Case Report Benign Prostatic Hyperplasia (BPH) in an elderly Ugandan male: a case report Niwagaba Peter, Chitayi Michael ABSTRACT B enign prostatic hyperplasia is a histological proliferation of the prostate gland that is symptomatically common among men older than 60 years as a result of androgen driven growth in the size of the prostate. Key modalities in management include watchful waiting in case it is mild. This however can involve the use of drugs and surgical intyerventions incase BPH progresses to moderate and/or severe with regard to the symptoms. We present a case of a 52 year old male presenting with classical symptoms of BPH Background Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. BPH involves the stromal and epithelial elements of the prostate arising in the periurethral and transition zones of the gland. The hyperplasia presumably results in enlargement of the prostate that may restrict the flow of urine from the bladder1. The prevalence of BPH increases with age. Histologic BPH is present in approximately 8% of men aged 31-40 years , 50% of men aged 51-60 years, 70% of men aged 61-70 years, and 90% of men aged 81-90 years. Correspondingly, symptomatic (clinical) BPH is present in approximately 26% of men in the fifth decade of life, 33% of men in the sixth decade, 41% of men in the seventh decade, and 46% of men in the eighth decade of life and beyond. 1,2,3 From 40 years of age the prostate increases in volume by 2.4 cm3 per year on average. The process begins in the periurethral (transitional) zone and involves both glandular and stromal tissue to a variable degree. Associated symptoms are common from 60 years of age, and some 50% of men over 80 years will have lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH).2 The etiology is multi-factorial with age, hormones such as serum testosterone levels slowly but significantly decrease with advancing age however, levels of estrogenic steroids are not decreased equally. According to this theory, the prostate enlarges because of increased estrogenic effects. Advanced age, obesity, increased fat intake, decreased physical activity, and diabetes increase the risk of BPH development.6 Clinical BPH represents the clinical consequences of, or can be attributed to, an increased prostate volume and is characterized by Lower urinary tract syndrome (LUTS), Bladder Outlet Obstruction (BOO), incomplete bladder emptying, acute and chronic urinary retention, UTI, urosepsis, bladder stones and hematuria. BPH is the most important pathologic condition that contributes to LUTS.2 BPH is diagnosed based on the clinical history, digital rectal examination (DRE) findings, and focused neurologic examination findings. Urinalysis is the only laboratory test universally recommended for BPH. Serum prostate-specific antigen (PSA) levels can be used as a marker for prostatic diseases, including BPH.5 Case Presentation MD, A 52 years old Male, farmer from Masaka District-Uganda presented to emergency ward at Mulago National referral and Teaching Hospital with a history of difficulty in passing urine of six weeks that progressed to complete failure to pass urine for two days. He also presented with sudden lower abdominal pain for two days. The difficulty in passing urine was associated with dysuria, urinary urgency, frequency and hesitancy, weak stream and incomplete emptying. The abdominal pain was localized to the supra pubic region, associated with distention and It was so intense that it denied MD sleep for the last two days. The pain was aggravated by sitting upright in bed and walking. No relieving factors were reported and there was no radiation. There was no associated history of hematuria and fever. There was no associated Gastro Intestinal tract or nervous system symptoms. The past medical history was remarkable as it revealed that this was MD├ö├ç├ûs fourth Hospital admission in a period of one year. In the last visit that was one month ago MD had been seen in Masaka Hospital where he was investigated and treated for Urinary tract infection (UTI) with Ciprofloxacin and Nitrofurantoin for one week with no appreciable relief. There was no history of Diabetes or Hypertension and did not have HIV. There was no history of past surgery, accidents, pelvic fracture or catheterization. The patient had a positive history of alcohol intake, reported taking spirits packed in Buvera and about 400mls per day on average for over ten years and he affirmed he had taken a binge of alcohol a night prior to onset of urine