Summary

Benign Prostatic Hyperplasia (BPH) is the non-malignant proliferation of the epithelial and stromal cells of the prostate gland. It is an almost ubiquitous part of male aging, affecting 50% of men aged 50 and 90% of men aged 80. The enlargement primarily affects the Transition Zone (peri-urethral), leading to Bladder Outflow Obstruction (BOO). This manifests clinically as Lower Urinary Tract Symptoms (LUTS), which are classified as Voiding (obstructive) or Storage (irritative). Complications include Acute Urinary Retention (AUR), recurrent UTIs, bladder stones, and obstructive renal failure. Management follows a stepwise approach: Watchful Waiting -> Medical Therapy (Alpha-Blockers, 5-ARIs) -> Surgical Intervention (TURP, Laser, Urolift).

Key Facts

• Prevalence: Extremely common. 50% at age 50.
• Site: Transition Zone (Central). Prostate Cancer usually occurs in the Peripheral Zone.
• PSA: BPH raises PSA, but usually <10.
• Complication: Acute Retention (AUR) is the most common emergency presentation.
• Gold Standard Surgery: TURP (Trans-Urethral Resection of Prostate).

Clinical Pearls

"LUTS is not just Prostate": Women get LUTS too. LUTS can be caused by diabetes (polyuria), heart failure (nocturia), or overactive bladder. Don't assume every man with frequency has BPH.

"The Silent Kidney Killer": Chronic High Pressure Retention. A man presents with nocturnal enuresis (wetting the bed) and a painless palpable bladder. His creatinine is 500. Rapid decompression can cause post-obstructive diuresis.

"Retrograde Ejaculation": The #1 side effect of Tamsulosin and TURP. Semen goes back into the bladder (dry orgasm). Warn EVERY patient, or they will be very unhappy.

"PSA Velocity": A rapidly rising PSA (>0.75 ng/mL/year) is more worrying for cancer than a stable high PSA due to a big gland.

The Anatomy of Enlargement (McNeal's Zones)

The prostate is not a uniform organ. It has distinct zones with different pathologies.

1. Transition Zone (5%): Surrounds the proximal urethra. This is the site of BPH. It grows inward, compressing the lumen.
2. Peripheral Zone (70%): Surrounds the posterior aspect. This is the site of Cancer. Palpable on DRE.
3. Central Zone (25%): Surrounds the ejaculatory ducts. Pathologically quiet.
4. Anterior Fibromuscular Stroma: Non-glandular shield.

The 7-Step Molecular Cascade

BPH is a failure of apoptosis (cell death) coupled with proliferation.

Step 1: The Hormonal Trigger

• Circulating Testosterone enters the prostatic stromal cell.
• Type 2 5-Alpha-Reductase converts it into Dihydrotestosterone (DHT).
• DHT is 10x more potent than Testosterone.

Step 2: Nuclear Translocation

• DHT binds to the Androgen Receptor (AR).
• The complex moves into the nucleus and binds to DNA (Androgen Response Elements).

Step 3: Growth Factor Release

• This triggers the transcription of growth factors: FGF (Fibroblast Growth Factor), EGF (Epidermal), and IGF (Insulin-like).

Step 4: Stromal-Epithelial Interaction

• These growth factors act in a paracrine manner. Stromal cells tell Epithelial cells to grow.

Step 5: Apoptotic Blockade

• Simultaneously, TGF-Beta (which normally induces cell death) is downregulated. Cellular immortality is achieved.

Step 6: Static Obstruction (The "Bulk")

• The physical mass of the Transition Zone impinges on the bladder neck and urethra.

Step 7: Dynamic Obstruction (The "Tone")

• Up to 40% of the obstruction is Smooth Muscle Tone.
• Mediated by Alpha-1a Adrenoceptors in the capsule and stroma.
• This is why stress (sympathetic drive) makes voiding harder.

