also be carried out as day surgery.
  • Transurethral incision of the prostate (TUIP)
    • Suitable for patients with prostates < 30 ml in volume and with no median lobe protruding towards the bladder
  • Open prostatectomy
    • Used only in the case of a large prostate (> 100 ml)
  • Laser enucleation (TELP)
    • Endoscopic procedure
    • Best in treating patients with a large prostate
  • Green laser treatment Holmium:yag Laser in Urology
    • An alternative to transurethral resection
  • Stent or spiral
    • Can be used in selected cases in patients with a poor general condition.

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

References

  • Franco JV, Jung JH, Imamura M ym. Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis. Cochrane Database Syst Rev 2021;(7):CD013656. [PubMed]
  • Franco JV, Garegnani L, Escobar Liquitay CM ym. Transurethral microwave thermotherapy for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2021;(6):CD004135. [PubMed]
  • Pang R, Zhou XY, Wang X ym. Anticholinergics combined with alpha-blockers for treating lower urinary tract symptoms related to benign prostatic obstruction. Cochrane Database Syst Rev 2021;(2):CD012336. [PubMed]
  • Huang SW, Tsai CY, Tseng CS ym. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ 2019;(367):l5919. [PubMed]

Evidence Summaries