10.4 Benign Prostatic Hyperplasia & Renal Calculi
Key Takeaways
- Benign Prostatic Hyperplasia (BPH) arises in the transitional zone of the prostate causing lower urinary tract symptoms (LUTS), whereas Prostate Adenocarcinoma predominantly develops in the peripheral zone.
- Pharmacotherapy for BPH involves Alpha-1 blockers (Tamsulosin) for rapid dynamic symptom relief and 5-Alpha Reductase Inhibitors (Finasteride) to reduce prostate volume by inhibiting DHT synthesis.
- Transurethral Resection of the Prostate (TURP) is the gold-standard surgical repair; TURP syndrome is a life-threatening complication caused by systemic absorption of hypotonic non-conductive irrigation fluid (glycine) resulting in dilutional hyponatremia.
- Non-Contrast CT (NCCT) of the abdomen and pelvis is the gold-standard diagnostic imaging for renal and ureteric colic; uric acid stones are radio-lucent on plain X-ray but clearly visible on NCCT and respond to urinary alkalinization.
- Interventional stone management is determined by size and location: ESWL for renal stones <2 cm, PCNL for renal stones >2 cm or staghorn calculi, and URS/RIRS with Holmium laser lithotripsy for ureteric stones.
Last updated: July 2026
Benign Prostatic Hyperplasia & Renal Calculi
Urological emergencies and elective reconstructive procedures comprise a significant portion of general surgery in UPSC CMS. Mastery of prostatic disease pathology, surgical options, and urinary tract stone management algorithms is essential for clinical excellence.
1. Benign Prostatic Hyperplasia (BPH)
Prostatic Zonal Anatomy (McNeal's Zones)
- Transitional Zone: Surrounds the proximal pre-prostatic urethra. Site of origin of Benign Prostatic Hyperplasia (BPH).
- Peripheral Zone: Comprises 70% of glandular prostate, located posteriorly. Site of origin of Prostate Carcinoma (palpable on Digital Rectal Exam - DRE).
- Central Zone: Surrounds ejaculatory ducts.
Pathophysiology & Clinical Features
- Hormonal Basis: Dihydrotestosterone (DHT), synthesized locally from circulating testosterone by the enzyme 5-alpha reductase (Type 2), binds to androgen receptors in stromal and epithelial prostatic cells, driving nodular hyperplasia.
- Lower Urinary Tract Symptoms (LUTS):
- Storage (Irritative) Symptoms: Frequency, urgency, nocturia, urge incontinence.
- Voiding (Obstructive) Symptoms: Hesitancy, weak stream, intermittency, straining, terminal dribbling, sensation of incomplete emptying.
- Evaluation: International Prostate Symptom Score (IPSS), DRE (reveals smooth, elastic, symmetrical enlarged prostate with preserved median sulcus), Serum PSA (normal <4 ng/mL; rules out cancer), Uroflowmetry (peak flow rate Qmax <10 mL/s indicates bladder outlet obstruction), Post-Void Residual (PVR) urine volume (>100 mL is abnormal).
Pharmacotherapy of BPH
- Alpha-1 Adrenergic Blockers (Tamsulosin, Silodosin, Alfuzosin): Selective alpha-1A receptor antagonists. Relax smooth muscle tone in the prostate capsule and bladder neck. Provide rapid symptom relief within days. Side effects: Retrograde ejaculation, orthostatic hypotension, Intraoperative Floppy Iris Syndrome (IFIS during cataract surgery).
- 5-Alpha Reductase Inhibitors (5-ARIs) (Finasteride, Dutasteride): Block conversion of testosterone to DHT. Induce prostate epithelial apoptosis, reducing prostate volume by 20-30% over 6 months. Halves serum PSA levels (baseline PSA must be multiplied by 2 for cancer screening interpretation).
- Combination Therapy: Tamsulosin + Dutasteride is indicated for moderate-to-severe LUTS with prostate volume >30 cc.
Surgical Management: TURP & Complications
- Indications for Surgery: Refractory urinary retention, recurrent UTIs, recurrent gross hematuria, renal impairment attributable to BPH, secondary bladder calculi.
- Gold Standard: Transurethral Resection of the Prostate (TURP).
- TURP Syndrome:
- Pathophysiology: Excessive intravascular absorption of hypotonic non-conductive irrigation fluid (1.5% Glycine or Sorbitol) through opened prostatic venous sinuses during prolonged resection (>60 mins).
- Clinical Presentation: Dilutional Hyponatremia (Na+ <120 mEq/L) and fluid overload. Causes confusion, visual disturbances (transient blindness due to glycine ocular toxicity), nausea, bradycardia, pulmonary edema, seizures, and coma.
