Benign Prostatic Hyperplasia (BPH): Pathophysiology and Clinical Management

Clinical Note: It is important to remember that there is no direct correlation between the physical size of the prostate and the severity of the patient's symptoms.

Complications: Urine Stasis and Retention

When the urethra is obstructed, the bladder cannot empty completely, leading to urine stasis. This stagnant urine significantly increases the risk of:

• Urinary Tract Infections (UTIs)
• Bladder stones

Furthermore, BPH is associated with an increased risk of developing prostate cancer. Because the clinical presentation of BPH can mimic that of prostate cancer, clinicians must be diligent in diagnostic differentiation.

Clinical Presentation

Patients may be entirely asymptomatic, but when symptoms do occur, they generally fall into two categories: voiding symptoms and storage/complication symptoms.

Voiding Symptoms

These relate to the actual process of emptying the bladder:

• Frequency and urgency
• Hesitancy (difficulty starting the stream)
• A weak urinary stream or dribbling
• Dysuria (painful urination)
• A sensation of incomplete bladder emptying
• Straining to urinate

Storage and Complication Symptoms

These relate to how the bladder holds urine and the secondary effects of obstruction:

• Nocturia: Frequent urination at night
• Bladder distension
• Overflow incontinence: Involuntary leakage due to an overfull bladder
• Erectile Dysfunction (ED)

Diagnostic Procedures

To differentiate BPH from malignancy and assess the severity of the condition, several diagnostic steps are required:

1. Physical Examination (PE): Specifically, a Digital Rectal Exam (DRE) is used to assess the prostate's size and texture.
2. Laboratory Assessments:
   • Urinalysis to check for infection.
   • BUN (Blood Urea Nitrogen) and Creatinine to evaluate renal function and ensure the obstruction isn't causing kidney damage.
   • PSA (Prostate-Specific Antigen) to screen for prostate cancer.
3. Functional and Imaging Tests:
   • Urine flow measurements.
   • Rectal ultrasound.
   • Biopsy or Cystoscopy for definitive cancer differentiation.

Exam Tip: When monitoring a patient on 5-Alpha Reductase Inhibitors (like Finasteride), be aware that these drugs can lower PSA levels. This may cause a "false negative" result during cancer screening, so sustained elevation of PSA must still be investigated to rule out cancer.

---

Practice Question for Review: A patient is taking finasteride (Proscar) for benign prostatic hyperplasia (BPH). The nurse should explain to the patient that this medication has what primary effect?

• A. Decreases the size of the prostate gland.
• B. Relaxes smooth muscle of the prostate gland.
• C. Reduces the risk of prostate cancer.
• D. Improves sexual performance during intercourse.

Answer: A. Finasteride is a 5-alpha reductase inhibitor that prevents the conversion of testosterone to DHT, leading to the regression of prostate tissue and a decrease in prostate size.