Description

• Benign prostatic hyperplasia (BPH) is one of the most common diseases of older men.
• Diagnosed histologically, characterized by an increase in the total number of stromal and epithelial cells within the prostate gland
• Associated with bothersome lower urinary tract symptoms (LUTS) that affect quality of life
• Disease affects the renal, urologic, and reproductive systems

Epidemiology

In the US, near universal development in men; age-dependent

• No clear identifying characteristics
• Commonly involves prostate volume >30 mL and high prostate symptom score

Prevalence
From 8% in men aged 31–40; to 40–50% in men 51–60; and >80% in men >80 years

Risk Factors

• Increased risk of BPH with higher free prostate-specific antigen (PSA) levels, heart disease, and use of β-blockers
• Decreased risk with higher physical activity
• Conflicting data that tobacco use may lower risk of surgery for BPH symptoms
• Intact testes (BPH rare in eunuchs)
• No evidence of increased or decreased risk with smoking, alcohol, or any dietary factors
• Low androgen levels from cirrhosis/chronic alcoholism can reduce the risk of BPH.

• Males who had a 1st-degree relative with BPH are at increased risk.
• Race has some influence on the risk for BPH severe enough to require surgery.
• Black men <65 years may need treatment more often than white men.
• Asians have a lower risk for nocturia, whereas risks for African American and Caucasian men are similar.

General Prevention

The disease appears to be part of the aging process.

Pathophysiology

• Older age and functional Leydig cells in testes are determinant.
• BPH is rare in men with hypogonadism onset before age 40 years not treated with androgens.

Etiology

• BPH develops in the periurethral or transition zone of the prostate.
• Hyperplastic nodules of stromal and epithelial components increase glandular components.

Commonly Associated Conditions

• LUTS:
  • LUTS can be divided into 3 groups: Filling/Storage symptoms, voiding symptoms, and postmicturition symptoms.
  • Filling/Storage symptoms include frequency, nocturia, urgency, and urge incontinence.
  • Voiding: Irritative: Frequency, urgency, dysuria, nocturia. Obstructive symptoms: Poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence
  • Post micturition: Leakage
• BPH symptoms are strong and independent risk factors for sexual dysfunction, including erectile dysfunction and ejaculatory disorders (1)[C].

History

• International Prostate Symptom Score (IPSS) of Lower Urinary Tract Symptoms (LUTS):
  • Questionnaire: Over the past month, how often have you…
    • 1. Had the sensation of not emptying your bladder completely after you finished urinating?
    • 2. Had to urinate again <2 hours after you finished urinating?
    • 3. Found you stopped and started again several times when you urinated?
    • 4. Found it difficult to postpone urination?
    • 5. Had a weak urinary stream?
    • 6. Had to push or strain to begin urination?
    • 7. Been up to urinate from the time you went to bed at night until the time you got up in the morning?
    • 8. How would you feel if you were to spend the rest of your life with your current symptoms?
  • Scoring of the questionnaire:
    • Questions 1–6: No symptoms = 0 points, 1 in 5 times = 1 point, less than half = 2 points, about half = 3 points, more than half = 4 points, most of the time = 5 points
    • Question 7: No occurence = 0 points, 1 time = 1 point, 2 times = 2 points, 3 times = 3 points, 4 times = 4 points, and 5 times or more = 5 points.
    • Question 8: 0 = Delighted, 1 = Pleased, 2 = Mostly satisfied, 3 = Mixed, 4 = Mostly dissatisfied, 5 = Unhappy, 6 = Terrible
    • Symptoms are classified as mild (total score 0–7), moderate (total score 8–19), and severe (total score 20–35).
• Important to include in the history:
  • Gross hematuria
  • History of type 2 diabetes, which can cause nocturia and is a risk factor for BPH; chronically elevated glucose can cause neurogenic bladder
  • Symptoms of neurologic disease
  • Sexual dysfunction, which is correlated with LUTS
  • History of urethral trauma, urethritis, or urethral instrumentation that could lead to urethral stricture
  • Family history of BPH and prostate cancer
  • Treatment with drugs that can impair bladder function (anticholinergic drugs) or increase outflow resistance (sympathomimetic drugs)

Physical Exam

• Digital rectal exam finding of enlarged prostate, but size does not always correlate with symptoms
• Percussion to detect distended bladder, particularly if postvoid
• Signs of renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies)

Diagnostic Tests and Interpretation

• PSA may be elevated, but usually <10 ng/mL (10 μg/L). Acute urinary retention, prostatitis, urinary tract instrumentation, or prostatic infarction may elevate PSA.
• Urinalysis: Pyuria if stones or infection present, pH changes due to chronic residual urine
• Urine culture positive (sometimes due to chronic residual urine)
• BUN and creatinine (if concerns for uremia)

• Uroflow: Volume voided per unit time (peak flow <10 mL/sec is abnormal)
• Postvoid residual: Either with catheterization or bladder ultrasound (>100 mL demonstrates incomplete emptying)

Initial Imaging Approach
Postvoid residual to detect obstruction/distended bladder

• Transrectal ultrasound: Assessment of gland size; not necessary in the routine evaluation
• Abdominal ultrasound: Can demonstrate increased postvoid residual or hydronephrosis; not necessary in the routine evaluation

Geriatric Considerations
Drugs to avoid: Anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, narcotics, and skeletal muscle relaxants

