• Benign adenomatous increase of prostatic epithelial and stromal cells in the periurethral transition zone of the prostate leading to bladder outlet obstruction
• BPH is a histologic diagnosis. In the absence of histology, it is more correctly referred to as benign prostatic enlargement (BPE)
• System(s) affected: Renal/Urologic; Reproductive

Predominant age:

• Rarely seen in men <40
• Seen in 50% of men >50; 80% of men >70

Incidence

• In the US, BPH is a universal pathologic finding in older males.
• No hard evidence suggesting racial predisposition

• Intact testes (BPH rare in eunuchs)
• Aging (thus, rare in males <40 years old)
• No evidence of increased or decreased risk with smoking, alcohol, or any dietary factors
• Possible worsening of symptoms with abdominal obesity

Genetics

• Genetic factors may be involved.
• Males who had 1st-degree relative with BPH are at increased risk

Appears to be part of the aging process

Prostatic hyperplasia leading to bladder outlet obstruction, which may affect bladder function

Primary causal factors involve androgens, growth factors, and genetics.

BPH symptoms are a strong and independent risk factor for sexual dysfunction including erectile dysfunction and ejaculatory disorders (1)[C].

History

• Gross hematuria
• Obstructive symptoms:
  • Decrease force or caliber of stream
  • Hesitancy
  • Postvoid dribbling
  • Sensation of incomplete bladder emptying
  • Overflow incontinence
  • Inability to voluntarily stop stream
  • Urinary retention
• Storage symptoms:
  • Frequency
  • Nocturia
  • Urgency
  • Urge incontinence
• Symptom scores such as American Urological Association (AUA) or International Prostate Symptom Score (IPSS) may be helpful in management.

Physical Exam

• Distended bladder (>150 cc post-void residual in order to detect by percussion)
• Digital rectal exam finding of enlarged prostate, but size does not always correlate with symptoms
• Clinical clues suggesting renal failure due to obstructive uropathy (edema, pallor, pruritus, ecchymoses, nutritional deficiencies)

Lab
Initial Labs

• 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)
• Prostate-specific antigen (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

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

Imaging
Initial Imaging Approach
No radiologic imaging needed initially in the uncomplicated patient

Follow-Up and Special Considerations

• Transrectal ultrasound: Assessment of gland size; not necessary in the routine evaluation
• Abdominal ultrasound: Can demonstrate increased post-void 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, and site of obstructive tissue
  • Helps to show stricture, stones
  • 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)
  • 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
  • CHF
• Pharmacologic:
  • Diuretics
  • Sympathomimetics (e.g., cold medications)
  • Anticholinergics
• Other:
  • Bladder carcinoma
  • Prostatitis
  • Overactive bladder

• α-Adrenergic antagonists:
  • Terazosin (Hytrin): 1–10 mg/d PO (2)[A]
  • Doxazosin (Cardura): 1–8 mg/d PO
  • Tamsulosin (Flomax): 0.4 mg/d PO (3)[A]
  • Alfuzosin (Uroxatral): 10 mg/d PO
  • Silodosin (Rapaflo) 4–8 mg/d PO
• 5-α-reductase inhibitors (useful if demonstrable prostatic enlargement) (4):
  • 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 (5)[B].
• Anticholinergic agents may be combined with α-blockers for relief of persistent storage symptoms (6)[C].
• 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 PSA should be doubled for purposes of screening for prostate cancer.

General Measures

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

Issue for Referral

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

• Phytotherapy
• Saw palmetto (Serenoa repens) has shown mild improvement of peak flow rates and appears to work by blocking 5-α-reductase (7)[A].

• Indications for surgery:
  • Urinary retention due to prostatic obstruction, recurrent
  • Intractable symptoms due to prostatic obstruction (AUA sx score >8 and bother)
  • 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 (HOLEP)
  • 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

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.

Other
Activity
Patient more likely to void after surgery or illness when ambulatory and able to stand over the toilet

• The Prostate Book, published by Krames Communications, 312 90th St, Daly City, CA 94015-1898.
• 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% requires treatment because of worsening symptoms.
• 25% of men with lower urinary tract symptoms (LUTs) will have persistent storage symptoms after prostatectomy (8)[C].
  • 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.
• Of men with BPH, 11–33% have occult prostate cancer.

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

AUA Guideline on Management of Benign Prostatic Hyperplasia. Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;17(2 Pt 1):530–547.

Hoffman RM, et al. Laser prostatectomy for benign prostatic obstruction. Cochrane Database Syst Rev 2007:2.

• 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)

266569009 benign prostatic hyperplasia (disorder)

• Although medical therapy has changed the management of BPH, it appears that 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.

Pamela Ellsworth, MD
Sutchin R. Patel, MD

1. Rosen R, et al. Lower urinary tract symptoms and male sexual dysfunction: The multinational survey of the aging male. Eur Urol 2003;44:637–649.  [PMID:14644114]
2. Wilt TJ, et al. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002;4:CD003851.DOI:10.1002/14651858.CD003851.
3. Wilt TJ, et al. Tamsulosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2003;1:CD002081.DOI:10.1002/14651858.CD002081.
4. AUA Guidelines: Guideline on the Management of Benign Prostatic Hyperplasia (BPH): Updated 2006. AUAnet.org.
5. McConnell JD, et al. Medical Therapy of Prostatic Symptoms Research Group. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med 2003;349:2387–2398.  [PMID:14681504]
6. Athanasopoulos A, et al. Combination treatment with an α-blocker plus an anticholinergic for bladder outlet obstruction: A prospective randomized controlled study. J Urol 2003;169: 2253–2256.  [PMID:12771763]
7. Wilt T, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev 1999;1:CD001423. DOI: 10.1002/14651858. CD001423.
8. Abrams PH, et al. The results of prostatectomy: A symptomatic and urodynamic analysis of 152 patients. J Urol 1979;121:640–642.  [PMID:86617]