- Prevention: Limit resection time to <60 minutes, keep irrigation bag height <60 cm above patient, use Bipolar TURP (uses 0.9% normal saline irrigation, eliminating TURP syndrome).
- Treatment: Hypertonic (3%) Saline infusion slow rate, IV Furosemide, ICU supportive care.
2. Urolithiasis (Renal Calculi)
Chemical Composition & Radiogenicity Table
| Stone Type | Percentage | Radio-opacity (X-ray KUB) | Crystal Morphology | Etiology & Risk Factors |
|---|---|---|---|---|
| Calcium Oxalate | 75 - 80% | Radio-opaque | Envelope / Dumbbell shaped | Hypercalciuria, hyperoxaluria, inflammatory bowel disease (Crohn's), vitamin C excess. |
| Struvite (Triple Phosphate) | 10 - 15% | Moderately Radio-opaque | Coffin-lid shaped | Infection with urease-producing bacteria (Proteus, Klebsiella). Alkaline urine (pH >7.2). Forms Staghorn Calculi. |
| Uric Acid | 5 - 8% | Radio-lucent (invisible on X-ray) | Pleomorphic / Rhomboid | Hyperuricemia, gout, acidic urine (pH <5.5). Dissolves with urinary alkalinization. |
| Calcium Phosphate | 5% | Very Radio-opaque | Amorphous / Rosette | Associated with Primary Hyperparathyroidism and Renal Tubular Acidosis (RTA Type 1). |
| Cystine | 1 - 2% | Faintly Radio-opaque ('Ground-glass') | Hexagonal | Autosomal recessive defect in COLA amino acid transport. Positive Cyanide-Nitroprusside test. |
3. Clinical Features & Diagnostic Imaging
- Renal Colic: Sudden, excruciating, waxing-and-waning flank pain radiating to the groin, labia, or testicle (referred pain along T10-L2 dermatomes). Accompanied by micro/gross hematuria, nausea, vomiting, and costovertebral angle tenderness.
- Gold-Standard Investigation: Non-Contrast Computed Tomography (NCCT) of Abdomen and Pelvis. Detects 99% of all stones including radio-lucent uric acid stones (except rare indinavir protease inhibitor stones). Provides exact stone location, dimensions, and Hounsfield Unit (HU) density.
4. Management Algorithms for Urolithiasis
Conservative / Medical Expulsive Therapy (MET)
- Stones <5 mm have an 80-90% probability of spontaneous passage.
- Treatment: Adequate hydration (>2.5-3 L/day), analgesia (NSAIDs: Diclofenac/Ketorolac preferred over opioids), and Alpha-blockers (Tamsulosin) to relax distal ureteric smooth muscle.
Interventional Procedures Table
| Modality | Primary Indications | Key Contraindications & Limitations |
|---|---|---|
| ESWL (Extracorporeal Shock Wave Lithotripsy) | Renal pelvic or upper pole stones <2 cm; upper ureteric stones <1 cm. | Contraindications: Pregnancy, uncorrected bleeding diathesis, untreated UTI, severe skeletal deformity, aortic aneurysm, distal anatomical obstruction. |
| PCNL (Percutaneous Nephrolithotomy) | Renal stones >2 cm, Staghorn Calculi, lower pole stones >1 cm, or failed ESWL. | Invasive; percutaneous tract established into renal pelvis through posterior calyx under fluoroscopy. Risks: hemorrhage, pneumothorax. |
| URS / RIRS (Ureteroscopy / Retrograde Intrarenal Surgery) | URS: Choice for middle and lower ureteric stones.<br/>RIRS: Flexible scope with Holmium:YAG laser for intrarenal stones <2 cm. | Method of choice in obese patients, patients on anticoagulants, or pregnant women needing intervention. |
| Open / Laparoscopic Stone Surgery | Complex failed stones, anatomical anomalies (horseshoe kidney). | Rarely performed in modern urological practice (<1-2% of cases). |
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Test Your Knowledge
Benign Prostatic Hyperplasia (BPH) originates in which anatomical zone of the prostate gland?
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Test Your Knowledge
During a TURP procedure lasting 90 minutes, the patient becomes disoriented and develops bradycardia. Serum sodium is 114 mEq/L. Absorption of which irrigation fluid is responsible for TURP syndrome?
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B
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D
Test Your Knowledge
A 48-year-old male with a history of severe gout presents with left renal colic. NCCT demonstrates a 7 mm stone in the left renal pelvis, but plain X-ray KUB shows no visible calcification. What is the chemical composition of this stone?
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D
Test Your Knowledge
What is the surgical treatment of choice for a 2.8 cm complete staghorn renal calculus filling the left renal pelvis and calyces in a 52-year-old patient?
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B
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D