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Referral and warning signs
When to refer
Referral to Urology specialist for: Severe symptoms refractory to medical therapy. Complications (AUR, recurrent UTIs, bladder stones, renal impairment). Suspicion of prostate cancer (abnormal DRE, significantly elevated/rising PSA). Consideration for surgical management (TURP, laser prostatectomy, etc.).
Red flags
- Acute Urinary Retention
- Haematuria (needs investigation to rule out malignancy)
- Suspicious DRE (nodule, hardness, asymmetry)
- Significantly elevated or rapidly rising PSA
- Associated neurological symptoms
- Renal impairment suspected secondary to obstruction
Signs and symptoms
- Lower Urinary Tract Symptoms (LUTS):
- - Voiding (Obstructive) Symptoms: Weak urine stream, Straining to urinate, Hesitancy (difficulty starting stream), Intermittency (stream stops and starts), Feeling of incomplete bladder emptying, Post-void dribbling.
- - Storage (Irritative) Symptoms: Urinary frequency (daytime), Nocturia (waking at night to urinate), Urgency (sudden compelling need to void), Urge incontinence.
- Complications: Acute urinary retention, Recurrent UTIs, Bladder stones, Haematuria, Chronic kidney disease (due to chronic obstruction).
Risk factors
- Increasing age (>50 years)
- Family history of BPH
- Obesity
- Metabolic syndrome / Diabetes
- Lack of physical activity
- Erectile dysfunction
Diagnosis
Clinical assessment
Diagnosis based on characteristic LUTS in an older man. Assess symptom severity using standardized questionnaires (e.g., International Prostate Symptom Score - IPSS). Digital Rectal Examination (DRE): Assess prostate size (often enlarged, smooth, firm, non-tender), symmetry, rule out nodules/hardness (suspicious for cancer). Abdominal exam: Check for palpable bladder (retention). Differential diagnosis: Prostate cancer, Prostatitis, UTI, Bladder cancer, Urethral stricture, Neurogenic bladder, Overactive bladder.
Investigations
- Urinalysis: Rule out UTI, haematuria.
- Serum Creatinine/eGFR: Assess renal function.
- Prostate-Specific Antigen (PSA): Blood test. Optional, discuss risks/benefits with patient. Elevated PSA can be due to BPH, prostatitis, cancer, instrumentation. Used primarily for prostate cancer risk assessment, not required for BPH diagnosis itself.
- Post-Void Residual (PVR) Volume: Measured by ultrasound or catheterization. Assesses bladder emptying.
- Urinary Flow Rate (Uroflowmetry): Measures speed of urine flow (reduced in obstruction).
- Kidney/Bladder Ultrasound: Assess prostate size, bladder wall thickness, PVR, rule out hydronephrosis, stones.
Diagnostic criteria
Clinical diagnosis based on LUTS and DRE findings suggesting BPH, after excluding other causes.
Management
Non-pharmacological management
- Watchful Waiting: For mild symptoms not significantly impacting quality of life.
- Lifestyle Modifications: Reduce fluid intake in evening (esp. caffeine, alcohol), timed voiding, avoid constipation, review medications (decongestants, anticholinergics can worsen symptoms).
Pharmacological treatment
- Alpha-1 Adrenergic Blockers: Relax smooth muscle in prostate and bladder neck, improving flow. Rapid onset (days-weeks). Examples: Tamsulosin, Alfuzosin, Doxazosin, Terazosin. Side effects: Dizziness, postural hypotension, retrograde ejaculation.
- 5-Alpha Reductase Inhibitors (5-ARIs): Shrink prostate size over time (months). Most effective for larger prostates (>30-40g). Examples: Finasteride, Dutasteride. Side effects: Decreased libido, erectile dysfunction, reduced PSA level (need to adjust interpretation).
- Combination Therapy (Alpha-blocker + 5-ARI): Often used for moderate-severe symptoms and larger prostates.
- Antimuscarinics (e.g., Tolterodine, Oxybutynin) or Beta-3 Agonists (e.g., Mirabegron): Can be added cautiously to treat persistent storage symptoms IF PVR is low (risk of retention).
- PDE-5 Inhibitors (e.g., Tadalafil daily): Can improve both LUTS and erectile dysfunction.
- Treat associated UTIs if present.
Monitoring
Monitor symptom score (IPSS), urinary flow rate, PVR periodically. Monitor for side effects of medications. Monitor PSA if initially checked (consider trend/velocity).
Complications
- Acute Urinary Retention (AUR)
- Recurrent Urinary Tract Infections (UTIs)
- Bladder stones
- Gross haematuria
- Bladder damage (trabeculation, diverticula)
- Chronic Kidney Disease (secondary to obstruction)
Prevention
- Not truly preventable, but maintaining healthy lifestyle may play a role.
Patient education
- Explain BPH as non-cancerous enlargement.
- Discuss treatment options (watchful waiting, lifestyle, medications, surgery).
- How medications work and potential side effects.
- Lifestyle advice.
- Symptoms of acute urinary retention requiring urgent care.
- Importance of regular follow-up.
Uganda-specific notes
BPH is common. DRE is key initial assessment. PSA testing access limited. Alpha-blockers often first-line medical therapy where available. Surgical options (TURP) limited to specialized centers. Management of acute retention with catheterization crucial.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 7, Section 7.2.5