The Bladder's Response (Compensation vs Decompensation)

1. Compensation phase: The Detrusor muscle hypertrophies (trabeculation) to generate higher pressures. Flow is maintained but "high pressure".
2. Decompensation phase: The muscle eventually fails. Elasticity is lost. Fibrosis sets in. Residual volume rises.
3. Failure: The bladder becomes a compliant, thinning sac (Hypocontractile). Catheter dependent.

1. General Assessment

• Frailty: Is the patient fit for surgery?
• Abdomen: Palpable bladder? (Indicates chronic retention). If painless and palpable, DO NOT catheterize immediately (risk of AKI/Post-Obstructive Diuresis).
• External Genitalia: Exclude Meatal Stenosis or Phimosis (which mimic BPH).

2. Digital Rectal Examination (DRE)

The cornerstone of diagnosis.

• Technique: Patient in left lateral decubitus. Use lubricant. Index finger sweep.
• BPH Findings:
  • Consistency: Smooth, rubbery (like a thenar eminence/nose tip).
  • Contour: Enlarged, symmetrical.
  • Sulcus: Median sulcus is preserved (often).
  • Mobility: Mucosa moves over the gland.
• Cancer Findings:
  • Consistency: Hard, nodular, craggy (like a knuckle/forehead).
  • Contour: Irregular, asymmetrical.
  • Sulcus: Obliterated.
• Size Estimation: Each finger-width across the gland approx 15-20g. A "small" prostate can still obstruct (median lobe).

3. Focused Neurological Exam

• Anal Tone: Check S2-S4 integrity (Cauda Equina exclusion).
• Lower Limb Power/Sensation: Exclude neurological causes of bladder dysfunction.

Natural History

• BPH is progressive. Prostate grows 2% per year.
• Risk of AUR increases with age and prostate volume (>30g).
• Watchful Waiting Outcome: 50% remain stable, 50% progress.

Post-Surgical Outcomes

• TURP: 10-15 year durability. Re-operation rate 1-2% per year.
• HoLEP: Defined as "permanent" (Complete adenoma removal). Re-operation <1%.
• UroLift: Higher re-operation rate (13% at 5 years) but better sexual function profile.

Landmark Trials: The "Big 4"

1. MTOPS Study (2003)

• Citation: The long-term effect of doxazosin, finasteride, and combination therapy.... NEJM. [PMID: 14672920]
• Design: RCT (n=3047). 4 arms (Placebo, Doxazosin, Finasteride, Combo).
• Result: Risk of clinical progression reduced by 39% (Doxazosin), 34% (Finasteride), and 66% (Combo).
• Takeaway: 1 + 1 = 3. Combination is supreme for preventing retention/surgery.

2. CombAT Study (2010)

• Citation: The effects of combination therapy with dutasteride and tamsulosin.... Eur Urol. [PMID: 19819619]
• Design: RCT (n=4844). Tamsulosin vs Dutasteride vs Combo.
• Result: Combination therapy superior in men with moderate-severe symptoms and prostates >30g.
• Takeaway: Confirmed MTOPS in a modern cohort.

3. PLESS Study (1998)

• Citation: Finasteride in the treatment of men with benign prostatic hyperplasia.... N Engl J Med. [PMID: 9478761]
• Design: RCT (n=3040). Finasteride vs Placebo.
• Result: 55% reduction in risk of Acute Urinary Retention.
• Takeaway: 5-ARIs are "Prostate Insurance".

4. GOLiATH Study (2014)

• Citation: GreenLight 120-W laser vaporization vs transurethral resection.... Eur Urol. [PMID: 24765666]
• Design: RCT. GreenLight Laser vs TURP.
• Result: Equivalent IPSS reduction. Shorter hospital stay and catheter time with Laser.
• Takeaway: Laser is non-inferior and safer.

Guidelines

• EAU (European Association of Urology): Strong recommendation for HoLEP in glands >80g.
• AUA (American Urological Association): UroLift recommended for men prioritizing ejaculation preservation.