incontinence as his friend had visited him. He also reported being a chronic cigarette smoker. He was married to two wives with thirteen children all alive and healthy. History of prostate cancer in his father and grandparents was unknown. On examination, MD was sick looking and in pain, unable to stand upright unsupported. He was afebrile with a body weight of 78kg. Abdominal examination revealed a distended and very tender bladder up to about 5cm above the umbilicus. The digital rectal examination (DRE) revealed external hemorrhoids, normal anal tone, smooth mucosa from anterior, smooth walled mass about the size of a tennis ball, empty rectum with narrowed rumen and there was no blood on the examining finger. The nervous system was unremarkable. Decision to admit patient was reached, immediate attempt to pass a urethral catheter to relieve the bladder was futile and thus an emergency supra pubic puncture (SSP) was done and about 3litres of urine was voided. In addition, he was investigated for the causes of Urinary obstruction. A urine dipstick was positive for nitrites and RBC├ö├ç├ûs, Prostate-specific antigen (PSA) was 10ng/ml, serum creatinine 120pneumol/l, International prostate symptom score (IPSS) of 14. Ultrasound scan showed enlarged prostate 54cm3. The Liver function test (LFT├ö├ç├ûs) and electrolytes were normal. At that time the differential diagnosis of Lower urinary tract syndrome (LUTS), Bladder Outlet Obstruction (BOO) secondary to BPH, Prostate hypertrophy were made. Discussion For centuries, it has been known that BPH occurs mainly in older men and that it doesn├ö├ç├ût develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH. Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination. The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems. International Consensus Committee (ICC) and the American Guidelines Group concur that mandatory investigations should include: full medical history, urinary symptom review,digital rectal examination (DRE),urine analysis, and serum creatinine. Other tests Include: Prostatic Specific Antigen (PSA): if suspicion of cancer or positive family history of prostatic cancer in men aged <75 is noted, PSA blood test is done to rule out cancer as a cause of urinary symptoms. PSA test is approved for use in conjunction with DRE to help detect prostate cancer and also for monitoring men with prostate cancer after treatment. Although PSA is a reliable marker for the progression of advanced disease, it├ö├ç├ûs neither specific nor sensitive in the differential diagnosis of early prostate cancer and BPH. The aim of therapy for benign prostatic hyperplasia (BPH) is to improve quality of life by providing symptom relief and an increased maximum flow rate (Qmax), as well as to reduce disease progression and the development of new morbidities. From the perspective of the patient, the goal becomes a current reduction in bother and a reduction in the fear of significant consequences of BPH by treating the underlying cause of the disease.7 Strong indications for treatment (usually prostatectomy) include: acute retention in fit men with no other cause for retention (drugs, constipation, recent operation, etc.) accounts for 25% of prostatectomies, chronic retention and renal impairment-accounts for 15% of prostatectomies, complications of bladder outflow obstruction (stone, infection and diverticulum formation), hemorrhage(occasionally, venous bleeding from a ruptured vein overlying the prostate will require prostatectomy to be performed), elective prostatectomy for severe symptoms which accounts for about 60% of prostatectomies.2 Currently, the main ways of dealing with BPH are: watchful waiting (no treatment), medical treatments (drugs), minimally-invasive treatments and surgical treatment. Watchful waiting cannot physiologically reduce the present symptoms or the likelihood of future major events any more than it can have a direct impact on prostate size or growth. However, it is a well-established and accepted course of action that is recommended when the symptom score is less than 7, that is, mild symptoms that do not interfere with daily life activities.8 Individuals with moderate symptoms that are bothersome, treatment options include pharmacologic as well as surgical therapies.Approved medications for symptomatic BPH/LUTS include; Alpha-Blockade and 5Ôò¼ÔûÆ-reductase inhibitors (5Ôò¼ÔûÆRIs) Alpha-Blockade became established as a therapy for BPH on the basis of its effects on symptoms and flow rates. The benefits of