Prostate Disorders: Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

• BPH occurs in men over 50 years old, with 50% of men showing histological evidence by the age of 60.
• Lower urinary tract symptoms (LUTS) associated with BPH include:
• Voiding symptoms: hesitancy, poor flow, intermittent stream, and dribbling
• Storage symptoms: frequency, nocturia, urgency, urge incontinence, and nocturnal incontinence
• BPH is the most common cause of bladder outflow obstruction in men over 70 years old.

Management of Men with BPH or Bladder Outflow Obstruction

• Acute retention in fit men without other causes (e.g., drugs, constipation, recent operation)
• Chronic retention and renal impairment: residual urine of 200 mL or more, raised blood urea, hydroureter, or hydronephrosis
• Complications of bladder outflow obstruction: stone, infection, and diverticulum formation
• Haemorrhage: venous bleeding from a ruptured vein overlying the prostate may require prostatectomy
• Elective prostatectomy for severe symptoms: increasing difficulty in micturition, frequency, and poor stream

Carcinoma of the Prostate

• Carcinoma of the prostate is the most common malignant tumor in men over 65 years old
• Screening for prostate cancer involves measurement of PSA (prostate-specific antigen)
• Local spread: locally advanced tumors tend to grow upwards to involve the seminal vesicles, bladder neck, and trigone
• Spread by the bloodstream: particularly to bone, with the pelvic bones and lower lumbar vertebrae being the most frequently involved sites

Presentation and Clinical Features of Prostate Cancer

• Men are often asymptomatic, with detection occurring through opportunistic PSA testing
• Cancer may be detected in men describing lower urinary tract symptoms or presenting with symptoms of metastatic disease
• Clinical features: BOO, pelvic pain, haematuria, bone pain, malaise, ‘arthritis’, anaemia, pancytopenia, and renal failure

Treatment and Stage of Prostate Cancer

• Treatment options depend on stage of disease, life expectancy, and patient preference
• Prostate-specific antigen, digital rectal examination, and biopsy Gleason grade are used to predict pathological stage
• Localized cancer can be treated by radical prostatectomy, radiation therapy, and active monitoring
• Treatment of advanced disease is palliative, with hormone ablation being the first-line therapy

Prostatitis

• Acute prostatitis is common but underdiagnosed
• Usual organisms responsible: Escherichia coli, Staphylococcus aureus, Staphylococcus albus, Streptococcus faecalis, Neisseria gonorrhoeae, or Chlamydia
• Infection may be haematogenous from a distant focus or secondary to acute urinary infection