(See above for detailed breakdown)

What is BPH?

As men get older, the prostate gland (which sits around the water pipe as it leaves the bladder) naturally gets bigger. It's like a doughnut getting thicker, squeezing the hole in the middle. This makes it harder to pee.

Is it Cancer?

No. BPH is benign (harmless growth). However, prostate cancer can cause similar symptoms, so we usually check a blood test (PSA) and examine the prostate to rule it out.

What are the symptoms?

• Flow is slow to start and weak.
• You have to push to go.
• You go often, especially at night.
• You feel like you haven't finished.

How is it treated?

• Mild: Just watch it. Cut down caffeine and evening drinks.
• Moderate: Tablets. One type relaxes the muscle (Tamsulosin), another shrinks the gland (Finasteride).
• Severe: An operation (TURP) to "re-bore" the pipe and clear the blockage.

Case 1: The "Watchful Waiter"

• Profile: 55-year-old male. IPSS 6. Qmax 18 ml/s. Prostate 35g.
• Presentation: "I wake up once a night and my stream is a bit slower."
• Analysis: Mild symptoms (IPSS <7). No complications.
• Management: Watchful Waiting.
  • Advice: "Fluid discipline" (stop drinking at 8pm). Avoid caffeine. Double void.
  • Follow-up: 12 months.

Case 2: The "Acute Angle" (AUR)

• Profile: 68-year-old male. History of hesitation. Had a few beers at a cold wedding.
• Presentation: Agonizing lower abdominal pain. Cannot void. Palpable bladder.
• Immediate Action: Catheterize (14Fr Foley). Drain 900ml.
• Next Step: Start Tamsulosin (Alpha-blocker) immediately.
• Plan: TWOC (Trial Without Catheter) in 3 days.
• Learning Point: Distension injures the detrusor. Do not delay catheterization.

Case 3: The "Silent Killer" (High Pressure Retention)

• Profile: 78-year-old male. "Bed wetting" (Nocturnal Enuresis).
• Exam: Painless, firm bladder palpable to umbilicus.
• Labs: Creatinine 450 (AKI). U&E shows Hyperkalemia.
• Diagnosis: High Pressure Chronic Retention (HPCR).
• Pathophysiology: The bladder pressure has transmitted back to the kidneys (Hydronephrosis).
• Action: Catheterize WITH MONITORING.
• Risk: Post-Obstructive Diuresis. The kidneys may dump liters of fluid/salt. Patient needs IV fluids to match output.

Case 4: The "Bleeder" (Haematuria on 5-ARI)

• Profile: 72-year-old on Finasteride for 5 years.
• Presentation: Painless frank haematuria.
• Trap: blaming the BPH. Finasteride suppresses vascularity (VEGF). A patient on Finasteride should NOT bleed.
• Action: CT Urogram + Cystoscopy. This is Bladder Cancer until proven otherwise.

Case 5: The "Failed TURP"

• Profile: 6 months post-TURP. Flow was good, now poor again.
• Differential:
  1. Stricture (Urethral trauma): Most likely if early (<1 year).
  2. Regrowth (Adenoma): Unlikely so soon (takes 10 years).
  3. Bladder Neck Contracture: Scarring at the sphincter.
• Investigation: Ascending Urethrogram / Cystoscopy.

1. The Difficult Catheter

BPH elevates the bladder neck and creates a "steep curve" for the catheter.

• Step 1: Use plenty of gel (Instillagel). 11ml is standard, use 2 tubes if needed.
• Step 2: Coude Tip (Curved tip). Keep the curve facing UP (towards the ceiling/navel) to ride over the median lobe.
• Step 3: Large prostate? Use a larger catheter (16Fr or 18Fr). It is stiffer and pushes through better than a flooding 12Fr.

2. Three-Way Catheter (Irrigation)

Used for haematuria/post-op.

