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SOURCE

Source: Lee M, Sharifi R. Benign prostatic hyperplasia. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133892664. Accessed March 23, 2017.

DEFINITION

  • Benign neoplasm of the male prostate gland.

ETIOLOGY

  • Benign prostatic hyperplasia (BPH) caused by androgen-driven growth in size of prostate.

PATHOPHYSIOLOGY

  • Precise pathophysiologic mechanisms that cause BPH are not clear.

  • Intraprostatic dihydrotestosterone (DHT) and type II 5α-reductase are thought to be involved.

  • BPH commonly results from both static (gradual anatomic enlargement of prostate producing a physical block at the bladder neck obstructing urine outflow) and dynamic (agents or situations that increase α-adrenergic tone and resulting in contraction of the prostate gland around the urethra and narrowing of the urethral lumen) factors.

  • Drugs can exacerbate symptoms:

    • Testosterone.

    • α-Adrenergic agonists (eg, decongestants such as pseudoephedrine, ephedrine, and phenylephrine)

    • Anticholinergics (eg, antihistamines, phenothiazines, tricyclic antidepressants, antispasmodics, antiparkinsonian agents)

    • β-Adrenergic agonists (eg, terbutaline)

EPIDEMIOLOGY

  • Common in men >60 years old, with peak incidence at 63–65 years of age.

RISK FACTORS

  • Male gender.

  • Age >60

CLINICAL PRESENTATION

  • Presents as obstructive or irritative signs and symptoms that vary over time.

    • Mild disease may stabilize, whereas others experience progressive disease.

SIGNS AND SYMPTOMS

  • Obstructive.

    • Results when dynamic and/or static factors reduce bladder emptying:

      • Urinary hesitancy.

      • Straining.

      • Weak urine stream.

      • Dribbling.

      • Bladder feels full even after voiding.

  • Irritative.

    • Results from long-standing obstruction at the bladder neck.

      • Urinary frequency.

      • Urinary urgency.

      • Nocturia.

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

  • Diagnosis requires careful medical history, including medication history and physical examination.

LABORATORY TESTS

  • Urinalysis.

    • Used to rule out other urologic disorders (hematuria, urolithiasis, infection)

  • Prostate-specific antigen (PSA)

    • Should be performed in all men aged 40 years or over.

  • Objective measures of bladder emptying:

    • Peak and average urinary flow rate using a uroflowmeter.

    • Postvoid residual urine (PVR) volume.

IMAGING

  • Transabdominal ultrasound to determine PVR volume.

DIAGNOSTIC PROCEDURES

  • Digital rectal examination: prostate is usually but not always enlarged (>20 g), soft, smooth, and symmetric.

DIFFERENTIAL DIAGNOSIS

DESIRED OUTCOMES

  • Control symptoms.

  • Prevent complications of BPH

  • Delay need for surgical intervention.

TREATMENT: GENERAL APPROACH

  • Management options depend on severity of signs and symptoms (Table 1).

    • Watchful waiting.

      • Appropriate with mild disease and uncomplicated moderate disease with mildly bothersome symptoms (...

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