Benign Prostatic Hyperplasia

Glandular nodular proliferation in Prostatic transition zone (surrounding urethra) & Stromal nodular proliferation in Periurethral zone due to Hormonal effect of DHT (Dihydrotestosterone) leading to compression of urethra and development of Bladder Outflow Obstruction (BOO) which can result in clinical manifestation of Lower Urinary Tract Symptoms (LUTS)

{Testosterone produced in testes is converted to dihydrotestosterone by 5-alpha-reductase 2 in prostate stromal cells}

LUTS can be subdivided into Storage symptoms and Voiding symptoms. In BPH both Storage symptoms and Voiding symptoms are seen 

1) Storage symptoms (due to bladder irritation) - Frequency (Earliest symptom in BPH) , Urgency , Incontinence (urge and nocturnal) , Nocturia , altered bladder sensation

2) Voiding symptoms (due to BOO) - Hesitancy , dribbling , Slow stream , splitting or spraying , straining , Intermittency , Terminal dribble , Poor bladder emptying sensation .

The pathogenesis of BPH has a Static component and Dynamic component  responsible for LUTS. Static component is DHT induced Stromal hypertrophy and Dynamic component is Smooth muscle contraction in Prostate. Medical therapy aims to treat both these components.

Medical therapy -

1. Finasteride 5mg once daily / Dutasteride (5-alpha-reductase inhibitors) (Inhibits conversion of Testosterone to dihydrotestosterone and addresses static component) . To be taken for atleast 6 months

2. Tamsulosin (400mcg OD) & Alfuzosin (10mg OD) (Alpha blockers) (inhibit smooth muscle contraction in prostate and address Dynamic component) . these drugs work quickly

Note - Alpha 1 adrenoreceptors are present on prostate stromal smooth muscle & bladder neck

3. Solifenacin , Tolterodine , oxybutynin (Antimuscarinics)  (Blocks muscarinic receptors on detrusor muscle leading to decrease in smooth muscle tone and improves symptoms in those with overactive bladder)

Alternative drug - Mirabegron (Beta 3 agonist)

Surgical therapy -

1)  TURP (Transurethral Resection of Prostate) - Bipolar TURP (B-TURP) is Preferred over Monopolar TURP (M-TURP) due to increased benefits like resection in saline and reduced risk of "TUR syndrome" 

[ In M-TURP Usage of Ionic solution leads to dissipation of cutting current and poor cutting efficacy so saline can't be used . Thus non ionic non conducting fluid is used for irrigation  in M-TURP unlike B-TURP where normal saline can be used safely ]

2) HoLEP (Holmium Laser Enucleation of Prostate) -Showed improved Qmax(Flow rate) , reduction in post void residue , IPSS compared to TURP

3) Urolift (Tissue sparing approach)

EAU (European Association of Urology) Guidelines for surgery in BPH :-

1. High pressure chronic retention (Absolute indication) (residual urine >/= 200ml) 

2. Renal impairement (Hydronephrosis/Hydroureter)

3. Acute retention

4. Bladder stones

5. Recurrent urinary infections

6. Hematuria refractory to medical treatment

7. Increased post void residual

Differential diagnosis for LUTS -

RED FLAG CONDITIONS CAUSING LUTS - Bladder/Prostate cancer , Cauda equina ,High pressure chronic retention

#crackmbbs