• Inlet: Saline irrigation.
• Outlet: Urine + Saline.
• Balloon: 30ml (Standard is 10ml).
• Technique: "Keep it rose wine". Adjust flow rate to clear the blood. If it stops ("Clot Retention"), flush vigorously with a 50ml bladder syringe.

3. Suprapubic Catheter (SPC)

• Indication: Failed urethral access, Stricture, Trauma.
• Contraindication: Carcinoma of Bladder (Seeding), Unpalpable Bladder (Bowel injury risk).
• Landmark: 2 fingers above symphysis pubis, midline.

Day 0 (Surgery)

• Sensation: Strong urge to void (Catheter spasm). Do NOT push (causes bleeding).
• Meds: Anticholinergics (Solifenacin) or Belladonna suppositories for spasms.

Day 1-2 (Catheter Removal)

• TWOC: Remove catheter. Monitor voids.
• Success: Voids > 50% of functional capacity.
• Failure: Re-catheterize. Try again in 1 week.

Weeks 1-4 (Home)

• The "Scab": The internal scab falls off around Day 10-14. This causes "Secondary Hemorrhage".
• Advice: "If you see blood in 2 weeks, drink 2 liters of water and rest. It usually stops."
• Sex: No ejaculation for 4-6 weeks (Bleeding risk).

Metabolic Syndrome & BPH

BPH is no longer seen as just "aging". It is a systemic metabolic disease.

• Insulin Resistance: Hyperinsulinemia increases IGF-1, driving prostate growth.
• Inflammation: C-Reactive Protein (CRP) correlates with BPH severity.
• Nitric Oxide: Reduced NO in metabolic syndrome prevents smooth muscle relaxation in the pelvis.
• Clinical Implication: Treat the patient, not just the prostate. Weight loss and exercise reduce LUTS severity.

What is BPH?

Imagine a doughnut (the prostate) with a straw (the urethra) going through the hole. As you age, the doughnut gets thicker and squeezes the straw. This makes it hard to push liquid through. It is NOT cancer. It is just a part of aging, like grey hair.

The "Fork in the Road" Decision

You have 3 options:

1. Do Nothing: If it doesn't bother you much, we just watch it. It might not get worse.
2. Tablets:
   • The Door Opener (Tamsulosin): Relaxes the muscle. Works in days. Side effect: No semen comes out (dry orgasm).
   • The Shrinker (Finasteride): Shrinks the gland. Takes 6 months. Side effect: Loss of libido for some.
3. Re-boring the Pipe (Surgery): We scrape away the inside of the doughnut to make the hole bigger. best flow, but higher risks.

When should I worry?

• If you cannot pee at all (painful).
• If you see blood.
• If you initiate wetting the bed (silent blockage).

Q1: What is the specific mechanism of Tamsulosin vs Finasteride? A: Tamsulosin is a selective Alpha-1a antagonist. It relaxes smooth muscle in the bladder neck/prostate (Dynamic obstruction). Finasteride is a 5-Alpha Reductase Inhibitor. It prevents conversion of T to DHT, inducing apoptosis and shrinkage (Static obstruction).

Q2: How do you interpret PSA in a patient on Finasteride? A: Finasteride reduces PSA by approx 50% after 6 months. You must double the laboratory value to get the "true" PSA for cancer risk stratification.

Q3: Explain "Retrograde Ejaculation" to a patient. A: "During climax, the bladder neck usually closes tight to force semen out the penis. This medication keeps the bladder neck open. So, the semen takes the path of least resistance backwards into the bladder. It is not harmful, but you will have a 'dry orgasm'. The semen comes out when you pee later."

Q4: What causes TUR Syndrome? A: Absorption of large volumes of hypotonic irrigation fluid (Glycine 1.5%) during Monopolar TURP.

• Pathophysiology: Dilutional Hyponatremia + Glycine toxicity (Visual disturbances).
• ** Prevention**: Use Bipolar TURP (Saline irrigation).

