Benign prostatic hyperplasia
Updates to Article Attributes
Benign prostatic hyperplasia (BPH) is an extremely common condition in elderly men and is a major cause of bladder outflow obstruction. Although the term prostatomegaly is often used interchangeably, strictly speaking prostatomegaly may refer to any cause of prostatic enlargement.
Terminology
The term 'benignbenign prostatic hypertrophy' was was formerly used for this condition, but since there is actually an increase in the number of epithelial and stromal cells in the periurethral area of the prostate, not an enlargement of cells, the more accurate term is 'hyperplasia'hyperplasia.
Although the term prostatomegaly is often used interchangeably with BPH, strictly speaking prostatomegaly may refer to any cause of prostatic enlargement.
Epidemiology
By the age of 60, 50% of men have BPH, and by 90 years of age the prevalence has increased to 90%. As such it is often thought of essentially as a 'normal' part of ageing 1.
Clinical presentation
Although a degree of prostatomegaly may be completely asymptomatic, the most common presentation is with lower urinary tract symptoms (LUTS) including 1-4:
- poor stream despite straining
- hesitancy, frequency and incomplete emptying of the bladder
- nocturia
An enlarged prostate may also be incidentally found on imaging of the pelvis or on rectal exam.
Pathology
Benign prostatic hyperplasia is due to a combination of stromal and glandular hyperplasia prostatic hyperplasia is due to a combination of stromal and glandular hyperplasia, predominantly of the transitional zone (as opposed to prostate cancer which typically originates in the peripheral zone).
Risk factors
- increasing age
- family history
- race: Blacks > Whites > Asians
- cardiovascular disease
- use of beta-blockers
- metabolic syndrome: diabetes, hypertension, obesity8
Complications
Complications of untreated benign prostatic hyperplasia include 4:
- urinary retention
- bladder calculi andbladder diverticula
- recurrenturinary tract infection
- recurrent grosshaematuria
- hydronephrosis andhydroureter and eventualrenal failure
Markers
- prostate specific antigen (PSA): elevated but non-specific
Radiographic features
Ultrasound
Ultrasound has become the standard first line investigation after the urologist's finger.
- there is an increase in volume of the prostate with a calculated volume exceeding 30
ml ((AmL (width xBheight xC) *length x 0.52) - the central gland is enlarged, and is hypoechoic or of mixed echogenicity
- calcification may be seen both within the enlarged gland as well as in the pseudocapsule (representing compressed peripheral zone)
Post
Fluoroscopy -
On IVPThe
CT
Not typically used to assess the prostate, BPH is more frequently an incidental finding. Extension above the symphysis pubis was used as a marker on axial imaging, however now that volume acquisition and coronal reformats are standard, the same criteria as on US can be used (>30 mlmL)
MRI
- enlarged central zone
- heterogenous signal with an intact low signal pseudocapsule in the periphery
.
Treatment and prognosis
Medical management for early disease typically commences with finasteride (a 5-alpha-reductase inhibitor).
Surgical management for symptomatic patients is typically with a transurethral resection of the prostate (TURP), and careful patient selection is important given the high prevalence of both BPH and lower urinary symptoms (LUTS) in this population.
Urodynamic studies and prostate size estimation are often used to guide therapy, although prostate size in isolation is a poor predictor of symptom severity4.
