The aetiology of benign prostatic hyperplasia (BPH) is multi-factorial involving smooth muscle hyperplasia, prostatic enlargement, and bladder dysfunction, as well as input from the central nervous system.
Presents with both storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining).
Physical examination may demonstrate prostate size/volume ≥30 grams, nodules or tenderness suspicious of prostate cancer or prostatitis.
Evaluation includes history and examination including an abdominal examination for a palpable bladder, a digital rectal exam, and a neurological assessment.
Urinalysis, prostate-specific antigen (PSA) level, and International Prostate Symptom Score are first-line tests of powerful diagnostic impact in the appropriate patient groups. Given the debate regarding the morbidity and mortality reduction of prostate cancer with PSA testing, discuss the implications with the patient before testing.
Use shared decision-making based on understanding the patient’s desires and risks associated with specific therapies to guide treatment strategies.
If symptoms or disease severity warrant, initiate therapy with an alpha-blocker, 5-alpha-reductase inhibitor, combination therapy, or other agents depending on symptom profile.
Common complications are disease progression and urinary retention, which may require invasive therapy.
Failure or intolerance of medical management or renal complications are indications for surgical intervention. There are a host of procedural treatments, which have unique risk/benefit profiles for consideration.
Lower urinary tract symptoms (LUTS) caused by bladder outlet obstruction due to BPH, also known as benign prostatic enlargement, are predominantly due to 2 components: a static component related to an increase in benign prostatic tissue narrowing the urethral lumen and a dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors. Symptoms related to bladder outlet obstruction may also be contributed by bladder overactivity. LUTS are further defined as storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining).
History and exam
Key diagnostic factors
- presence of risk factors
- storage symptoms
- voiding symptoms
Other diagnostic factors
- fever with dysuria
- urinary retention
- age over 50 years
- family history of BPH
- non-Asian race
- cigarette smoking
- male pattern baldness
- metabolic syndrome
1st investigations to order
- prostate-specific antigen (PSA)
- International Prostate Symptom Score
- volume charting
Investigations to consider
- CT abdomen/pelvis
- MRI abdomen/pelvis
- urodynamic study
bothersome symptoms with no indications for surgery
bothersome symptoms with indication for surgery: prostate volume ≤30 grams
bothersome symptoms with indication for surgery: prostate volume 30-80 grams
bothersome symptoms with indication for surgery: prostate volume ≥80 grams
Claus Roehrborn, MD
University of Texas Southwestern Medical Center
CR is on an ad board for Teleflex; consults for Teleflex, Zenflow, and Medeon; and has done research with Zenflow and Teleflex. CR is an author of several references cited in this topic.
Ramy Goueli, MD
University of Texas Southwestern Medical Center
RG declares that he has no competing interests.
Professor Claus Roehrborn and Dr Ramy Goueli would like to gratefully acknowledge Professor Michael T. Flannery and Dr Erika Abel, the previous contributors to this topic. Regretfully, Professor Flannery died in December 2020.
EA declares that she has no competing interests.
Christopher R. Chapple, BSc, MD, FRCS (Urol), FEBU
Consultant Urological Surgeon
Royal Hallamshire Hospital
Honorary Senior Lecturer of Urology
University of Sheffield
Visiting Professor of Urology
Sheffield Hallam University
Adjunct Secretary responsible for Education
European Association of Urology
CRC is Chairman of NICE Male LUTS Guidelines Development Group.
Robert Pickard, MD, FRCS (Urol)
Professor of Urology
Institute of Cellular Medicine
Newcastle upon Tyne
RP has received funding from the UK NHS (NIHR) to undertake commissioned reviews of treatment for benign prostatic enlargement.
Steven K. Brooks, MD
Department of Surgery
South Seminole Hospital
SKB is a member of the National Speakers Bureau for Boehringer Ingelheim, Astellas Pharmaceuticals, and Glaxo Pharmaceuticals and has served as a consultant for these companies.
- Overactive bladder
- Prostate cancer
- Suspected cancer: recognition and referral
- Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia
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