Q5: What are the absolute indications for BPH Surgery? A: 1. Refractory Retention. 2. Refractory Hematuria. 3. Recurrent UTIs. 4. Bladder Stones. 5. Renal Failure (HPCR).

Q6: Differentiate High Pressure vs Low Pressure Chronic Retention. A:

• High Pressure: Tense bladder, Hydronephrosis, Renal Failure. Do NOT decompress rapidly. Late night bed wetting.
• Low Pressure: Detrusor failure. Dilated bladder but no Renal Failure. Often poor outcome with surgery (pump failure, not obstruction).

Q7: Why is HoLEP superior to TURP for large glands? A: HoLEP (Enucleation) follows the surgical capsule, removing the entire adenoma regardless of size. TURP leaves residual tissue. HoLEP has lower re-operation rates and less bleeding.

Q8: What is "Florid Intrasphincteric Iris Syndrome" (IFIS)? A: A complication of cataract surgery in patients taking Alpha-Blockers. The iris becomes floppy and billows, increasing risk of complications.

Q9: What is the significance of the "Median Lobe"? A: It acts like a ball-valve. Even a small prostate can cause severe obstruction if it has a median lobe projecting into the bladder. UroLift is contraindicated for median lobes.

Q10: Management of Acute Urinary Retention? A: Catheterize. Record residual volume. Start Alpha-Blocker immediately. Trial Without Catheter (TWOC) after 3-7 days.

Tamsulosin (Flomax)

• Class: Selective Alpha-1a Adrenergic Antagonist.
• Chemistry: Sulfonamide derivative.
• Pharmacokinetics:
  • Absorption: >90% bioavailability under fasting conditions. Food delays absorption.
  • Metabolism: Hepatic via CYP3A4 and CYP2D6. Slow metabolizers have higher exposure.
  • Half-life: 9-13 hours (modified release).
  • Excretion: Urine.
• Pharmacodynamics:
  • High affinity for Alpha-1a (Prostate) vs Alpha-1b (Vascular).
  • 10x more selective for prostate than prazosin.
  • Relaxes prostatic smooth muscle / bladder neck.
• Dosing: 400mcg once daily.
• Contraindications: Severe hepatic impairment. History of IFIS.
• Interactions:
  • Strong CYP3A4 inhibitors (Ketoconazole) -> Increase levels.
  • PDE5 Inhibitors -> Hypotension risk.
  • Other Alpha-blockers -> Severe hypotension.

Finasteride (Proscar)

• Class: Type II 5-Alpha Reductase Inhibitor.
• Mechanism Details:
  • Irreversibly binds to 5-AR enzyme.
  • Prevents reduction of Testosterone to DHT.
  • DHT is the primary androgen for prostate growth.
  • Serum DHT reduced by 70%.
  • Prostate DHT reduced by 85-90%.
• Impact on T: Serum Testosterone increases slightly (intra-prostatic T conversion blocked).
• Clinical Timeline:
  • 3 months: Volume reduction starts.
  • 6 months: Maximal regression (-20%).
  • 12 months: Stability.
• Pregnancy Warning: Teratogenic. Women of childbearing age should not handle crushed tablets (absorbable through skin). Causes feminization of male fetus.
• Cancer Chemoprevention?: PCPT Trial showed 25% reduction in prostate cancer risk, BUT slight increase in high-grade tumors (Gleason 8-10). Currently NOT recommended for prevention.

Dutasteride (Avodart)

• Class: Dual (Type I and II) 5-Alpha Reductase Inhibitor.
• Difference from Finasteride:
  • Blocks Type I (Skin/Liver) and Type II (Prostate).
  • Serum DHT suppression >90% (vs 70% for Finasteride).
  • Half-life: 5 weeks (vs 6 hours for Finasteride).
  • Washout period: 6 months (Cannot donate blood).