-<p><strong>Benign prostatic hyperplasia (BPH)</strong> is an extremely common condition in elderly men and is a major cause of bladder outflow obstruction. Although the term prostatomegaly is often used interchangeably, strictly speaking prostatomegaly may refer to any cause of prostatic enlargement. </p><h4>Terminology</h4><p>The term 'benign prostatic hypertrophy' was formerly used for this condition, but since there is actually an increase in the number of epithelial and stromal cells in the periurethral area of the prostate, not an enlargement of cells, the more accurate term is 'hyperplasia'.</p><h4>Epidemiology</h4><p>By the age of 60, 50% of men have BPH, and by 90 years of age the prevalence has increased to 90%. As such it is often thought of essentially as a 'normal' part of ageing <sup>1</sup>.</p><h4>Clinical presentation</h4><p>Although a degree of prostatomegaly may be completely asymptomatic, the most common presentation is with <a href="/articles/lower-urinary-tract-symptoms">lower urinary tract symptoms (LUTS)</a> including <sup>1-4</sup>: </p><ul>- +<p><strong>Benign prostatic hyperplasia (BPH)</strong> is an extremely common condition in elderly men and is a major cause of bladder outflow obstruction. </p><h4>Terminology</h4><p>The term <strong>benign prostatic hypertrophy</strong> was formerly used for this condition, but since there is actually an increase in the number of epithelial and stromal cells in the periurethral area of the prostate, not an enlargement of cells, the more accurate term is <strong>hyperplasia</strong>.</p><p>Although the term <a href="/articles/prostatomegaly-2"><strong>prostatomegaly</strong></a> is often used interchangeably with BPH, strictly speaking prostatomegaly may refer to any cause of prostatic enlargement. </p><h4>Epidemiology</h4><p>By the age of 60, 50% of men have BPH, and by 90 years of age the prevalence has increased to 90%. As such it is often thought of essentially as a 'normal' part of ageing <sup>1</sup>.</p><h4>Clinical presentation</h4><p>Although a degree of prostatomegaly may be completely asymptomatic, the most common presentation is with <a href="/articles/lower-urinary-tract-symptoms">lower urinary tract symptoms (LUTS)</a> including <sup>1-4</sup>: </p><ul>
-</ul><p>An enlarged prostate may also be incidentally found on imaging of the pelvis or on rectal exam. </p><h4>Pathology</h4><p>Benign prostatic hyperplasia is due to a combination of stromal and glandular hyperplasia, predominantly of the transitional zone (as opposed to <a href="/articles/prostatic-carcinoma-1">prostate cancer</a> which typically originates in the peripheral zone).</p><p>Complications of untreated benign prostatic hyperplasia include <sup>4</sup>:</p><ul>- +</ul><p>An enlarged prostate may also be incidentally found on imaging of the pelvis or on rectal exam. </p><h4>Pathology</h4><p>Benign prostatic hyperplasia is due to a combination of stromal and glandular hyperplasia, predominantly of the transitional zone (as opposed to <a href="/articles/prostatic-carcinoma-1">prostate cancer</a> which typically originates in the peripheral zone).</p><h5>Risk factors</h5><ul>
- +<li>increasing age</li>
- +<li>family history</li>
- +<li>race: Blacks > Whites > Asians</li>
- +<li>cardiovascular disease</li>
- +<li>use of beta-blockers</li>
- +<li>metabolic syndrome: diabetes, <a href="/articles/hypertension">hypertension</a>, <a href="/articles/obesity">obesity</a> <sup>8</sup>
- +</li>
- +</ul><h5>Complications</h5><p>Complications of untreated benign prostatic hyperplasia include <sup>4</sup>:</p><ul>
-<a href="/articles/bladder-calculus-1">bladder calculi</a> and <a href="/articles/urinary-bladder-diverticulum">bladder diverticula</a>- +<a href="/articles/bladder-calculus-1">bladder calculi</a> and <a href="/articles/urinary-bladder-diverticulum">bladder diverticula</a>
-<li>recurrent <a href="/articles/urinary-tract-infection">urinary tract infection</a>- +<li>recurrent <a href="/articles/urinary-tract-infection">urinary tract infection</a>
-<li>recurrent gross <a href="/articles/haematuria">haematuria</a>- +<li>recurrent gross <a href="/articles/haematuria">haematuria</a>
-<a href="/articles/hydronephrosis">hydronephrosis</a> and <a href="/articles/hydroureter">hydroureter</a> and eventual <a href="/articles/renal-failure">renal failure</a>- +<a href="/articles/hydronephrosis">hydronephrosis</a> and <a href="/articles/hydroureter">hydroureter</a> and eventual <a href="/articles/renal-failure">renal failure</a>
