• Prostate gland is the largest accessory gland of the male reproductive system.
• The prostate gland grows at various stages of a man’s life. The aetiology of the condition is unknown. This growth does not usually cause problems until later in life, when individuals develop BPH.
• BPH is very common, affecting about 50% of men over age 50 and 90% of men over age 80. However, only 10% of the affected men will present with symptoms.
• Untreated BPH may lead to various complications like bladder stone, urinary tract infection, diverticulae of the bladder, bladder and kidney enlargement. It also will affect the kidney function and will cause renal failure.
Symptoms of BPH:
The severity of the symptoms depends on the degree of the obstruction.
• Difficulty in starting urination
• Poor stream
• Voiding symptoms (hesitancy, weak stream, prolonged voiding, post voiding dribbling, feeling of incomplete emptying)
• Decreased flow rate
• Post void residual urine
• Storage symptoms (urge, frequency, nocturia, urge incontinence)
• Decreased bladder capacity
• Urinary retention
• Haematuria (blood stained urine)
Signs:
• Occasionally, patient will present with palpable bladder.
• Smell of stale urine on patients.
• Enlargement of kidney
• Per rectal digital examination will reveal smooth and enlarged prostate gland
• Signs of uremia –nausea, vomiting, itchiness
Investigations:
• Full blood count
• ESR
• Urine investigations – UFEME
• Serum creatinine – to look for kidney function
• Tumor marker like PSA (prostate specific antigen) and PAP (prostatic acid phosphatase) – to exclude malignancy
• MSU (midstream specimen of urine)
• USS (ultrasound scan) – to assess upper urinary tract (to look for hydronephrosis or enlargement of the kidney), bladder, residual urine
• If operation was done, the resected prostate should be sent for histology to rule out carcinoma.
• Cystoscopy – to check for diverticulae, tumor or stone
Treatment:
• Patients with mild to moderate symptoms – managed by ‘watchful waiting’. This is because symptoms following therapy sometimes even worse than symptoms without therapy.
• Patients with moderate symptoms can be treated medically with beta-blocker such as daxazosin and competitive inhibitor of 5 alpha-reductase such as finasteride. Finasteride will decrease prostatic volume with an increase in urine outflow. Some studies have been done showing that BPH medications may increase risk for erectile dysfuntion.
• TURP (transurethral resection o the prostate) – a device will be inserted through the urethra to resects some prostate tissue to release the obstruction. This will be decided by your urologist when there is deterioration in renal function or there is upper tract dilatation.
• Open prostatectomy is another surgical option and reserve for very large glands. (TURP carries a lower morbidity and mortality with shorter stay in hospital)
• Microwave hyperthermia, balloon dilatation and prostatic stents are all being tried, but evidence from long term randomized prospective controlled trials is not yet available.
• Acute urinary retention needs an urgent attention because the patient will be presented with severe suprapubic pain. Bladder catheter will be inserted immediately. If it fails, SPC (suprapubic percutaneous catheter) will be inserted through your suprapubic region to release the urine.
Reference:
1. Churchill’s Pocketbook of Surgery. Andrew T Raftery. 2nd edition. 2001.
2. Fact sheet by Sanofi Aventis.
3. Clinical Medicine by Kumar and Clark. 4th edition. 1999.
4. Grant’s Atlas of Anatomy.
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