Benign prostatic hyperplasia

What it is

Benign prostatic hyperplasia is a nonneoplastic glandular and stromal hyperplasia of the transition zone of the prostate. It is common, affecting about 40% of the male population by the age of 50 years. The underlying etiology has not been conclusively established, but sex hormones likely play a key role. It is the usual cause of bladder outlet obstruction in an older male, together with prostate cancer. In a male child the cause is a posterior urethral valve or meatal stenosis; in a young male, urethral stricture or acute prostatitis. At all ages and in both sexes, consider a neurogenic bladder.

How it presents

It manifests as lower urinary tract symptoms:

• Bladder irritation: urinary frequency, urgency, urge incontinence
• Bladder outlet obstruction: urinary hesitancy, straining to urinate, a sensation of incomplete voiding
• Hematuria

The incontinence it causes is overflow incontinence.

The lower urinary tract symptoms, split in two

For bladder outlet obstruction the GOLD standard test is urodynamic studies, and the symptoms patients present with are split in two.

• Obstructive: weak stream and incomplete urination; difficulty to initiate, which is hesitancy, difficulty to maintain, which is intermittency, and difficulty to terminate, which is post micturition dribbling - and on to urinary retention, that is absence of urine flow with a palpable bladder.
• Irritative: urgency, frequency, nocturia, incontinence and dysuria.

The examination includes the genital area, the bladder and per rectum. Make sure the patient voids before you start, or ask when the last void was. And the things to comment on in the PR examination of the prostate are set out one by one: felt or not; surface smooth or not; median sulcus obliterated; nodular; rigid or firm; size, that is whether you can go above it or not; and regular or not - hard and irregular in prostate cancer.