-</ul><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound has become the standard first line investigation after the urologist's finger.</p><ul>-<li>there is an increase in volume of the prostate with a calculated volume exceeding 30 ml ((A x B x C) * 0.52)</li>- +</ul><h5>Markers</h5><ul><li>
- +<a href="/articles/psa-prostate-specific-antigen">prostate specific antigen (PSA)</a>: elevated but non-specific</li></ul><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound has become the standard first line investigation after the urologist's finger.</p><ul>
- +<li>there is an increase in volume of the prostate with a calculated volume exceeding 30 mL (width x height x length x 0.52)</li>
-</ul><p>Post-micturition residual volume is typically elevated.</p><h5>Fluoroscopy - IVP</h5><p>The bladder floor can be elevated and the distal ureters lifted medially (<a href="/articles/j-shaped-ureters">J-shaped ureters</a> or <a href="/articles/fishhook-ureters">fishhook ureters)</a>. Chronic bladder outlet obstruction can lead to <a href="/articles/detrusor-hypertrophy">detrusor hypertrophy</a>, trabeculation and formation of <a href="/articles/bladder-diverticula">bladder diverticula</a>.</p><h5>CT</h5><p>Not typically used to assess the prostate, BPH is more frequently an incidental finding. Extension above the <a href="/articles/symphysis-pubis">symphysis pubis</a> was used as a marker on axial imaging, however now that volume acquisition and coronal reformats are standard, the same criteria as on US can be used (>30 ml)</p><h5>MRI</h5><ul>- +<li>post-micturition residual volume is typically elevated</li>
- +</ul><h5>Fluoroscopy</h5><p>On IVP, the bladder floor can be elevated and the distal ureters lifted medially (<a href="/articles/j-shaped-ureters">J-shaped ureters</a> or <a href="/articles/fishhook-ureters">fishhook ureters)</a>. Chronic bladder outlet obstruction can lead to <a href="/articles/detrusor-hypertrophy">detrusor hypertrophy</a>, trabeculation and formation of <a href="/articles/bladder-diverticula">bladder diverticula</a>.</p><h5>CT</h5><p>Not typically used to assess the prostate, BPH is more frequently an incidental finding. Extension above the <a href="/articles/symphysis-pubis">symphysis pubis</a> was used as a marker on axial imaging, however now that volume acquisition and coronal reformats are standard, the same criteria as on US can be used (>30 mL)</p><h5>MRI</h5><ul>
-<li>heterogenous signal with an intact low signal pseudocapsule in the periphery.</li>-</ul><h4>Treatment and prognosis</h4><p>Medical management for early disease typically commences with finasteride (a 5-alpha-reductase inhibitor).</p><p>Surgical management for symptomatic patients is typically with a <a title="Transurethral resection of the prostate" href="/articles/transurethral-resection-of-the-prostate">transurethral resection of the prostate (TURP)</a>, and careful patient selection is important given the high prevalence of both BPH and lower urinary symptoms (LUTS) in this population.</p><p>Urodynamic studies and prostate size estimation are often used to guide therapy, although prostate size in isolation is a poor predictor of symptom severity <sup>4</sup>. </p>- +<li>heterogenous signal with an intact low signal pseudocapsule in the periphery</li>
- +</ul><h4>Treatment and prognosis</h4><p>Medical management for early disease typically commences with finasteride (a 5-alpha-reductase inhibitor).</p><p>Surgical management for symptomatic patients is typically with a <a href="/articles/transurethral-resection-of-the-prostate">transurethral resection of the prostate (TURP)</a>, and careful patient selection is important given the high prevalence of both BPH and lower urinary symptoms (LUTS) in this population.</p><p>Urodynamic studies and prostate size estimation are often used to guide therapy, although prostate size in isolation is a poor predictor of symptom severity <sup>4</sup>. </p>
References changed:
- 8. Alan J. Sinclair, John E. Morley, Bruno Vellas. Pathy's Principles and Practice of Geriatric Medicine, 2 Volumes. (2012) ISBN: 9780470683934 - <a href="http://books.google.com/books?vid=ISBN9780470683934">Google Books</a>
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