Trans-Urethral Resection of Prostate (TURP)

Setup:

1. Lithotomy position.
2. Prophylactic Antibiotics (Gentamicin).
3. 30Fr Sheath. 1.5% Glycine (Monopolar) or Saline (Bipolar).

The Procedure:

1. Inspection: Cystoscopy to rule out bladder tumors/stones. Identify Ureteric Orifices (Safety landmark).
2. The Middle Lobe: Resected first. Create a channel from bladder neck to Verumontanum.
3. Lateral Lobes: Resected systematically from 12 o'clock to 6 o'clock.
4. The Apex: The danger zone. Resect carefully near the Veru to preserve the sphincter (Incontinence risk).
5. Hemostasis: Coagulate bleeding vessels.
6. Evacuation: Ellik evacuator to suck out chips.
7. Catheter: 22Fr 3-Way Catheter on traction.

Post-Op Care:

• Continuous Bladder Irrigation (CBI) until clear.
• Monitor Na+ (TUR Syndrome risk).
• TWOC Day 2.

Holmium Laser Enucleation (HoLEP)

Concept:

• Anatomical removal of the entire transition zone along the surgical capsule.
• "Like scooping ice cream out of the tub."

Steps:

1. Bladder Neck Incision: 5 and 7 o'clock.
2. Median Lobe Enucleation: Dissected retrograde back to the bladder.
3. Lateral Lobe Enucleation: Developing the plane between adenoma and capsule.
4. Trigone Sparing: Critical to avoid ureteric injury.
5. Morcellation: Using the "Piranha" scope to grind floating tissue in the bladder.

The "Prostate Diet"

Evidence suggests metabolic health drives BPH.

1. Lycopene:
   • Source: Cooked tomatoes (release increases with heat).
   • Evidence: Antioxidant, concentrates in prostate. May inhibit IGF-1.
2. Zinc:
   • Prostate has highest Zn concentration in body.
   • Source: Pumpkin seeds, Oysters.
   • Role: Regulates apoptosis.
3. Anti-Inflammatory:
   • Reduce red meat (Arachidonic acid -> Prostaglandins).
   • Increase Omega-3 (Fish).
   • Turmeric/Curcumin (NF-kB inhibition).

Supplements: The Evidence

1. Saw Palmetto (Serenoa repens):
   • Mechanism: Weak 5-ARI activity? Phytosterol effect?
   • Cochrane Review: "No better than placebo for LUTS."
   • Expert View: May help mild inflammation, but do not replace medical therapy.
2. Beta-Sitosterol:
   • Plant sterol.
   • Evidence: Improves flow rate slightly in some small trials.
3. Pygeum Africanum:
   • African plum tree bark.
   • Evidence: Modest improvement in nocturia.

Q: Will BPH turn into cancer? A: No. They are separate diseases. You can have both, but one does not cause the other.

Q: Can I still have children after surgery? A: You can have an erection and orgasm, but you will likely have "Retrograde Ejaculation" (Dry orgasm). If you want children, you will need sperm harvesting or IVF. Discuss this BEFORE surgery.

Q: Does sitting down to pee help? A: Yes! It relaxes the pelvic floor and opens the angle of the urethra. A m-analysis showed improved emptying in men with BPH who sit.

Q: Why is my symptoms worse when I'm cold? A: Cold triggers the sympathetic nervous system ("Fight or Flight"). This releases Noradrenaline, which activates the Alpha-1a receptors in the prostate, tightening the muscle tone.

Q: What is "Prostatic Infarction"? A: Sometimes the prostate grows so fast it outstrips its blood supply. A piece dies (infarcts), causing sudden pain and blood in the urine. It heals on its own.

Q: Can I ride a bike? A: Cycling puts pressure on the perineum (prostate area). It can raise PSA temporarily and cause numbness. Get a "prostate-friendly" saddle with a cut-out.

(End of Topic)