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Urology Resources
Benign Prostatic Hyperplasta (BPH)
Benign prostatic hyperplasia (BPH) is the benign enlargement of the prostate. The prostate gland is a small organ located just below the bladder and surrounds the urethra. It produces fluid for nourishment of sperms. However, after the age of 50 years, it tends to enlarge due to hormone imbalance; resulting in compression of the urethra . This causes obstruction and irritation of the bladder, causing symptoms like slow stream, urinary frequency and dribbling of urine. Left untreated, it can damage to the bladder and cause urine infections, bladder stones and even kidney failure. Many patients mistake their symptoms to be due to ageing, but BPH needs to be excluded and treated before assuming that the bladder symptoms are age-related.
Assessment of BPH:
BPH is assessed from the history, physical examination, ultrasound and uroflow investigations.
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International Prostate Symptom Score (IPSS)
IPSS is a questionnaire that covers the symptoms caused by the enlarging prostate. The total score gives an indication of the severity of the prostatic symptoms. -
Physical examination
This consists of a pelvic examination to detect any bladder distension from chronic obstruction, and a rectal exam (DRE) to determine the consistency of the gland, estimate its size and detect possible prostate cancer. -
Prostate Specific Antigen (PSA)
This is a blood test to detect prostate cancer. It should not exceed 4 ug/L. If so, a transrectal ultrasound guided biopsy is recommended. -
Ultrasound
A prostate ultrasound is useful from the point of assessing the prostate shape, measuring the prostate size, and determining the post-void residual urine volume. A prostate size of > 20 ml and residual urine of > 100 ml is considered abnormal. Ultrasound also assesses the state of the kidneys and if they are blocked.
Uroflow
The uroflow is a measure of the speed of urination. A transducer in the machine records and translates the urine flow into a graph which indicates the degree of bladder blockage.
Complications of BPH
BPH can be a progressive disease. Left untreated, there is a risk of bladder blockage leading to high residual urine which in turn, can lead to repeated urinary infection and bladder stone formation. When the blockage gets worse, swelling of the kidneys can occur and ultimately, sudden inability to pass urine. In such an event, surgery is needed to remove the enlarged prostate using a resectoscope. This surgery is called TURP (transurethral resection of the prostate).
Treatment of BPH
Medical therapy is the first-line treatment. There are 2 main groups of drugs available. The first are the alpha1-blockers, (eg. Hytrin, Xatral) which help relax the tone of the prostate and bladder neck. They are taken at bedtime but carry a 10% chance of causing giddiness in the morning due to drop in the blood pressure. However, they do not change the prostate size. The second group are the 5-alpha reductase inhibitors, (eg. Proscar, Avodart) which block the action of the male hormone on the prostate, thereby reducing prostate size. They are indicated for large glands (> 30 ml size) but because the drug can take up to 3 months to effectively reduce the prostate size, combination with alpha1-blocker drugs is still needed for the initial months.
Surgery is indicated when complications arise or when medical treatment fails. The most effective surgery is TURP, which recreates an open channel. It is done under spinal or general anaesthesia and takes about an hour to do.. Hospital stay is approximately 4 days with the main complications of bleeding and retrograde (backward) ejaculation. There are many variants to TURP but they are essentially different techniques using different machines. Of latest interest is the Greenlight laser which has the advantage of less bleeding and shorter hospital stay. However, it is slower to perform and costs more than the standard TURP. Thermotherapy (heat treatment) is also an alternative lesser-invasive option, but they do not create an immediate channel and do not have durable results. Open prostatectomy requires an incision over the pubis and is reserved for very huge BPH. It is rarely done nowadays.
