Benign Prostatic Hyperplasia (BPH) - Reproductive

Overview



Snapshot
A 52-year-old man presents to his primary care physician with nocturia and increased day-time urinary frequency. He notices that he needs to strain when beginning to void and tends to dribble after he finishes urinating. Medical history is significant for hypertension treated with hydrochlorothiazide and type 2 diabetes mellitus treated with metformin. On digital rectal exam, there is a non-tender, smooth, elastic, and firm enlarged prostate. A urinalysis and prostate-specific antigen level is ordered.
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 side effects hypotension (e.g., orthostatic hypotension) and reflex tachycardia the newer medication tamsulosin does not cause hypotension at the doses used to relax prostatic smooth muscle 5α-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
Complications
UTI Nephrolithiasis Bladder stones Chronic kidney disease