Ôò¼ÔûÆ1-blocker therapy appear shortly after starting therapy due to the alteration in dynamic smooth muscle tension within the prostate and bladder neck. The intermediate-term benefits of alpha 1-blockers can be seen in terms of an improvement in Qmax of 10├ö├ç├┤15% and in symptom scores of 15├ö├ç├┤20%9 .The four main alpha 1-blockers include alfuzosin, doxazosin, tamsulosin, and terazosin.10,11 Therapy of BPH with 5Ôò¼ÔûÆRIs is based on the fact that inhibiting dihydrotestosterone (DHT) production will, in the prostate, alter epithelial growth, cause atrophy, and, thereby, reduce prostate volume and increase flow rate. Common 5Ôò¼ÔûÆRIs include; Finasteride and Dutasteride. Several sources of data suggest that in the longterm, reducing prostate volume or limiting prostate growth may be key in controlling prostate symptoms and risk from prostate-based morbidities. These arguments point to the potential benefit of combining a Ôò¼ÔûÆ-blocker with a 5Ôò¼ÔûÆRI as a long-term treatment option. Additionally, the rapid action of the Ôò¼ÔûÆ-blockers supports their role at the start of therapy for symptomatic BPH and the presence of another effective agent during ongoing therapy mitigates their relatively high discontinuation rates. Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery; they are generally termed minimally invasive therapy. They include: transurethral microwave procedure, transurethral needle ablation and water-induced thermotherapy. Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following are the types of surgery that are used. Transurethral surgery. In this type of surgery, no external incision is needed. After giving anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra. A procedure called transurethral resection of the prostate (TURP) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and half inch in diameter, contains light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. Most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period. One possible side effect of TURP is retrograde, or backward, ejaculation Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established. Open surgery. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient├ö├ç├ûs general health help the surgeon decide which of the three open procedures to use. With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland. Laser surgery. In March 1996, the FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energylasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. Newer procedures that use laser technology can be performed on an outpatient basis. Photo-selective vaporization of the prostate (PVP). PVP uses a high-energy laser to destroy prostate tissue and seal the treated area. Unlike other laser procedures, interstitial laser coagulation places the tip of the fiberoptic probe directly into the prostate tissue to destroy it. Conclusion BPH is the most common disease that causes morbidity among the elderly men. Screening for this disease should always begin as early as possible so that appropriate interventions are accorded in time. References 1. Boon A.N, Cumming A.D, John G, 2007, Aging and Disease, Chapter 7, Part 1 Davidson├ö├ç├ûs principles and practice of Medicine 20thEd,churchhill Livingstone. 2. Norman S.Williams Christopher J.K.Bulstrode and P.RonanO├ö├ç├ûconnell.(2008) Bailey and Love├ö├ç├ûs short practice of surgery,25thedn. Hodder Arnold part of HatchetteLivre UK. 3. Simpson R.J.(1997) Benign Prostatic Hyperplasia (BPH), British Journal of General Medicine. 4. American Urological Association Foundation, Benign Prostatic Hyperplasia (BPH) 5. Diagnosis of Lower Urinary Tract symptoms resulting from Benign Prostatic Hyperplasia, 2012 ,InnovAiT Advance access. 6. Prostatic Enlargement;Benign Prostatic Hyperplasia, National kidney and Urologic diseases information, clearing house 2006, US Department of Health and Human Service. 7. Teillac P. Relief of BPH or improvement in quality of life? EurUrol 1998;34:3├ö├ç├┤9. 8. de la Rosette JJMCH, Alivizatos G, Madersbacher S, et al.EAU guidelines on benign prostatic hyperplasia (BPH). EurUrol 2001;40:256├ö├ç├┤63. 9. Djavan B, Marberger M. A meta-analysis on the efficacy and tolerability of a1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.EurUrol 1999;36:1├ö├ç├┤13.
- AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003).Chapter 1.Diagnosis and treatment recommendations.J Urol 2003;170:530├ö├ç├┤47.
- American Urology Association (AUA) Guidelines on BPH 2003. http://www.auanet.org/guidelines/bph.cfm.