• Increase in number of cells (both stroma and epithelial cell lines) within prostate, ultimately increasing its size.
• As it grows in volume, the central urethra may become compressed and narrowed, causing symptoms of obstruction and results in clinical symptoms (difficulty initiating urination, frequency, dysuria).
• May result in increased risk for upper and lower tract infections, and may progress to acute renal failure causing partial, or sometimes virtually complete, obstruction of the urethra, which interferes with the normal flow of http://urine

• 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

• In the US, near universal development in men, age-dependent
• Average prostate weighs 20 g in a normal 20–30-year-old male

Incidence

• 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 over 80% in men <80 years old

• Increased risk of BPH with higher free prostate-specific antigen (PSA) levels, heart disease, and use of β-blockers
• Decreased risk with cigarette smoking, higher physical activity
• 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

Genetics

• Males who had a first-degree relative with BPH are at increased risk.
• Race has some influence on the risk for BPH severe enough to require surgery.
• Black men who are younger than 65 may need treatment more often than white men.
• Asians have a lower risk for nocturia, while risks for blacks and whites are similar.

The disease appears to be part of the aging process.

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

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

• Lower urinary tract symptoms (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].

• Symptom scores such as American Urological Association (AUA). It consists of 7 questions, each of which is scored on a scale of 0 (not present) to 5 (almost always present). Symptoms are classified as mild (total score 0–7), moderate (total score 8–19), and severe (total score 20–35):
  • Frequency
  • Nocturia
  • Weak urinary stream
  • Hesitancy
  • Intermittence
  • Incomplete emptying
  • Urgency
• Gross hematuria
• History of type 2 diabetes, which can cause nocturia and is a risk factor for BPH
• Symptoms of neurologic disease that would suggest a neurogenic bladder
• 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)

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

LabInitial Labs

• 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)

Follow-Up and Special Considerations

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

ImagingInitial Imaging Approach Postvoid residual in order to detect obstruction/distended bladder

Follow-Up and Special Considerations

• 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

ALERT
Geriatric Considerations
Drugs to be avoided include anticholinergics, antihistamines, sympathomimetics, tricyclic antidepressants, narcotics, and skeletal muscle relaxants when possible.

Diagnostic Procedures/Other

• 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

• 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

The AUA recommends watchful waiting for patients with mild symptoms or without bothersome LUTS who have not developed a serious complication.

First Line

• 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.

General Measures

• Patients in urinary retention require bladder drainage.
• If catheterization is difficult, consider coude catheter or flexible cystoscopy.
• Consider possible postobstructive diuresis; if present, monitor electrolytes.
• Avoid prolonged periods of not voiding.
• Avoid sympathomimetic and anticholinergic medications.

Issue for Referral

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

• Phytotherapy
• Saw palmetto (Serenoa repens) may provide mild improvement of peak flow rates and appears to work by blocking 5-α-reductase.

• 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: Not a primary treatment alternative for the standard patient, but considered in 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

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

Patient Monitoring

• 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.

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

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

• Symptoms improve or stabilize in 70–80% of patients; 20–30% require treatment because of worsening symptoms.
• 25% of men with LUTS will have persistent storage symptoms after prostatectomy.
• Of men with BPH, 11–33% have occult prostate cancer.

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

• 600.20 Benign localized hyperplasia of prostate without urinary obstruction and other LUTS
• 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other LUTS

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

266569009 Benign prostatic hyperplasia (disorder)

• Although medical therapy has changed the management of BPH, it has only delayed the need for TURP by 10–15 years, not eliminated it.
• Urinary retention, obstructive uropathy, recurrent UTIs, bladder calculi, and recurrent hematuria are indications for surgical management of BPH.
• Indications for referral include recurrent UTIs, elevated PSA, failure of medical therapy, hematuria, retention, and patient desire.

David Longstroth, MD

1. Rosen R, Altwein J, Boyle P. Lower urinary tract symptoms and male sexual dysfunction: The multinational survey of the aging male (MSAM-7). Eur Urol. 2003;44:637–49.  [PMID:14644114]
2. Rich KT. FPIN's clinical inquiries. Medical treatment of benign prostatic hyperplasia. Am Fam Physician. 2008;77:665–6.  [PMID:18350766]
3. Neal RH, Keister D. What's best for your patient with BPH? J Fam Pract. 2009;58:241–7.  [PMID:19442387]
4. Wilt TJ. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;4:CD003851.  [PMID:12519611]
5. Wilt TJ. Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2003;1:CD002081.  [PMID:12535426]
AUA Guidelines: Guideline on the Management of Benign Prostatic Hyperplasia (BPH): Updated 2006. www.AUAnet.org.
6. Hollingsworth JM, Wei JT. Does the combination of an alpha1-adrenergic antagonist with a 5alpha-reductase inhibitor improve urinary symptoms more than either monotherapy? Curr Opin Urol. 2010;20:1–6.  [PMID:19881352]

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