Benign prostatic hyperplasia

Last reviewed: June 2019

Last updated: September 2018

Summary

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 volume ≥30 g, 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 (IPSS) 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, the implications of such testing should be discussed with the patient prior to testing.

If symptoms or disease severity warrant, therapy can be initiated with an alpha-blocker, 5-alpha-reductase inhibitors, combination therapy, or other agents depending on symptom profile.

Common complications are disease progression and urinary retention, which may require invasive therapy.

Failure 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.

Definition

Lower urinary tract symptoms (LUTS) caused by bladder outlet obstruction due to benign prostatic hyperplasia (BPH), also known as benign prostatic enlargement (BPE), 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 over-activity. LUTS are further defined as storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining). [1]

History and exam

Key diagnostic factors

presence of risk factors
storage symptoms
voiding symptoms

Full details

Other diagnostic factors

fever with dysuria
urinary retention

Full details

Risk factors

age over 50 years
family history
non-Asian race
cigarette smoking
male pattern baldness
metabolic syndrome

Full details

Diagnostic investigations

1st investigations to order

urinalysis
PSA
International Prostate Symptom Score
global bother score
volume charting

Full details

Investigations to consider

ultrasound
CT abdomen/pelvis
cystoscopy
uroflowmetry
urodynamic study

Full details

Treatment algorithm

ACUTE

non-bothersome symptoms

bothersome symptoms with no indications for surgery

bothersome symptoms with indication for surgery: prostate <80 grams

bothersome symptoms with indication for surgery: prostate ≥80 grams

Contributors

Authors VIEW ALL 

Michael T. Flannery, MD

Professor

Internal Medicine

University of South Florida College of Medicine

Department of Internal Medicine

Tampa

Disclosures

MTF declares that he has no competing interests.

Erika Abel, MD

Associate Professor and Program Director

Internal Medicine

University of South Florida College of Medicine

Department of Internal Medicine

Tampa

Disclosures

EA declares that she has no competing interests.

Peer reviewers VIEW ALL 

Christopher R. Chapple, BSc, MD, FRCS (Urol), FEBU

Consultant Urological Surgeon

Royal Hallamshire Hospital

Honorary Senior Lecturer of Urology

University of Sheffield

Newcastle University

Visiting Professor of Urology

Sheffield Hallam University

Adjunct Secretary responsible for Education

European Association of Urology

Sheffield

Disclosures

CRC is Chairman of NICE Male LUTS Guidelines Development Group.

Robert Pickard, MD, FRCS (Urol)

Professor of Urology

Institute of Cellular Medicine

Newcastle University

Newcastle upon Tyne

Disclosures

RP has received funding from the UK NHS (NIHR) to undertake commissioned reviews of treatment for benign prostatic enlargement.

Steven K. Brooks, MD

Chief

Department of Surgery

South Seminole Hospital

Longwood

Disclosures

SKB is a member of the National Speakers Bureau for Boehringer Ingelheim, Astellas Pharmaceutics, and Glaxo Pharmaceuticals and has served as a consultant for these companies.

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Benign prostatic hyperplasia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

non-bothersome symptoms

bothersome symptoms with no indications for surgery

bothersome symptoms with indication for surgery: prostate <80 grams

bothersome symptoms with indication for surgery: prostate ≥80 grams

Contributors

Authors VIEW ALL 

Michael T. Flannery, MD

Disclosures

Erika Abel, MD

Disclosures

Peer reviewers VIEW ALL 

Christopher R. Chapple, BSc, MD, FRCS (Urol), FEBU

Disclosures

Robert Pickard, MD, FRCS (Urol)

Disclosures

Steven K. Brooks, MD

Disclosures

Differentials

Guidelines

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