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Benign Prostatic Hyperplasia (BPH)

Topic updated on 08/15/17 9:50pm

Overview
 

 
Snapshot
  • A 70-year-old man presents to his physician with difficulty initiating a stream and post-void dribbling. He also reports having increased urinary urgency and a weak urinary stream. Medical history is significant for hypertension and is not on medication. On digital rectal exam, his prostate is enlarged, non-tender, firm, and smooth. Urinalysis is unremarkable and prostate-specific antigen is elevated. He is started on tamsulosin to improve his lower urinary tract symptoms.
Introduction
  • Clinical definition
    • benign hyperplasia of the stromal and epithelial cells of the prostate that results in lower urinary tract symptoms (LUTS) such as
      • post-void dribbling
      • increased urinary frequency and urgency
      • nocturia
      • weak urinary stream
  • Epidemiology
    • demographics
      • men > 45 years of age
  • Pathogenesis
    • unclear; however, chronic inflammation and hormonal and vascular mechanisms may play a role
  • Associated conditions
    • obesity and metabolic syndromes
    • hypertension
    • type 2 diabetes mellitus
  • Prognosis
    • symptoms slowly and progressively worsen
Presentation
  • Symptoms
    • issues with urinary storage
      • e.g., nocturia, increased urinary frequency, urinary incontinence, and urgency
    • issues with voiding
      • e.g., weak urinary stream, hesistancy, straining to void, and post-void dribbling 
    • irritative issues
      • e.g., urgency and increased urinary frequency
  • Physical exam
    • digital rectal exam
      • a non-tender, smooth, elastic, and firm enlarged prostate
Studies
  • Labs
    • urinalysis
      • to detect the presence of a urinary tract infection or blood
    • prostate-specific antigen
      • non-specific
  • Diagnostic criteria
    • this is a clinical diagnosis based on history (e.g., storage, voiding, and/or irritating urinary symptoms) and physical exam (e.g., a non-tender, smooth, elastic, and firm enlarged prostate)
Differential
  • Prostate cancer
  • Prostatitis
  • Urinary tract infection
  • Bladder cancer
Treatment
  • Medical
    • α1-blockers (e.g., terazosin and tamsulosin)
      • indication
        • considered initial therapy in patients with LUTS secondary to BPH
          • results in immediate relief
          • caution in patients on a phosphodiesterase-5 inhibitor as this can cause severe hypotension
    • 5-α reductase inhibitors (e.g., finasteride)  
      • indication
        • can be used as alternative treatment in patients with LUTS secondary to BPH who cannot tolerate α1-blockers
          • takes time (6-12 months) for symptom improvement to be appreciated
    • phosphodiesterase-5 inhibitors (e.g., sildenafil)
      • indication
        • a reasonable treatment option in patients with LUTS secondary to BPH who have erectile dysfunction
  • Surgical
    • transurethral resection of the prostate
      • indication
        • a treatment option in patients who are unresponsive to medical treatment
        • in patients with recurrent UTIs, bladder stones, or gross hematuria secondary to their BPH
      • complication
        • retrograde ejaculation
        • erectile dysfunction
          • this is uncommon
Complications
  • UTI
  • Nephrolithiasis
  • Bladder stones
  • Chronic kidney disease
  • Hydronephrosis

 



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(M3.RL.11) A 70-year-old male presents to his primary care physician with complaints of urinary frequency, urgency and nocturia. Physical exam shows an enlarged, rubbery, non-tender and firm prostate without discrete nodules or masses. Which of the following treatments for this condition is matched with its most common side effect? Topic Review Topic

1. Prazosin - Hypertension
2. Finasteride - Hair loss
3. Transurethral electrovaporization (TUEVP) - Urinary incontinence
4. Holmium laser treatment (HLT) - Infection
5. Transurethral resection of the prostate (TURP) procedure - Retrograde ejaculation

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