• Pressure-flow studies (urine flow vs. voiding pressures):
  • Best test to determine etiology of voiding symptoms
  • Obstructive pattern shows high voiding pressures with low flow rate
• Cystoscopy:
  • Demonstrates presence, configuration, cause (stricture, stone), and site of obstructive tissue
  • May help determine best minimally invasive therapeutic option
  • Not recommended in initial evaluation unless other factors, such as hematuria, are present

Pathological Findings
Confirmation obtained by biopsy, resection, or surgical removal

Differential Diagnosis

• Obstructive:
  • Prostate cancer
  • Urethral stricture or valves
  • Bladder neck contracture (usually secondary to prostate surgery)
  • Prostatitis
  • Inability of bladder neck or external sphincter to relax appropriately during voiding
• Neurologic:
  • Spinal cord injury
  • Stroke
  • Parkinsonism
  • Multiple sclerosis
• Medical:
  • Poorly controlled diabetes mellitus
  • Congestive heart failure (CHF)
• Pharmacologic:
  • Diuretics
  • Sympathomimetics (e.g., cold medications)
  • Anticholinergics
• Other:
  • Bladder carcinoma
  • Overactive bladder
  • Bladder calculi
  • UTI

Medication (Drugs)

The American Urological Association (AUA) recommends watchful waiting for patients without bothersome LUTS who have not developed a serious complication.

• α-adrenergic antagonists more effective than other methods alone (2)[A]:
  • Nonselective, reduce prostatic smooth muscle tone, improving urinary flow (3):
    • Terazosin (Hytrin): 1–10 mg/d PO (4)[A]
    • Doxazosin (Cardura): 1–8 mg/d PO
  • Selective, may produce fewer side effects; generally more expensive:
    • Tamsulosin (Flomax): 0.4 mg/d PO (5)[A]
    • Alfuzosin (Uroxatral): 10 mg/d PO
• 5-α-reductase inhibitors reduce prostatic volume (useful if prostatic enlargement) (6)[A]:
  • Finasteride (Proscar): 5 mg/d PO
  • Dutasteride (Avodart): 0.5 mg/d PO
  • Also useful in controlling prostatic bleeding
• Combination therapy of α-blocker plus 5-α-reductase inhibitor is superior to monotherapy when used for very large prostates and evaluated over at least 4.5 years (7):
  • Dutasteride and tamsulosin combination known as Jalyn
• Contraindications:
  • α-blockers can cause orthostatic hypotension; less risk with tamsulosin and alfuzosin
  • See specific recommendations for α-blocker use with phosphodiesterase type-5 inhibitors (for erectile dysfunction).

ALERT
5-α-reductase inhibitors reduce PSA by 1/2, so the PSA result should be doubled for purposes of screening for prostate cancer.

Additional Treatment

• Patients with urinary retention require bladder drainage.
• If catheterization is difficult, consider coude catheter or flexible cystoscopy.
• With postobstructive diuresis, monitor electrolytes.
• Avoid prolonged periods of not voiding.

• Recurrent UTIs
• Hematuria
• Failure to respond to medical therapy
• Bladder stones

Complementary and Alternative Therapies

Saw palmetto (Serenoa repens) did not improve LUTS in Cochrane Review (8)[A].

Surgery/Other Procedures

• Indications for surgery:
  • Urinary retention due to prostatic obstruction, recurrent
  • Intractable symptoms due to prostatic obstruction AUA score >8 and symptoms
  • Obstructive uropathy (renal insufficiency)
  • Recurrent or persistent UTIs due to prostatic obstruction
  • Recurrent gross hematuria due to enlarged prostate
  • Bladder calculi
• Surgical procedures:
  • Transurethral resection of the prostate (TURP): Gold standard
  • Open prostatectomy: Treatment of choice for patients with extremely large prostates (>100 g)
  • Transurethral incision of the prostate: Treatment of choice for men with obstruction and small prostates
  • Transurethral laser ablation: Holmium laser ablation of the tissue; useful in patients on anticoagulant therapy
  • Transurethral needle ablation: Office-based, minimally invasive approach usually used with small prostates
  • Transurethral microwave thermotherapy: Office-based minimally invasive approach usually used with small prostates
  • Transurethral laser resection/enucleation
  • UroLume stent placement: Only for those too ill for other surgical procedures
• Complications of TURP:
  • Bleeding can be significant.
  • TUR syndrome: Hyponatremia secondary to absorption of hypotonic irrigant
  • Retrograde ejaculation
  • Urinary incontinence

Follow-Up Recommendations

The patient is more likely to void after surgery or illness when able to stand over toilet.

• Symptom index (IPSS) monitored every 3–12 months
• Digital rectal exam yearly
• PSA yearly: Should not be checked while patient is in retention, recently catheterized, or within a week of any surgical procedure to the prostate
• Consider monitoring postvoid residual, if elevated.

Diet

Avoid large boluses of oral or IV fluids or alcohol intake.

Patient Education

National Kidney and Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893; (301) 468-6345

Prognosis

• Symptoms improve or stabilize in 70–80% of patients.
• 25% of men with LUTS will have persistent storage symptoms after prostatectomy.
• Of men with BPH, 11–33% have occult prostate cancer.

Complications

• Urinary retention (acute or chronic)
• Bladder stones
• Prostatitis
• Renal failure
• Hematuria

ICD-9

• 600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)
• 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)

ICD-10

• N40.0 Enlarged prostate without lower urinary tract symptoms
• N40.1 Enlarged prostate with lower urinary tract symptoms

SNOMED

• 266569009 Benign prostatic hyperplasia (disorder)