Spermatocele

Non-malignant hyperplasia of prostatic transition zone tissue causing bladder outlet obstruction, increasing in prevalence with age from the 40s onward.

Lower urinary tract symptoms (LUTS): storage (frequency, urgency, nocturia) and voiding (hesitancy, weak/intermittent stream, straining, incomplete emptying, terminal dribble). DRE: smooth, symmetrically enlarged, firm-elastic prostate (irregular/hard/asymmetric nodularity raises malignancy concern). Complications: acute urinary retention, recurrent UTI, bladder stones, chronic retention with overflow incontinence, hydronephrosis/renal impairment.

• IPSS score: mild (0-7), moderate (8-19), severe (20-35) — guides management
• DRE: size, consistency, nodules
• PSA: discuss risks/benefits first; elevated in BPH, prostatitis, and cancer — not diagnostic alone
• Urinalysis: exclude infection/hematuria
• U&E/creatinine: if chronic retention/hydronephrosis suspected
• Post-void residual (bladder scan): assesses incomplete emptying
• Uroflowmetry: objective flow assessment (specialist)

Differentials: prostate cancer, urethral stricture, bladder neck dysfunction, overactive bladder, UTI, neurogenic bladder, prostatitis.

• Mild (IPSS <8): watchful waiting, reduce evening fluids/caffeine/alcohol, bladder training
• Alpha-blockers (first-line, rapid relief): tamsulosin 400mcg od, alfuzosin 10mg od, doxazosin 1-8mg od (titrate) — side effects: postural hypotension, retrograde ejaculation, intraoperative floppy iris syndrome (inform ophthalmologist pre-cataract surgery)
• 5-alpha reductase inhibitors (larger prostates, reduces volume over months): finasteride 5mg od, dutasteride 0.5mg od — 3-6 months for effect, reduces PSA ~50% (adjust interpretation), side effects: ED, reduced libido, gynecomastia
• Combination therapy: superior long-term outcome for larger prostates with moderate-severe symptoms
• Tadalafil 5mg od: alternative/add-on, particularly with comorbid ED
• Antimuscarinic/beta-3 agonist (mirabegron): add-on for persistent storage symptoms — ensure adequate voiding first
• Acute retention: urgent catheterization, trial without catheter after alpha-blocker initiation; urology referral if fails
• Surgery (severe/refractory, complications): TURP — gold standard; laser enucleation/vaporization, minimally invasive options (UroLift, Rezum) for selected patients

Referral: urology for refractory symptoms, complications, or suspected malignancy.