Bengin Prostatic Hyperplasia (BPH)
Other names: adenoma, bengin prostatic hyperplasia, nodular hyperplasia, Benign Prostatic Hypertrophy
The prostate gland is of walnut size surrounding the urethra, just below the bladder (for anatomy refer article on prostate).
Benign Prostatic Hyperplasia (BPH) is a very common disorder of men over the age of 50 years. BPH is not a cancer. The main symptoms are difficulty in passing urine and frequent lower urinary tract infections secondary to BPH. It is characterized by increase in number of stromal cells and epithelial cells (hyperplasia) of the prostate. This results in formation of large nodules which can obstruct the urine out flow from the urethra.
Follow up:
Incidence
BPH can be seen in 20% of men over 40 years, 50% of men over 60 years and 90% of men over 85 years. 14 million men in United States and 30 million men worldwide suffers from symptoms of BPH.
Cause
The cause is not known definitely.
Dihydrotestosterone (DHT) is produced from testosterone (male Hormone) by the enzymatic action of 5 alfa reductase in the stromal cell of prostate. DHT which is 10 times more potent than testosterone mediates growth of prostate. Any drug which inhibits 5 alfa reductase may reduce the growth of benign hypertrophy of prostate. Example- Finasteride.
Testosterone can not be blamed for the hyperplasia of the gland, as the disease occurs at a time when the androgenic activity of the individual is decreasing. Many scientists believe that the imbalance between androgen and oestrogen, which is decreased in advance age in men is the causative agent.
Pathology
Changes are of two types; overgrowth of glandular tissue, which is softer in consistency and overgrowth of connective tissue elements, which is firm in consistency.
The enlarged nodules may join together to form one big mass. The hyperplasia is more common in median lobe and two lateral lobes.
The prostate is covered by a capsule which restricts enlargement outwards. Urethra which is present inside the prostatic tissue will get compressed by the enlargement and causes urinary out flow obstruction
Symptoms
- Hesitancy: difficulty in starting urination. Patient notices that he must wait for urination to start. If he strains, he has to wait more as median lobe bends down on straining to obstruct the internal urethral orifice
- Frequency: frequency of urination increase, especially during night
- Urgency: sudden and urgent desire to pass urine
- Haematuria: blood in the urine is quite common in this condition. It is due to rupture of the dilated veins at the base of the bladder.
- Incomplete emptying of the bladder and retention of urine as a result of median lobe of the prostate compressing the urethra.
- Patient may experience dribbling of urine after urinating.
- Pain is mainly due to secondary cause like infection of the bladder or acute retention of the urine.
Signs
- Lateral lobe and posterior lobe enlargement can be palpated on rectal examination.
- In complete obstruction of the urethra, enlarged bladder can be palpated.
- Edema and other signs of renal insufficiency should be ruled out.
Complications
Urinary tract infections
Renal failure
Prostatism
Lab Works
- Urine examination should be done for the evidence of infection and blood
- Prostate specific antigen (PAS): it is a glycoprotein, helps in liquefaction of semen and used as a tumor marker. Normal value is less than 4nmol/ml. in cancer of prostate it increases 15nmol/ml or more. In BPH there will be slight rise up to 10nmol/ml.
- transrectal ultrasonography (TRUS) gives the exact size of the gland. TRUS guided biopsy is recommended in case of raised PAS.
Treatment
In early stages of BPH watchful waiting is wise before starting any treatment. In some cases BPH regress without intervention.
Pharmacological management
5 alfa reductase inhibitors like finateride reduces the need for surgery and reduces the risk of acute retention of urine.
Invasive management
- Transurethral prostatectomy
- Open prostatectomy
- Suprapubic prostatectomy
- Retropubic prostatectomy