Elsevier

Surgery (Oxford)

Volume 26, Issue 5, May 2008, Pages 218-222
Surgery (Oxford)

Renal and urology
Benign prostatic hyperplasia

https://doi.org/10.1016/j.mpsur.2008.04.007Get rights and content

Abstract

Histological evidence of benign prostatic hyperplasia (BPH) develops in most Western men with increasing age, due to a complex interplay of hormonal and dietary influences. Urinary symptoms, in association with prostatic enlargement, affect 25% of the male population, increasing to 43% of the male population aged > 60 years. About 50% of symptomatic men have measurable BPH/enlargement. Dietary, hormonal, cardiac, renal and habitual factors contribute to urinary symptoms in both sexes, particularly as they age. A focused history and examination, simple tests (prostate-specific antigen, creatinine) and assessment of voiding function (flow rate, ultrasound) help make the diagnosis. Many can be stratified according to the severity of their symptoms by scoring systems. Lifestyle advice can lessen mild symptoms, medical therapy is most appropriate for mild or moderate symptoms and may help severe symptoms. Severely symptomatic or obstructed men do best with a surgical or high energy technique chosen according to prostate size. Pressure-flow studies can improve the accuracy of diagnosis and the selection of candidates for surgery. Outcomes for obstructed or moderate to severely symptomatic men are good. 5-alpha reductase inhibitor therapy offers the opportunity to prevent the development of further BPH instead of, or after, surgical treatment.

Section snippets

Prostate gland

Development: male and female embryos develop identically initially. Each have undifferentiated gonads and Wolffian ducts (which develop into most male genital structures) and Mullerian ducts (which develop into most female genital structures). The male phenotype develops under the influence of testicular androgens and Mullerian-inhibiting substance (‘anti-Mullerian-hormone’). Mullerian-inhibiting substance is a peptide hormone in the transforming growth factor-β family that acts via type I and

Pathophysiology of BPH

Population prevalence of BPH: several large population studies have shown that progressive enlargement of the prostate gland is extremely common, and is seen in most men aged >70 years. The most studied populations are those of Baltimore (Maryland, USA), the Forth valley (Stirling, Scotland) and Olmsted County (Minnesota, USA). They have provided much information about the complex interactions between BPH, lower urinary tract symptoms, serum concentration of prostate-specific antigen in serum,

Diagnosis and assessment of BPH/lower urinary tract symptoms

Men rarely come complaining of a big prostate, but usually present with LUTS or a complication from unrelieved bladder outflow obstruction (BOO). Many men are anxious that they may have prostate cancer or may be going into renal failure; they are often aware of the risks of painful and unexpected acute urinary retention. Rapid estimation of these risks can be achieved by assessment incorporating:

  • a history of symptoms, comorbidity and age

  • careful examination of the prostate and lower abdomen

Lifestyle changes

Advice on lifestyle changes is useful for most men. Stopping smoking and altering the nature, volume and timing of fluid intake may help significantly. A trial of a non-invasive therapy is usually indicated initially (and usually preferred by the patient). A surgical option should be offered (see below) if there are very severe symptoms, rapid failure of medical treatment or if the patient prefers definitive surgical treatment.

Medical

Pharmacotherapy is used to relieve excessive smooth muscle tone

Summary

Men in western society or those who are increasingly exposed to western diets will develop BPH microscopically. About 50% will develop macroscopic BPH and measurable enlargement of the prostate. The response and the development of symptoms depends on an interplay of factors, in particular bladder function. Asymptomatic men rarely present and can usually be reassured; symptomatic men or those with an established complication may wish treatment. Lifestyle changes can reduce mild to moderate

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