Benign prostatic hyperplasia

The aetiology of benign prostatic hyperplasia 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 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.

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]D'Ancona C, Haylen B, Oelke M, et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn. 2019 Feb;38(2):433-77. http://www.ncbi.nlm.nih.gov/pubmed/30681183?tool=bestpractice.com