This refers to benign enlargement of the prostate gland which is giving rise to symptoms. The average age of patients is about 66 years. The two main aetiological factors are aging and the presence of testosterone. There is no correlation between sexual activity and the aetiology.

SYMPTOMS

Lower Urinary Tract Symptoms (LUTS), previously referred to as prostatism.

A. Obstructive

• Hesitancy - delay in initiating urination
• Poor/weak urinary stream
• Straining
• Terminal dribbling
• Overflow incontinence
• Urinary retention

• Acute retention - sudden, painful over-distention of the bladder due to inability to void urine
• Chronic retention - bladder distention which is painless, gradual in onset and associated with some inability of the patient to completely empty the bladder on voiding

B. Irritative

• Frequency by day or night (nocturia)
• Urgency
• Urge incontinence

SIGNS

• A tender bladder will be palpable in acute urinary retention
• In chronic retention the distended bladder is non-tender. There may be associated uraemic signs
• The kidneys may also be palpable due to hydronephrosis
• Rectally the prostate gland is enlarged (size assessed in grades or grams); firm in consistency, smooth surface, non-tender and the median sulcus is palpable. The rectal mucosa moves freely over the prostate which has well defined edges

INVESTIGATIONS

• Full blood count
• Blood urea, electrolytes and creatinine
• Prostate specific antigen (PSA)
• Urinalysis
• Urine (mid stream) for culture and sensitivity
• Abdominal ultrasound and transrectal ultrasound (TRUS) of the prostate if available

TREATMENT

Therapeutic objectives

• Identify and correct associated complications which may be life-threatening
• To relieve the obstruction to urinary flow

Depending on the severity of symptoms, treatment may be pharmacological (drug therapy) or non-pharmacological (surgery).

Immediate Treatment

Acute retention of Urine

• Urethral catheterisation
• Suprapubic cystostomy - if urethral catheterisation fails REFER.
• Suprapubic needle puncture and aspiration/drainage of urine - partially decompresses the bladder and relieves pain, when suprapubic cystostomy is delayed.

Definitive Treatment

(Evidence rating: A)

Patients with very mild symptoms which are not bothersome may be put on a programme of monitoring (watchful waiting) through regular checkups.

Patients with mild symptoms:

Drug therapy

• Prostate smooth muscle relaxants (selective alpha-adrenergic blockers)

These medications may have side effects such as lowering of blood pressure and dizziness. Some are therefore only recommended to be taken at night.

Terazosin, oral, 2 to 10 mg at night. Initial start dose of 1 mg at night; this may be doubled at weekly intervals according to response up to a maximum of 10 mg or

Tamsulosin 400 microgram once daily.

• Androgen Suppression

These drugs block the enzyme that is responsible for growth of the prostate. Their use will cause shrinkage of the prostate and relief of the attendant obstruction.

Finasteride, oral, 5 mg daily.

Treatment is indefinite

• Combined Drug Therapy

A combination of a selective alpha blocker and androgen suppression may produce better response than either used alone.

REFER

Refer patients with moderate tosevere symptoms to a Urologist or Surgical specialist.